Inspection on 14/08/08 for Olivet Christadelphian Care Homes

This inspection was carried out on 14th August 2008.

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

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

Other inspections for this house

Olivet Christadelphian Care Homes 05/09/06

Olivet Christadelphian Care Homes 30/11/05

Olivet Christadelphian Care Homes 19/07/05

Olivet Christadelphian Care Homes 07/01/05

Olivet Christadelphian Care Homes 15/06/04

Olivet Christadelphian Care Homes 17/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Olivet Christadelphian Care Homes 17 Sherborne Road Acocks Green Birmingham West Midlands B27 6AD Lead Inspector Karen Powell Unannounced Inspection 14th August 2008 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Olivet Christadelphian Care Homes DS0000024873.V369667.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. Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Olivet Christadelphian Care Homes Address 17 Sherborne Road Acocks Green Birmingham West Midlands B27 6AD 0121 683 8700 0121 683 8701 rosehanson@cch-uk.com www.cch-uk.com Christadelphian Care Homes 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) Mrs Christine Furniss Care Home 65 Category(ies) of Dementia - over 65 years of age (65), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60), Sensory Impairment over 65 years of age (60) Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of beds is 65, of which up to 36 may be for nursing care and up to 34 for residential care. Males and females over the age of 65 years That one named service user under the age of 65 can be accommodated and cared for within this home for reasons of old age 5th September 2006 Date of last inspection Brief Description of the Service: Olivet provides nursing and residential care for up to 65 persons of 65 years of age or above and the service is exclusively offered to those of the Christadelphian faith. The home is situated on a site that also provides sheltered housing and operates as part of the Christadelphian Nursing and Residential Care Organisation and has other establishments around the country. There is sufficient off road parking for 27 vehicles as well as a dedicated space for the visiting GP. The home has an attractive enclosed garden area to the rear of the property, which resident’s have access to. The premises are close to public transport links to the city centre and within walking distance of a range of local amenities. Nursing and residential areas are located in separate wings of the building; the nursing area is a recent build and has a dedicated section for care of those suffering from dementia. The home has two shared rooms with en-suite facilities. One is currently used as a single room. The remaining single rooms, with the exception of one room have en-suite facilities and these have recently been upgraded to include a walk in shower facility. Each wing has a lounge and there are a number of dining and bathing areas, the home also has on site kitchen and laundry facilities. The home has hoists and pressure relieving equipment available to meet the assessed needs of the residents at the home. There are assisted toilets and bathrooms available and corridors are wide and spacious and enable residents to move around the home freely with any mobility aids they require. Entrance to the home is via reception. Out of hours there is a phone available Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 5 and numbers to ring to gain access to the home and this ensures that staff are aware of who is entering the building, and this promotes the safety of residents. In the reception area, there are many biblical leaflets and copies of the homes Statement of Purpose and Service User Guide. Comment forms are also available for visitors to the home to complete if they wish. The current scale of charges for the home is £435.00 - £850.00 per week. Additional charges include hairdressing, chiropody, toiletries and newspapers. Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means that people who use this service experience excellent quality outcomes. The inspection was unannounced and took place on 14th August 2008 by one inspector over six and a half hours. A range of evidence was used to make judgements about this service to include discussions with people who use the service, the registered manager, staff on duty, a tour of the home and observation of care experienced by people using the service. We also looked at a number of records to include care records held on behalf of four people, staff training, recruitment and health and safety records. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the manager for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. Some of the manager’s comments have been included within this inspection report. The purpose of the inspection was to assess all ‘Key’ National Minimum Standards for older people and progress with requirements made at the last key inspection on 5th September 2006. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: People are assessed to ensure the home are able to meet their needs prior to admission. There is a comprehensive care planning and review system in place. The health care needs of people are met in a sensitive and professional manner. People who use the service told us they are respected and treated with dignity and their privacy is maintained. People are able to have flexible daily routines, social activities are tailored to meet individual needs. Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 7 The home has comprehensive policies and procedures in place that protect people from abuse and promote the legal rights of people using the service. There is a clear and accessible complaints procedure in place. People are encouraged to raise their concerns, complaints and compliments. The environment is well maintained, clean and tidy. The staff group are trained and supervised on a regular basis. The health safety and welfare of people living at Olivet Christadelphian Care Home is promoted by regular safety checks and maintenance of equipment. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 8 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. Olivet Christadelphian Care Homes DS0000024873.V369667.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 Olivet Christadelphian Care Homes DS0000024873.V369667.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): 3 Quality in this outcome area is excellent. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was stated in the AQAA when we asked the service what they do well in relation to this outcome group that “ a statement of purpose and residents guidance notes are given to prospective residents when they are visited and assessed in their own home to ensure their specific needs can be met by our home. A welcome pack is given out on admission and we publicise the home through leaflets and publicity meetings. We hold open days to give people the Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 11 opportunity to visit and see how the home is run we offer a respite service and prospective residents come for a trial period before making a final decision.” We spoke to someone who was happy to share with us their experience of moving into the home. They told us that they came in for a trial period before making a decision about moving in on a permanent basis. They liked the idea of being able to experience what living at the home was like before making a final decision about their long-term future care. We found that a comprehensive needs assessment had been carried out by the home. The care plan had been generated from the assessment of need. We saw evidence of the welcome pack and observed that the residents guide and statement of purpose were made available in the homes reception area. The Olivet garden party was held on the 12th of July, which was an open day where people enjoyed refreshments, games for the children were also provided. People who use the service told us how they enjoyed the day. The event was publicised in the Olivet news, a publication about interesting events and photograph’s of activities that have taken place at the home over the last few months. Olivet Christadelphian Care Homes DS0000024873.V369667.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 excellent. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has a plan of care in place. We examined the care plans of four people who live at the home. Care plans are clearly recorded and document peoples personal and health care needs and how they will be delivered. These Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 13 were signed by the person using the service or their representative. Care plans promoted peoples independence and described the things people are still able to do and activities they like to be supported with. It was considered that the requirement made at the last inspection which, stated “residents and/or their representatives must be involved in the agreeing of care plans” was met. Records of specialist health care visits were seen. There are regular in house visits from the doctor, dentist and chiropodist and residents can also make use of the in-house physiotherapist. Reviews are held regularly and care plans were seen to be a working tool, to ensure people receive effective personal and health care support tailored to suit their individual needs. The requirement made at the last inspection which, stated “all resident care plans must be reviewed at least monthly and this must include a written review of the care needs” was considered to be met. Aids and equipment were seen to be in place on the tour of the home to encourage maximum independence for people. It was stated in the AQAA that there is a policy for control, storage, disposal, recording and administration of medication, which was reviewed in 2007. Medication administration, recording, storage and disposal was discussed with the senior nurse on duty and considered to meet national minimum standards. The requirement made at the last inspection, which stated “quantities of all medicines received and balances carried over from previous MAR charts must be recorded” was considered to be met. We saw evidence of this on the medication administration records that we examined during the inspection. The requirement made at the last inspection which stated “protocols for when required medication should be written” was considered to be met at this inspection from an examination of individuals who take medication on a ‘ as required basis’. Observations and discussions with people using the service confirmed that people’s privacy and dignity is maintained. We observed care staff respectfully interacting with individuals. Evidence that privacy and dignity is considered when writing care plans were seen with examples such as “ ensure privacy and dignity is respected at all times.” “speak slowly and clearly giving x time to respond.” Olivet Christadelphian Care Homes DS0000024873.V369667.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 excellent. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides individual and group activities for people who live at the home. On the day of the inspection the reflexologist was providing individual leg massages, the hairdresser was visiting and the activities co-ordinator was Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 15 offering activities to people living at the home. One individual had been out for lunch with a friend. Through life story work the home obtains information about an individuals past life and an insight into interests and abilities when planning routines of daily living and arranging activities. The home view the life story books important to them and the people who use the service because as dementia progresses life story work helps care staff to see the person behind the dementia. There is an activities coordinator in post who arranges group activities and individual activities. An example of what the home provides include poetry classes, art classes, music and movement sessions and gardening activities. Activities are displayed throughout the home of forthcoming events. Pictures of activities that have taken place are displayed around the home. People living at the home told us “ there is always something to do here”, “ there is never a dull moment, there is always something on offer.” The AQAA stated being church based there is considerable involvement with social events and services” we saw activities relating to bible readings, and hymn singing. People living at the home and who may not be able to physically attend a service can use the facility of a link to their television, which transmits the service to their room. There is a welfare committee who visit and organise outings and social events. They recently organised a candlelit dinner in the dementia care unit. People living at the home, their family and staff enjoyed a three course meal together. The activities coordinator has painted two beautiful paintings in two of the bedrooms. The individuals had chosen pictures, which they liked. These were painted onto wall space and enhance and personalise the rooms. Routines of individuals living at the home were seen to be flexible, and observations and discussions with staff demonstrated that where possible people can make choices about daily activities. People who use the service receive a healthy, varied diet according to their assessed requirement and choice. The lunchtime meal was observed and was relaxed, choices were offered along with second helpings. Care plans documented likes and dislikes of people in relation to diet. Nutritional screening is undertaken. Special dietary needs are recorded in the care plan and reviewed. People spoken to told us the quality of food is good and choice is offered. Staff spoken to told us that the menu is on an eight week rolling programme. The home has taken considerable effort to ensure that they are able to display the menu in more than a written list. They have produced a pictorial booklet in addition to the printed weekly menu. Olivet Christadelphian Care Homes DS0000024873.V369667.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. 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 has policies and procedures in place relating to the protection of vulnerable adults This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a complaints procedure. The complaints procedure is available within the home and is also available in the service user guide given to all prospective service users. It was stated in the AQAA that no complaints have been received since last inspection. There have been no complaints received by CSCI since the last inspection. People spoken to during the inspection said they had no complaints that would know who to speak to if they had any concerns. People who use the service and family members are invited to meetings to discuss ideas and issues relating to the development of the service. One person said “that there is now a communication book in each room but I have no complaints this is a home from home.” Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 17 There are clear policies and procedures relating to abuse. Staff are trained in the topic of abuse. This ensures that people who use the service are protected at all times. Staff training records and discussion with staff evidenced this. There have been no safeguarding concerns raised relating to Olivet Christadelphian care home since the last inspection. A welfare group visit the home and each member befriends a number of people using the service. They will raise any concerns they have with the management team. The group act as independent advocates for people using the service. Information about other advocacy services are made available to people living at the home. People who use the service are supported to live as independently as possible, exercising their right to make choices and decisions with assistance when needed. The home encourages the right for all people to vote in elections whenever possible. A communication book is in place in all individual’s rooms to allow communication from staff to family/friends and vice versa. Olivet Christadelphian Care Homes DS0000024873.V369667.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 & 26 Quality in this outcome area is excellent. People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained; a full time handyman is in post and ensures the home is maintained to a good standard. A routine checking and maintenance programme is in place. A purpose-built dementia unit was opened in January 2007 equipped to cater for 18 individuals. The area includes a sensory garden in a secure environment. There are four lounges and all bedrooms have en suite bathrooms. The communal areas have all been redecorated during the year. Individual bedrooms are personalised with their own possessions and familiar items. The environment of the four people we case tracked were Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 19 looked at and were equipped as their care plans described. Lifts make all areas of the home accessible to all. Furniture and specialist equipment is provided to ensure individual’s needs are fully met and to maximise their independence. The grounds are well maintained and are used for a variety of purposes. There is a greenhouse for communal use, and people living at the home are encouraged to assist in the garden. The laundry is handled in a separate area in the home and there is a good infection control policy in place. We observed staff following infection control procedures during our visit. The home is clean and tidy and is maintained by a dedicated housekeeping team, who keep the home pleasant for the people who live there. People living at the home told us, “ the home is always clean and tidy” “ they clean my room every day” “my bed linen is changed regularly and my shower and bedroom is kept in tiptop condition” “I have been allowed to bring in things from my own home, it makes my room feel my own” “I am very happy with the standard of my personal space, the home is an excellent place to live” Olivet Christadelphian Care Homes DS0000024873.V369667.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, 29 & 30 Quality in this outcome area is adequate. People have safe and appropriate support as there are enough competent staff on duty at all times. Recruitment procedures did not demonstrate that people who use the service are protected by robust vetting procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident through discussion with staff, examination of the rotas and observation of staff on duty that the home provides a mix of trained nursing staff, senior carers trained to NVQ level 3 and carers trained to NVQ level 2. A total of 75 of the care staff are qualified to NVQ level 2 or above. This exceeds national minimum standards. The manager has also accessed NVQ training for the housekeeping staff. It was considered on the day of the inspection that the home was adequately covered in terms of the level of clinical and personal care input required. Training is provided in food safety, infection control, fire safety, health and safety, control of substances hazardous to health, dementia care and advanced dementia care, first aid, safe handling of medication, person centred care and safeguarding of vulnerable adults. Evidence of certificates for completed training were not always available on staff training files examined. Discussion with a senior nurse who could access the computer records confirmed what Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 21 training had been carried out by those individuals case tracked by us. We examined three long term members of staff files and in one case their manual handling training was out of date. The home should make sure that paper copies of completed training are contained on staff training files. The home does not have a robust recruitment procedure in place. We examined the files of three individuals recruited since the last inspection. Evidence of checks required by regulation were incomplete on all files. In the case of one individual there was no CRB on their file. The second individual has only one written reference on file. The administrator rang head office and was informed that their CRB had been returned but evidence of this once again was not on file. The third file was also incomplete, it contained evidence of a CRB being carried out but there were no references contained on the file, verbal or written. The registered manager had stated on the completed AQAA that “we have clear recruitment policies which are always followed. No one works in the home without supervision while waiting for their CRB clearance. References are always taken up and again we will not employ until satisfactory verbal references have been received while waiting for written confirmation.” A clear audit trail could not be demonstrated that the home protect people at all times. The home must protect people using the service by obtaining all checks required by regulation before a care worker commences post. Only in extenuating circumstances and following the department of health guidance must employ people before these checks are complete. The requirement made at the last inspection which stated “ staff files must contain an identity photograph” was considered met at this inspection following the examination of individual staff files. Olivet Christadelphian Care Homes DS0000024873.V369667.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, 36 & 38 Quality in this outcome area is good. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 23 The registered manager is experienced in managing care homes. She holds the registered managers award and has recently successfully completed an MSc in Ageing and Mental Health. She has also undertaken periodic training to update her knowledge, skills and competence. There is also a full-time head of care who is a Registered Nurse with much experience of caring for older people and has a Diploma in the Management of Care Services. Funding has recently been agreed for the head of care to undertake a diploma in dementia. Staff interviewed felt that the management structure works well and they are clear about the responsibility both the general manager and head of care hold within the structure. Quality assurance is evident throughout the home both formally and informally through meetings, audits and day-to-day contact with staff through observation and practice discussions. In addition to this senior managers undertake monitoring visits. Staff told us that regular staff meetings and departmental meetings are held, this encourages staff involvement in the running of the home. People who use the service told us that they and their family members are encouraged to give feedback to the managers and staff about their views on how the service is run. It was stated on the completed AQAA that the home plan to develop the use of dementia care mapping as a quality assurance tool and to use it to identify areas to be improved. On 31/01/08 the home received an internal quality audit award in recognition of outstanding commitment to the provision of high-quality care. A number of thank you cards and letters have been received by relatives who have had loved ones cared for at the home. Comments taken from these cards include “ thank you for all the support and hard work”, loving greetings for appreciation of the care that x received”, “ we cant thank you enough for kindness, patience, support and care given to mum. This was beyond good professional practice, it was ‘ love in action’ a great example, we will never forget.” There are policies and procedures in place for handling service users money, valuables and financial affairs. The administrator discussed the system with us and this appeared to be in line with good practice. It was stated on the completed AQAA that the home acknowledged the need to “ensure full compliance with supervision six times a year.” Staff files examined confirmed that currently staff are not receiving the minimum requirements and the home need to address this to ensure that staff are appropriately supervised. The completed AQAA sent to us contains excellent information fully supported by appropriate evidence. It demonstrates a high level of understanding about Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 24 the importance of treating people as individuals and a wide range of evidence showing how they have listened to people who use the service, staff and relatives/representatives. The home recognises the areas that it wishes to develop further, and has clearly detailed some excellent ways in which they are planning to do so. The home has a comprehensive range of policies and procedures to promote and protect people who live at the home and employees health and safety. Staff are well trained and demonstrated that they understand the need to follow policies and procedures. Health and safety records were sampled at this inspection and were found to be well maintained. Olivet Christadelphian Care Homes DS0000024873.V369667.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 4 2 x 4 Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19 (1) (a) (b) (c) schedule 2 Requirement All pre-employment checks must be carried out to ensure that people who use the service are protected at all times. Timescale for action 09/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP36 Good Practice Recommendations Care staff receive formal supervision at least six times a year. Olivet Christadelphian Care Homes DS0000024873.V369667.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Olivet Christadelphian Care Homes DS0000024873.V369667.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. 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