Inspection on 03/12/08 for Old Shenfield Place

This inspection was carried out on 3rd December 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Old Shenfield Place 02/12/09

Old Shenfield Place 31/07/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Old Shenfield Place 2 Hall Lane Shenfield Essex CM15 9AB     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Michelle Love     Date: 0 3 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Old Shenfield Place 2 Hall Lane Shenfield Essex CM15 9AB 01277220636 01277223638 shenfield@ardtully.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Jeanette Stapley Type of registration: Number of places registered: Mr Rajan Dhirjal Madlani care home 31 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Old Shenfield Place is an attractive 17th century building, which has been renovated and refurbished to provide comfortable accommodation for 31 older people. There is a choice of three lounges, a dining room and a visitors room. 21 bedrooms are single and five are double. The majority of rooms have an en-suite hand washing and WC facility. A separate hairdressing room is available. The gardens are well maintained and accessible to residents. To the front of the house there is limited space for car parking. Old Shenfield Place is situated close to local shops, bus and train services. The home has use of a mini bus for outings. The current weekly fees are from 580.00 for a twin room en suite, from 680.00 for a single room en suite, from 710.00 for a bed-sit and 775.00 for a twin room en suite single occupancy. 0 Over 65 31 Care Homes for Older People Page 4 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection. The visit took place over one day by one inspector and lasted a total of 8.15 hours with all but one key standard inspected. Additionally the managers progress against previous requirements and recommendations from the last key inspection were also inspected. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used throughout the main text of the report. Prior to the site visit, surveys for relatives, staff and healthcare professionals were forwarded to the home for distribution and for people to complete and return to us. Where surveys have been Care Homes for Older People Page 5 of 30 returned to us, comments have been incorporated into the main text of the report. The manager and members of the staff team assisted the inspector throughout the inspection. Feedback on the inspection findings, were given as a summary to the manager. The opportunity for discussion and/or clarification was given. As a result of concerns relating to a lack of appropriate risk assessments and care plans not being reviewed and updated regularly, a Serious Concern letter was forwarded to the registered provider. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 7 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 8 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an appropriate process in place for assessing the needs of prospective residents, however, people cannot be assured all of their care needs will be recorded. Evidence: There is a Statement of Purpose and Service Users Guide in place for Old Shenfield Place. This provides specific information about the service so that prospective residents have the information they need so as to make an informed choice as to whether or not this is the right care home for them. There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective residents needs. In addition to the formal assessment procedure, supplementary information is sought from the individual residents placing authority and/or hospital. Care Homes for Older People Page 9 of 30 Evidence: As part of the inspection process, two care files for the newest people to be admitted to Old Shenfield Place were examined. These showed that pre admission assessments were completed prior to their admission to the care home. The pre admission assessment for one person was noted to be relatively informative, however the pre admission assessment for the other person was noted to be incomplete and lacking detail. It was unclear from the documentation available as to how the decision was reached by the person undertaking the assessment that the needs of the latter could be met, based on the information recorded. There was little evidence to show that the pre admission assessment process had been conducted with the resident and/or their representative or that the person had been offered an opportunity to visit the home prior to admission. From discussion with one resident, they confirmed to us they had not visited the care home prior to admission but their next of kin had undertaken this on their behalf. The next of kin confirmed they had been provided with a copy of the homes Statement of Purpose. The manager advised that all prospective residents are visited and assessed either within their own home environment, in hospital and with a friend and/or next of kin present. We were also advised that wherever possible the potential resident is invited to spend a day at the care home, so as to meet other people who live at Old Shenfield Place, to experience a day in the life of a residential care home and to meet staff and the management team of the home. The home does not provide intermediate care. Care Homes for Older People Page 10 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Shortfalls within some aspects of the care planning processes and medication practices and procedures, potentially places people at risk of not having their care and health and wellbeing needs met. Evidence: As part of this inspection, a random sample of 5 care files were examined. Records show there is a formal care planning system in place to help staff identify the care needs of individual residents and to specify how these needs are to be met by care staff. Additionally, formal assessments relating to manual handling and pressure area care were also completed for individual people. Staff surveys returned to us confirmed that staff felt they were given sufficient information about people admitted to the care home. Records show that in general terms the care plans for individual people were seen to be informative, detailing their individual care needs and how these needs are to be met by care staff. However, records show that further development of the care Care Homes for Older People Page 11 of 30 Evidence: planning and risk assessment process is required as shortfalls identified, potentially place people at risk of not having all of their care needs met and provides staff with inaccurate and not up to date information about individual people who live at Old Shenfield Place. Records showed of those care files examined, none of these had been regularly reviewed and updated to reflect the most up to date information about the individual resident. For example the care file for one person made reference to them requiring the regular use of oxygen. Daily care records detailed on occasions that this person could refuse to use their nebuliser however this was not updated and reflected on their care plan. Following discussions with the manager, we examined the care file for two people who had pressure sores/ulcers. No care plan was devised for one person pertaining to their pressure area care, however on inspection of healthcare records these evidenced regular interventions/visits by specialist healthcare professionals for an approximate period of 3 months. The care plan for the other person recorded them as having ulcers and requiring regular healthcare interventions and their daily care records and specialist healthcare records detailed the persons wounds had deteriorated over a period of time, however this had not been updated and/or reflected within the persons care file. Daily care records recorded on several occasions that the person experienced pain, that their mobility was poor and legs continue to smell. However there was little evidence detailing staffs interventions. Although records did not accurately reflect the care provided to individual people living at the care home, the actual delivery of care provided to individual residents by care staff was observed throughout the site visit to be person centred, individualised and with due respect and dignity to people living at the care home. Following discussions with individual members of care staff/senior care staff and the management team of the home, we were assured that staff were knowledgeable and understanding of individuals care needs, including their personal preferences, likes and dislikes. People spoken with during the inspection were very positive about the care provided by individual members of staff and confirmed that their care needs were met in a timely manner. Comments included, the staff are lovely, theyre very attentive and you want for nothing, the girls are very caring. Two relatives spoken with were also very complimentary about the staff/care provided and these included, the care is second to none and my relative is well cared for and I couldnt wish for anything better. Of those care files examined, no risk assessments were devised, identifying specific areas of risk and how these were to be minimised/proactive steps to be taken to minimise the risk. This was highlighted at the previous key inspection to the home. This lack of a thorough assessment, means the resident may be at potential risk of not having their care needs met. The daily care records for one person recorded them as Care Homes for Older People Page 12 of 30 Evidence: having several falls/found on the floor, however no risk assessment was devised and implemented. As stated previously records showed that all care files examined had not been reviewed and updated regularly and in some cases had not been reviewed since July and August 2008. At the last key inspection to the home (July 2007), a statutory requirement was made detailing, the care plan must be kept under review and changed in consultation whenever there is a change in need, with a timescale of 31/10/07. The response by the registered provider recorded this as completed December 2007/January 2008 and on-going. It was evident at this inspection that the above had not been met and remains outstanding. One staff survey returned to us recorded, our care plans are updated every month. This did not concur with the inspectors findings. As a result of concerns relating to a lack of risk assessments and care plans not being updated/reviewed regularly to reflect the most up to date information, a Serious Concern letter was forwarded to the registered provider following the inspection. A response was received from the registered provider advising us of measures put in place with immediate effect to address the identified shortfalls. Progress to meet compliance will be examined at the next inspection to the home. Medication practices and procedures were examined within the home. Storage systems within the care home were observed to be appropriate and secure. Additionally, the administration of medication was observed both at lunchtime and teatime and this was seen to be safe and appropriate. On inspection of Medication Administration Records (MAR) evidence showed a number of shortfalls. These refer specifically to some people not having their prescribed medication administered as waiting for prescription and would not wake up/sleeping and where the medication dose can be variable (1 or 2) the specific dose was not always recorded. Additionally the MAR record for one person showed a discrepancy whereby the quantity of medication received pertaining to an antibiotic did not tally with the amount of medication administered. The MAR records for one person showed they administered their own medication. Whilst we recognise that a risk assessment had been devised, this was dated September 2007 and there was no evidence to show this had been reviewed and updated to reflect their continued competence to administer their own medication. On inspection of the residents medication storage facilities in their room, medication was observed to be stored safe and secure. All staff who administer medication have undergone medication awareness training Care Homes for Older People Page 13 of 30 Evidence: and the advanced medication training delivered by Boots. The training matrix for 2009 showed that training is planned for some staff members in January, February and March 2009. We were advised that the training manager commenced annual medication administration assessmentsfor staff in February 2008. It is recommended that competency assessments for staff are undertaken more regularly. Records for controlled drug medication for individual residents were inspected and these showed that records and actual medication available tallied. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the care home can be assured that their social care needs and dietary needs will be well managed. Evidence: All staff working within the care home are responsible for ensuring that residents participate within a varied programme of social activities. The manager advised that 3 planned activity sessions are planned per week on Tuesday, Wednesday and Thursday and once fortnightly an external entertainer provides entertainment at the home. On the day of the site visit, staff were observed to undertake a quiz in the afternoon and this was followed by several residents enjoying some gentle exercises. Throughout the day residents were observed to read newspapers, read books, to chat with others (residents and staff) and to knit. An activity information sheet is completed for each resident and activities available for people included games, quizzes, physical exercises, newspapers, bingo, skittles, dominoes, listening to music, watching television/films, manicures and religious observance etc. Additionally a record detailing activities/events planned for the week was noted to be displayed. Residents spoken with confirmed they were happy with the Care Homes for Older People Page 15 of 30 Evidence: range of activities provided and felt they were able to exercise choice and some control over their lives. For example two residents confirmed they are able to get up/retire to bed when they choose, whether or not they participate with social activities, where they choose to have their meal etc. In addition to the above activities a hairdresser visits the care home once weekly. There is an open visiting policy at the care home, whereby visitors can see their member of family and/or friend at any reasonable time. There was evidence to show that people living at the care home are actively encouraged and supported to maintain friendships and relationships. Relatives spoken with confirmed that they are made to feel welcome by staff and the management team of the home. The manager advised that the menu is planned 7-10 days in advance by the chef. Records showed that residents are provided with a varied menu, with alternatives readily available as and when required. Several residents spoken with were able to advise us of the choices available for both the lunchtime and teatime meals. Meals provided to residents were attractively presented and portions of food seen to be plentiful. The dining experience for residents was observed to be positive and staff worked efficiently as a team to ensure that residents received their meals promptly. Staff were observed to interact well with residents and to assist them with support where required that was both respectful and sensitive. Residents comments pertaining to meals provided included, the food is very good here, I have no complaints about the food and it is all very very good. Prior to the lunchtime and teatime meals residents are offered pre dinner drinks i.e. wine, sherry, beer, baileys and soft drinks. Care Homes for Older People Page 16 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect that their concerns are dealt with proactively and that they will be listened to. Evidence: There is a complaints policy and procedure in place. On inspection of the complaints procedure, this needs to be amended to reflect that the Commission for Social Care Inspection no longer investigates complaints. Residents spoken with confirmed that should they need to make a complaint, they would discuss this with the manager or another member of staff. Relatives confirmed they felt assured that any issues raised would be dealt with effectively by the management team of the home. On inspection of the complaints log, records showed that since the last key inspection there have been 7 complaints. There was evidence to show that complaints received relate to the conduct of some staff members/staff disputes, staff attitudes towards some residents and a medication error. There was evidence to show the specific nature of each complaint, action taken and investigation undertaken, however outcomes were not always recorded. It was disappointing that only 1 record of compliment was readily available. This recorded, thank you for everything that you have done for [name of resident]. Since the last inspection there have been no safeguarding issues highlighted. Care Homes for Older People Page 17 of 30 Evidence: Appropriate policies and procedures were available pertaining to safeguarding and staff spoken with, were able to demonstrate an understanding and awareness of safeguarding procedures. The training matrix showed that all staff working within the care home have received training relating to safeguarding. Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, comfortable, homely and well maintained environment which meets their needs. Evidence: A partial tour of the premises was undertaken during the site visit. The home is well maintained, decorated and furnished to a good standard. All communal areas of the home were observed to be comfortable and homely and since the last key inspection the main lounge, small lounge, main reception area and dining room have been redecorated. All areas of the home were observed to be clean, tidy and odour free and no health and safety issues were highlighted at this inspection. A random sample of residents bedrooms were inspected and all were seen to be personalised and individualised with many personal items on display. Since the last key inspection several bedrooms have been redecorated and new curtains, furniture and carpets have been purchased. Residents spoken with, all confirmed that they liked their personal space and found the home environment warm, inviting and to their liking. A maintenance person is employed at the care home Monday to Friday between 08.30 a.m. and 17.00 p.m., however these hours are flexible to cover evenings and Care Homes for Older People Page 19 of 30 Evidence: weekends. A random sample of maintenance certificates were inspected relating to fire equipment, gas and electrical safety installation certificates, fire alarms, emergency lighting etc and all were seen to be regularly serviced. The training matrix evidences that the maintenance person has up to date training relating to manual handling, health and safety, infection control and fire awareness, with updates due in 2009. Care Homes for Older People Page 20 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The level of staffing and staff deployment ensures the ability of the service to deliver person centred care and to ensure that peoples care needs can be met. Some gaps in recruitment processes and staff training mean that residents are not safeguarded and staff working at the care home may not have the necessary skills to meet the assessed needs of residents. Evidence: The staffing levels at the home as advised by the manager are, 4 staff between 07.00 a.m. and 14.00 p.m. and 1 senior member of staff between 07.00 a.m. and 14.30 p.m., 3 staff between 14.00 p.m. and 21.00 p.m. and 1 senior member of staff between 14.00 p.m. and 21.30 p.m. and 1 senior and 2 staff between 21.00 p.m. and 07.30 a.m. each day. The managers hours are supernumerary to the above. Additionally a variety of ancilliary staff are employed and these include a chef, housekeepers and a laundry person. On inspection of 4 weeks staff rosters these evidence that staffing levels as detailed above have been maintained. Staff deployment throughout the inspection was observed to be appropriate for the numbers and needs of current residents living at Old Shenfield Place. The manager advised that occasionally agency staff are utilised at the care home to provide cover for staff sickness/staff annual leave. Care Homes for Older People Page 21 of 30 Evidence: The staff files for 3 members of staff were examined at this site visit. The majority of records as required by regulation were available, however some shortfalls were identified. These related to the employment history for two people not fully explored, one written reference for two people, no proof of identification for one person and no evidence of a criminal record bureau check (CRB) for one person. Records of induction were not in line with Skills for Care. The training matrix (2008) provided to us showed some training deficits for staff pertaining to both core subject areas (health and safety, food hygiene, COSHH, infection control etc) and those conditions associated with the needs of older people (nutrition, pressure area care, Parkinsons disease, sensory impairment etc). The manager advised that the majority of training is organised internally by the organisations training manager. A training schedule for 2009 for staff was readily available and this included both core and specialist subject areas. At the time of the site visit, 9 people had attained NVQ Level 2, 1 person was completing NVQ Level 2 and 6 people had achieved NVQ Level 3 with a further 5 people having a qualification which is deemed equal to NVQ Level 3. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst management arrangements in some areas are good, shortfalls identified could potentially affect positive outcomes for the people living at the care home. Evidence: The manager has over 18 years experience within a care field setting and has been employed at Old Shenfield Place for several years. The manager was the deputy manager for approximately three and a half years prior to taking the managers post in July 2007. The manager has achieved NVQ Level 3 and is currently working towards achieving their NVQ Level 4/Registered Managers Award. In addition to the above formal training, the manager advised that she also undertakes both core and specialist subject training alongside other staff members. The manager advised that the ethos of the home is, to provide quality care and to ensure that the residents at the home are happy, content and well cared for. Residents and relatives spoken with during the inspection were very complimentary Care Homes for Older People Page 23 of 30 Evidence: about the care provided and the quality of the staff team at Old Shenfield Place. Staff surveys returned to us recorded under the heading of what does the service do well, care for the residents with compassion and understanding, everything that is required and give the residents a safe happy and friendly home. They are well cared for with all their care needs. The manager advised that staff morale within the home is very good and that there are positive relationships between staff, residents and other parties. One healthcare professional survey returned to us recorded, an exceptionally well run and friendly residence showing great regard to residents and staff alike. Whilst we recognise there are some positive aspects of the service which promote positive outcomes for people living at the care home, shortfalls identified include further development relating to risk assessing/reviewing and updating of the care plan, medication practices and procedures, ensuring all records as required by regulation are in place pertaining to staff files, that all staff have up to date training and regular supervision. Information relating to the services quality assurance were requested. We were advised that questionnaires were circulated to all residents, staff and residents next of kin/representatives in 2008 and people were requested to make comments on care plans, communication, nutrition and general wellbeing. We were advised that responses from relatives were disappointing with only 12 out of 23 questionnaires being returned. The main findings were that there was room for improvement pertaining to communication, residents relatives/representatives to be encouraged in the care planning process and changes required to the menu. The manager advised that staff meetings are held every 8-10 weeks and records to confirm this were readily available. From discussion with the manager and on examination of a random sample of staff supervision records, evidence showed that staff are not receiving supervision in line with National Minimum Standards recommendations. This refers specifically to the staff file for one person evidencing that they had not received supervision since June 2008 and another file recording one persons last supervision as April 2008. Additionally on inspection of the managers file, there was only evidence of one supervision having taken place since their appointment as manager in July 2007. The manager confirmed that regular supervision for staff needs to be improved. There is a folder of policies and procedures currently available within the home. Care Homes for Older People Page 24 of 30 Care Homes for Older People Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 7 15 The registered person must 31/10/2007 ensure that a comprehensive care plan is devised in consultation with the resident concerned or there representative and that this is centred on their personal support needs. The care plan must be kept under review and changed in consultation whenever there is a change in need. Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Care planning at the home must identify, and be effective in meeting all residents assessed needs and ensure these are regularly updated and reviewed to reflect the most up to date information. This will ensure that staff have the most up to date information and can provide appropriate care to meet their needs. 06/01/2009 2 7 13 Risk assessments must be devised for all areas of assessed risk so that risks identified can be minimised. Records must be explicit, detailing the specific risk, how this impacts on the person and steps taken to reduce the risk. This will ensure that risk areas are identified and staff are aware of the associated 06/01/2009 Care Homes for Older People Page 27 of 30 risks to residents health and wellbeing. 3 9 13 Residents must be protected 06/01/2009 from harm by having their medication administered safely and in accordance with the prescribers instructions. So as to ensure residents safety and wellbeing. 4 29 19 Ensure that robust recruitment procedures are adopted at all times and all records as required by regulation are sought. This will ensure that residents and others feel assured that they are safeguarded by the homes procedures. 5 30 18 Staff receive appropriate training to the work they perform. This will ensure that staff, have the competence, confidence and ability to meet residents care needs and people living at the care home will feel assured that their care needs will be met by suitably trained staff. 6 36 18 Ensure that staff, receive regular supervision. So that staff feel supported and residents know that staff are appropriaetly managed. 06/01/2009 06/01/2009 06/01/2009 Care Homes for Older People Page 28 of 30 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 3 All elements of the pre admission assessment should be completed, so as to determine that the needs of the prospective resident can be met. Daily care records should include details of staff interventions. Amend the complaints procedure to reflect that the Commission for Social Care Inspection no longer investigates complaints. The outcome of individual complaints should be clearly recorded. 2 3 7 16 4 16 Care Homes for Older People Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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