Inspection on 07/06/07 for Old Charlton House

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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 Old Charlton House Baring Road Cowes Isle Of Wight PO31 8DW Lead Inspector Janet Ktomi Unannounced Inspection 7th June 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000068846.V339704.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. DS0000068846.V339704.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Charlton House Address Baring Road Cowes Isle Of Wight PO31 8DW 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) 01983 294453 01983 294453 Kensington Healthcare Ltd Mrs Linda Thearle Care Home 32 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Old age, not falling within any of places other category (32), Physical disability (3) DS0000068846.V339704.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service Brief Description of the Service: Old Charlton House is registered to provide personal care and accommodation for up to thirty-two older people. The home provides all accommodation in single bedrooms, although twin rooms can be made available for couples wishing to share. The majority of bedrooms have en-suite facilities. The home has two lounges, a large dining room and level access to a well maintained garden. Old Charlton House is located in a residential area of Cowes, with local buses stopping within a short walking distance of the home. Many rooms face the sea and have views of the Solent. The home has a shaft lift providing level access to most bedrooms. The home is owned by Kensington Healthcare Ltd and managed by Mrs Linda Thearle. Weekly fees are dependant on room selected and range from £440 to £475 per week plus any attendance allowance awarded/received. DS0000068846.V339704.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows the first key inspection of the service since Kensington Healthcare Ltd purchased it in December 2006. The inspection included an unannounced site visit to the home undertaken by one inspector over a period of one day lasting seven hours. The report also contains information received prior to the site visit from the home in their very well completed Annual Quality Assurance Assessment. Service user and relative questionnaires were sent to the home prior to the inspectors visit and three questionnaires were returned. During the visit to the service the inspector met staff on duty, visitors and people living at the home. Information from them is included in this report. The inspector telephoned local health professionals prior to the visit to the home. Information about planned training was provided by the homes training manager following the inspectors’ visit. What the service does well: What has improved since the last inspection? This was the first inspection of the home since Kensington Healthcare Limited registered it following purchase in December 2006. DS0000068846.V339704.R01.S.doc Version 5.2 Page 6 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. DS0000068846.V339704.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000068846.V339704.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. The home does not provide intermediate care therefore standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving to Old Charlton House have the information they need to make an informed choice about where to live and have a written contract/statement of terms and conditions of residency. People are only admitted to the home following a full needs assessment being completed and the home being satisfied that it can meet their needs. EVIDENCE: The inspector viewed pre-admission assessments completed by the home and spoke with people living at the home and staff. A copy of the homes service users guide containing information about contracts and terms of residency was provided to the inspector. Information from the Annual Quality Assurance Assessment completed by the home is also considered in this section. DS0000068846.V339704.R01.S.doc Version 5.2 Page 9 The service users guide was provided to the inspector during the visit to the home and read following the visit. The service users guide contains relevant information as specified in the National Minimum Standards in a format that is suitable for most people and is written in straightforward English. People spoken with during the inspection stated that they had received written information prior to moving into the home. People and/or their relatives also confirmed that they had been able to visit the home prior to admission where their physical condition enabled this to happen. Included with the service users guide is a sample contract and information about the fees payable. The inspector noted leaflets in the entrance hall detail support people might be entitled to with funding of residential care. The sample contract contains all the required information as specified in the National Minimum Standards and is written in straightforward easy to understand English. The inspector viewed the pre-admission assessments and resulting care plans for two people and saw further pre-admission assessments in peoples care plans. The manager explained the homes admission procedure. Following an initial telephone referral, if the home has a vacancy and the referral indicates that the persons needs may be met at the home; either the manager or the deputy manager will visit the person either at their home or at the hospital. An assessment tool is completed which includes all the areas necessary for the home to determine if they are able to meet the person’s needs. Completed pre-admission assessments seen had been fully completed and would indicate that the home would be able to meet the identified needs. The pre-admission assessment tool has a scoring system that helps the manager determine if the referred persons needs can be met alongside those people already living in the home. The manager was clear that she would not admit a person with high support needs if the home was already supporting a number of people with higher support needs. On the afternoon of the unannounced inspection visit the deputy manager visited and assessed a prospective person in the local hospital. Discussions with staff and people living at the home indicated that only appropriate people are admitted to the home whose needs could be met. The home has a range of moving and handling equipment and provides relevant training to ensure staff have the skills to meet peoples needs. The manager identified in the Annual Quality Assurance Assessment that when new people are admitted an additional staff member is provided to help them settle in and explain any routines or answer questions. This ensures that existing people continue to receive the care they require. The manager stated in the Annual Quality Assurance Assessment that she intends to produce a large print general information sheet that can be provided to all new people. DS0000068846.V339704.R01.S.doc Version 5.2 Page 10 DS0000068846.V339704.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. People’s health, personal and social care needs are set out in an individual plan of care and are appropriately met. Medication is appropriately stored and administered. People are treated with respect and their right to privacy and dignity is respected. EVIDENCE: The inspector viewed care plans and risk assessments and discussed these with care staff and with people living at the home. Everyone living at the home has a care plan. Care plans are produced initially from the pre-admission assessment and compiled onto preformatted record sheets that have space for additional individual needs and reviews. Care plans seen appeared relevant to the pre-admission assessments. People living at the home stated that they were aware of care plans. Also contained with care plans were relevant risk assessments in respect of moving and handling, falls, DS0000068846.V339704.R01.S.doc Version 5.2 Page 12 pressure areas and other specific risks pertinent to the individual. The inspector noted that one care plan identified that a person was no longer able to stand and should only be hoisted however a new risk assessment had not been completed. The deputy manager did this during the inspectors visit so a requirement is not made, however the home should ensure that new risk assessments are completed if identified needs/risks change. Care plans are reviewed monthly. Included with care plans were recordings made by senior care staff and any observations relevant to the person. People stated that they felt their care needs were met. The manager identified in the Annual Quality Assurance Assessment that the home intended to employ additional ancillary staff specifically to undertake laundry and servery duties, which are currently undertaken by care staff. This would then increase time for care duties. People living at the home and their relatives stated that they felt their healthcare needs were met. A section of the care plan contains a record of medical visits. People are able to remain with their own GP if they previously lived in the area, people moving to the area whose GP is unable to continue to provide a service due to locality, are registered with a local GP who visits as requested by the home. People may also be supported to attend appointments at the local health centre. The inspector telephoned the local health centre and spoke with a health professional who has regular contact with the home who stated that the home contacts health professionals appropriately and that the health team have no concerns in respect of the home. The home has a visiting chiropodist and can arrange dental and opticians if required. Care staff stated that they felt they had the necessary training to meet people’s needs. The home has a range of equipment for moving and handling and is aware of the risks of pressure injuries. The homes diary listed physiotherapy, GP and hospital appointments for various people. People living at the home and their relatives stated that they are treated with respect and dignity. Care staff confirmed that this is discussed during their induction. During the inspectors visit the atmosphere in the home appeared relaxed with staff happy and observed to be interacting positively with the people who live in the home. Interactions were initiated by staff and also by the people who live at the home. People living at the home able to voice an opinion stated that the staff were very nice. People unable to voice an opinion appeared relaxed and at ease when staff approached them. All bedrooms are for single occupancy, except where married couples have requested twin bedrooms, ensuring privacy during personal care. The inspector viewed the arrangements for the storage and administration of medication and the records of medication administered to people living at the home. Storage arrangements were appropriate with the relevant records maintained for the receiving of medication into the home and that returned to the pharmacy when no longer required. Medication administration records were DS0000068846.V339704.R01.S.doc Version 5.2 Page 13 seen to be fully completed with no gaps. Medication is always administered by senior care staff who have received additional training and been deemed competent. The home would support people to self administer and retain control of their medication if risk assessment indicated this was appropriate and all bedrooms have a suitable lockable drawer in which medication could be safely stored. The new owners have provided a new medications trolley, which staff stated is easier to move around the home and does not take up so much space in the corridors. DS0000068846.V339704.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. People find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious interests and needs. People are able to maintain contact with family and friends and exercise choice and control over their lives. A wholesome, appealing, balanced diet is provided in pleasing surroundings. EVIDENCE: People stated that the home provides various activities that they can choose to join or not. The inspector saw a notice about a forthcoming outing to which people had signed up for. People confirmed that there are outings approximately once a month with the manager stating that a minibus is hired by the home and staff provided. The choice of outings offered is discussed with people who are able to say what they would like to do. People stated that they enjoy outings. The home also provides some in house activities with people stating that card games, board games, quizzes etc are organised by a part time activities organiser who also undertakes a weekly session to ensure that DS0000068846.V339704.R01.S.doc Version 5.2 Page 15 people are aware of their rights in respect of various aspect of the home such as complaints. The manager identified in the Annual Quality Assurance Assessment that additional activities and 1-1 time will be possible once the new ancillary staff described in the earlier section of this report have commenced employment. Information was seen in care plans about hobbies and interests. The home operates a trolley shop at weekends for people to purchase small items or personal treats. The home would support any religious beliefs and practises. A monthly Church of England communion service is held with individual services for people who are catholic. People confirmed that they are able to have visitors and names of visitors were seen written in the homes visitors book. The home has a main lounge and a smaller upstairs lounge that can be made available for private visits if required. The inspector was able to speak with some visitors who confirmed that they are able to visit at any reasonable time, made welcome by staff and able to visit in private if they so wish. Visitors are able to stay for a meal if they so wish. Some people living at the home have electric scooters and the home plans to provide a tarmac area with recharging power points to the side of the house. People were overheard informing staff they were going out for a walk. People the inspector spoke with stated that they are able to make choices and decisions about the time they get up and go to bed, where and how they spend their time or have their meals. As stated the home has introduced a weekly session run by the activities person to ensure that people living at the home are aware of their rights and have an opportunity to have a say about the home. The inspector observed the main lunchtime meal and discussed food with people living at the home. They stated that the food was good and they were able to make a choice. Relatives are able to join people for a meal. Meals seen were well presented with sufficient staff to support people requiring assistance. Fluids were provided with meals and hot and cold drinks provided throughout the day. The home would be able to meet any special diets (therapeutic or cultural) that may be requested. The home has a large dining room with small tables seating about four people. People are able to choose where to eat and some choosing to remain in their rooms. The homes chefs were seen serving the lunchtime meal in the dining room and would therefore receive immediate feedback from people who appeared to be enjoying their meal. DS0000068846.V339704.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 an 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their relatives are able to complain and are confident that their complaints will be listen to and acted upon. People are protected from abuse. EVIDENCE: The home provides people with information as to how to complain in the service users guide and this has been included in the rights sessions undertaken at the home. The home maintains a record of complaints, which showed that two complaints had been received since the new owners registered the home in December 2006. These had been fully investigated and upheld. The inspector discussed these with the manager and appropriate action had been taken to resolve the concerns including the recruitment of a specific laundry staff member. Care staff spoken with during the inspectors visit were aware of what they should do if a person or their relative wished to complain. People living at the home or their visitors had no complaints to raise at the time of the inspectors visit and stated that they felt that any complaints would be treated appropriately by the home. Safeguarding adults is covered in the homes induction training with further information in the staff handbook. Staff spoken with confirmed that they had undertaken training and identified that they would raise any concerns with the DS0000068846.V339704.R01.S.doc Version 5.2 Page 17 senior in charge or the manager. The manager has an open door policy for staff to report any concerns. Previous actions by the home indicate that any concerns in respect of vulnerable people will be reported to the local authority and the commission. The home has introduced new procedures in respect of people’s personal money such that any additional services, chiropody, hairdressing and the trolley shop are now invoiced to people at the end of the month eliminating the need for people to hold larger sums of personal money at the home. The inspector viewed invoices for the trolley shop which detail exactly the items people have purchased. A lockable facility is provided in all bedrooms. The home has appropriate recruitment procedures, which should prevent unsuitable people being employed at the home. DS0000068846.V339704.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, well maintained, safe environment appropriate for their collective and individual needs. EVIDENCE: During the unannounced inspection visit a tour of the home was undertaken with the deputy manager and the inspector was able to move around the home on her own. All communal areas and some bedrooms were seen, as were the garden, laundry and kitchen. The premises has operated as a care home for a number of years and over time has been adapted and extended to meet peoples needs. The home is well maintained with a planned programme of redecorating before a new person moves in. Since the new owners purchased the home financial investment and improvements in the environment has been ongoing. Brighter lighting has been provided in the corridors and hallways. An DS0000068846.V339704.R01.S.doc Version 5.2 Page 19 office on the second floor has been converted into an additional bathroom that is large and spacious, equipped with a bath hoist. Several bedrooms have been completely redecorated and recarpeted with coordinating soft furnishings. New garden furniture and a gazebo have been provided. Laundry facilities have been improved with the addition of an extra washing machine and dryer. At the time of the unannounced inspection a second bathroom was being refurbished and the manager identified that the ground floor bathroom is to be made into a shower room. The manager stated in the Annual Quality Assurance Assessment that further improvements to the environment are planned including tarmac to the front drive to make the home more accessible for people using wheel chairs or frames (at present the drive is gravel). Also planned is complete redecoration and refurbishment of the lounge, two bedrooms to have new en-suites, a new external stairway to the first floor balcony, the kitchenette off the dining room to be enlarged and bedrooms to be redecorated as required. The home employs a maintenance person and gardener. All bedrooms are for single occupancy although twin rooms can be provided for married couples or people specifically requesting to share. Many have en-suite facilities of at least a WC and washbasin. All are fitted with a call bell system. Bedrooms are redecorated between long-term use and sometimes during if people are resident for a prolonged period of time. People stated they are happy with their private accommodation. The manager stated that when rooms become vacant these are offered to existing people if they wish to move to an alternative room, before being offered to new referrals. People confirmed that they had been offered or moved rooms since admission. The home provides a range of communal facilities appropriate to the people living at the home and equipped with the necessary furnishings. The home has a well-maintained accessible patio and garden and a balcony on the first floor. A gazebo in the garden and canopy on the balcony provides protection from the sun. The home does not allow smoking in the home and this is stated in the service users guide. On the day of the inspector’s unannounced visit the home was very clean and there were no offensive odours. People confirmed that this is always the case. The home employs dedicated domestic staff. Supplies of disposable gloves were seen and staff confirmed that they have received infection control training. Dissolvable bags are used for soiled laundry to eliminate the need for laundry staff to handle this although gloves are available in the laundry room. DS0000068846.V339704.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. People’s needs are met by staff who are provided in sufficient numbers, have been appropriately recruited, inducted and trained and are competent to do their jobs. EVIDENCE: The inspector viewed duty rotas and discussed the staffing arrangements with people who live at the home, care staff and the manager. Recruitment files were viewed. People living at the home and their relatives stated that staff are competent, helpful and provided in sufficient numbers to meet their needs. They stated that staff are cheerful and friendly and praised them. In addition to appropriate numbers of care staff the home has a full complement of ancillary staff, part time activities person and the manager are is also available weekdays daytime. The home has a deputy manager who generally works morning shifts but can cover other times and a training manager. The manager is available on-call for ad-hoc advice and support to staff when she is not at the home. People living at the home and their visitors DS0000068846.V339704.R01.S.doc Version 5.2 Page 21 stated that they felt that sufficient staff were available at the home. Care staff stated that they had sufficient time to meet people’s needs. The manager has been proactive in respect of staffing arrangements in the decision to appoint a dedicated laundry and servery person and additional kitchen staff. This will ensure that care staff are able to concentrate on care related work. The manager identified that the home has good staff retention. The inspector viewed the recruitment files of newly recruited staff. The evidence seen in recruitment files indicated that full and comprehensive recruitment procedures, including all the required pre-employment checks and induction had been undertaken. This should ensure that only appropriate people are employed at the home. The home undertakes an induction programme for all care staff and an in-house induction for other staff. The homes training manager is able to provided supervised practise as part of the induction process. The manager supplied the inspector with a copy of the homes information about the National Vocational Qualifications in Care passed by care staff employed at the home. This stated that of twenty-six care staff employed, twenty have either got or are undertaking an NVQ. This equates to approximately seventy-seven per cent of care staff having a relevant qualification. The home also supports training of ancillary staff with a new kitchen trainee undertaking HTP training in catering. The homes new deputy manager stated that she is undertaking NVQ level 4 training and will follow this with the Registered Managers Award. The deputy has attended other relevant training including a study day on the new Mental Capacity Act. The home employs a training manager who coordinates and provides a range of mandatory and specific training relevant to the needs of the people at the home. The training manager was not present on the day of the unannounced inspection visit and provided a staff training plan for 2007 following the inspection. This indicated that all care staff will complete mandatory training throughout the year. The manager identified some additional training such as dementia training that is to be organised, as the home is increasingly being referred people with this condition. The manager stated in the Annual Quality Assurance Assessment that it is made clear to all staff at interview that they are expected to attend training relevant to their role. The manager also stated that the training manager is able to undertake specific 1-1 training should a specific need be identified for individual staff. Care staff confirmed they received training and that they felt they had the necessary skills to meet people’s needs. DS0000068846.V339704.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, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements within the home ensure that peoples needs continue to be met and creates a homely atmosphere in which people feel valued and well cared for. The home must ensure that weekly checks of fire detection equipment are undertaken and recorded and it is recommended that automatic door closure devices are fitted to people’s bedrooms who wish to keep their doors open. EVIDENCE: People living at the home were positive about the manager and stated that they felt able to discuss any concerns or care issues with her if required. All DS0000068846.V339704.R01.S.doc Version 5.2 Page 23 staff were equally positive and also stated that should they have any problems or concerns they would approach the manager. The manager has been the homes registered manager for the past eighteen years and has gained the NVQ level 4 in Care, Registered managers award and attended regular relevant training to keep her up to date in issues affecting older people and the provision of care in a residential setting. The home now has a management structure with deputy manager, training manager and senior care staff. The home has part time administration support allowing the manager to focus on care related management issues. The home has quality assurance procedures both in house and has monthly regulation 26 visits from the provider. The Annual Quality Assurance Assessment was completed to a very high standard and demonstrated that the home has actively considered how the service can be improved and taken relevant steps to implement changes. The manager stated that she has visited other homes owned by the new provider and is incorporating positive aspects of these services into the home. The manager identified further improvements that she hopes to make in the future and these would appear to be to the benefit of both people living at the home and staff. The home has regular service users meetings with minutes maintained. As previously stated the home does not hold money on behalf of people who live at the home or become the appointee for anybody. Any services for which there may be an extra charge are invoiced monthly, invoices were seen and detail additional costs such as chiropody and hairdressing. During the inspectors visit to the home a number of records were viewed and have been identified in the relevant sections of this report. These were generally maintained to a high standard and stored appropriately. The inspector viewed the records of the weekly check of the fire detection equipment and this indicated that these were not been done on a weekly basis, also that the checks of fire exit routes were not being undertaken as the homes records indicated they should be. The home has a designated person to undertake these tasks and the manager is to determine if the missed weeks were due to holiday or missed due to excessive demands on his time. The manager must ensure that if the designated person is not able to complete these checks that another person does them. Whilst talking to some people who live at the home they stated that they usually keep their bedroom doors open with inappropriate items to prevent them closing and that staff had informed them that the inspector was visiting and their doors would have to be closed. The inspector discussed this with the manager who stated that many doors have been fitted with automatic door closure devises and would ensure that these are fitted to any other doors that are kept open by people. DS0000068846.V339704.R01.S.doc Version 5.2 Page 24 DS0000068846.V339704.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X 2 2 DS0000068846.V339704.R01.S.doc Version 5.2 Page 26 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. Standard OP37 Regulation 23 (4)(c)(v) 23 (4)(c)(i) Requirement The home must ensure that the weekly checks on the fire detection equipment are undertaken and recorded. Bedroom doors must not be held open with inappropriate items. Timescale for action 01/07/07 2. OP38 01/07/07 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 The home should consider fitting automatic door closure devises to any bedroom doors people like to keep open. DS0000068846.V339704.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000068846.V339704.R01.S.doc Version 5.2 Page 28 - 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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