Inspection on 19/01/07 for Overcliff House

This inspection was carried out on 19th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Overcliff House 22/02/06

Overcliff House 10/05/05

Overcliff House 09/09/04

Overcliff House 16/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Overcliff House 2 Cellars Farm Road Southbourne Bournemouth Dorset BH6 4DL Lead Inspector Marjorie Richards Key Unannounced Inspection 19th January 2007 09:50 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 DS0000003967.V327508.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. DS0000003967.V327508.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Overcliff House Address 2 Cellars Farm Road Southbourne Bournemouth Dorset BH6 4DL 01202 424929 01202 426523 overcliffhouse@hotmail.com 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 Marilyn Cooper Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (18) DS0000003967.V327508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 Brief Description of the Service: Overcliff House is a care home providing personal care and accommodation for 18 older people who have mental disorders or dementia. The home is owned and personally managed by Mrs Marilyn Cooper. It is situated in a pleasant residential area of Southbourne, Bournemouth, in an elevated position (sloping walk up to front entrance,) offering views of the sea. Local amenities, e.g., shops, post office, churches, doctors surgeries and cliff top walks are all within easy reach. Car parking is provided for visitors to the home and further parking is available on nearby roads. A bus stop is situated close to the home with buses from Southbourne into Bournemouth, Christchurch and beyond. Overcliff House is a large detached property that has been adapted to provide residential care. Accommodation for residents is provided on the ground and first floors, with a stairlift to assist access between floors. All residents have single bedrooms, seven of which have en-suite facilities. The home also has a dining room and separate lounge, which overlooks the sea. There are sufficient baths, a shower and WCs to meet the needs of residents. The home has very attractive gardens to the front and rear of the property, which are well maintained, easily accessible and well used by residents. Overcliff House is also home to two pet cats, two cockatiels, a tortoise and two ducks. Twenty-four hour care is provided. Laundering of personal clothing is carried out on the premises. All meals are prepared and cooked within the home. A choice of menu is offered and a variety of alternatives always available to suit individual taste and preference at mealtimes. Special diets can be catered for. DS0000003967.V327508.R01.S.doc Version 5.2 Page 5 Social activities and also entertainments are arranged to provide stimulation and interest for residents. The fees for the home, as confirmed to the Commission for Social Care Inspection (CSCI) at the time of inspection, range from £461 - £560 per week. Additional charges include hairdressing, chiropody, dry cleaning, toiletries and newspapers. The Office of Fair Trading has published a report highlighting important issues for many older people when choosing a care home, e.g., contracts and information about fees and services. The CSCI has responded to this report and further information can be obtained from the following website: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choosing a care home .aspx DS0000003967.V327508.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7.5 hours on the 24th January 2007. The main purpose of this inspection was to review all of the key National Minimum Standards, check that the residents living in the home were safe and properly cared for and to look at progress in meeting the one requirement and recommendation from the previous inspection. On the day of inspection, 18 residents were accommodated. A tour of the premises took place and records and related documentation were examined, including the care records for three residents. Additional information was provided to the Commission in the Pre-inspection Questionnaire, completed in advance of the inspection by Mrs Cooper. Time was spent observing the interaction between residents and staff, as well as talking with a total of six residents. The daily routine was also observed during the inspection. Discussion took place with Mrs Marilyn Cooper, the registered provider and with members of staff on duty. For the purposes of this report, people who live at Overcliff House are referred to as residents as this is the term generally used within the care home. The Inspector was made to feel very welcome in the home throughout the visit. What the service does well: Information about Overcliff House is available for prospective residents to help them decide if the home is right for them. Pre-admission assessments are carried out to ensure that only people whose needs can be met are offered places within the home. Every resident has a care plan, which sets out in detail the individuals care needs and how these are to be met. Residents and their relatives are encouraged to contribute to assessments and care plans. Staff carry out monthly reviews of care plans to ensure they are regularly updated as necessary. Copies of these reviews are sent to close relatives to keep them informed and to invite comment. There are satisfactory arrangements in place for managing medication and ensuring that the medication needs of residents are met. DS0000003967.V327508.R01.S.doc Version 5.2 Page 7 Residents are encouraged to maintain contact with family and friends and the wider community. There are no restrictions on visiting at Overcliff House. The home promotes a homely, relaxed, non-institutional family atmosphere, which is beneficial to residents, staff and visitors alike. Overcliff House is also home to two cats, two Cockatiels, a tortoise and two ducks. Flexibility of lifestyle is encouraged and residents have the opportunity to choose their own way of living in the home. They are able to bring their own possessions into the home to personalise their bedrooms. Residents confirm that their individual preferences and routines are respected. Overcliff House has an Adult Protection policy in place to protect residents from possible abuse. All staff have received Adult Protection training to ensure a proper response to any suspicion or allegation of abuse. Residents are treated with respect, with due regard for privacy and dignity. Staff were observed throughout the inspection to be treating residents with courtesy, patience and kindness. A range of activities is provided within the home. Some of these are planned, but others take place spontaneously such as having a sing-along. Residents can participate with tasks such as washing and wiping dishes, laying tables, gardening etc, if they wish. Meals are varied and take into account the likes and dislikes of residents. Mealtime arrangements are flexible enough to accommodate individual preferences and any social activities etc. Overcliff House is set in very attractive, well-kept grounds and is close to the sea. Seating is provided and residents also have access to patio areas and a summerhouse. The home is kept clean, with no unpleasant smells and is well maintained. Further improvements are always being sought to ensure that residents live in safe and comfortable surroundings. The needs of residents are well met by the numbers and skill mix of a staff team well trained and competent in their work. All but two of the care staff working in the home have National Vocational Qualifications at level 2 and above, which is a considerable achievement. (The remaining two staff are currently undertaking NVQ level 2 training.) Mrs Cooper works very much hands-on within the home and is assisted by a team of experienced care, catering, cleaning, gardening, clerical and maintenance staff, including some members of her family. She leads by example to ensure that residents receive a consistently high standard of care. Her management style provides clear leadership and promotes a happy, relaxed atmosphere where residents are at ease. DS0000003967.V327508.R01.S.doc Version 5.2 Page 8 Quality Assurance questionnaires are sent quarterly to residents’ relatives or representatives and any comments or suggestions are discussed and actioned wherever possible. Residents are assured of sound management of their financial interests. Good management practice ensures the health and safety of all in the home. 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. 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. DS0000003967.V327508.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 DS0000003967.V327508.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Standard 6 is not applicable at Overcliff House. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Overcliff House. Information provided about Overcliff House and a thorough admissions procedure allows prospective residents to make informed decisions about admission to the home and ensures that only those whose needs can be met by the home are offered places there. The home assures prospective residents in writing that their needs can be met. EVIDENCE: The Statement of Purpose and Service User Guide contain all of the information required about the home and its facilities. The Service User Guide gives a good indication of what a resident can expect from the home. It is displayed in the hallway at Overcliff House and a copy is also available in every residents bedroom. DS0000003967.V327508.R01.S.doc Version 5.2 Page 11 Overcliff House has a written admissions policy. Clear pre-admission assessment information had been recorded for two residents who recently moved into Overcliff House. Mrs Cooper says that she always visits prospective residents or invites them to the home, prior to making a decision as to whether Overcliff House is suitable to meet their needs. An assessment form has been developed for this purpose. A letter of confirmation is then written to the prospective resident so that they may feel assured their care needs can be met. Copies of such letters were evidenced on file. The information contained in pre-admission assessments and also any assessments supplied by funding authorities, is then used to help draw up a detailed plan of care. DS0000003967.V327508.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Overcliff House. Overcliff House has a care planning system in place, which ensures that staff have the information they need to meet the needs of residents. Health needs are also well met, with evidence of good support from community health professionals. The home has procedures in place for managing residents’ medication, to ensure the safety of residents. Residents are treated with respect and their privacy and dignity is promoted at all times. DS0000003967.V327508.R01.S.doc Version 5.2 Page 13 EVIDENCE: Following admission to the home, further assessments are carried out and a care plan is drawn up, identifying the needs of each resident and how staff are to meet these needs. Relatives are encouraged to contribute to the development of care plans by providing important background information, social history etc. Evidence was seen to show that at least once a month, care plans are reviewed and updated where necessary. Relatives are encouraged to contribute to this review process, as the home sends them a copy every month. They are asked to sign the review and send it back, making comments if they wish. To aid correct identification, each record contains a recent photograph of the resident. Care plans give personalised information to assist staff in ensuring good quality care. For example, Likes a gentle quiet approach.” Loves political programmes and news. Listens to Radio 4.” Detailed daily records are written by staff to evidence the care being provided. Members of staff are able to demonstrate that they have a good knowledge of residents’ individual care needs. Care plans show that where care needs change, appropriate professionals have been consulted to carry out further assessments etc. Records demonstrate that residents have access to GPs, district nurses, psycho-geriatricians, chiropodists, opticians, etc and attend for hospital appointments, etc. Risk assessments are in place and appropriate steps taken to minimise any of the identified risks. The home has systems in place for managing medicines. Only senior staff deal with medication and they first have to undertake a Safe Handling of Medicines course at Bournemouth and Poole College, so they know how to recognise and deal with any problems in use. Medicines are stored securely, to ensure the protection of residents. A Monitored Dosage System is in use. Samples of the cassettes were checked to confirm that the quantity left agreed with the Medicine Administration Records (MAR) charts, to ensure that medicines had been administered correctly, as prescribed. Those MAR charts examined were well maintained, Staff record all medicines received in the home and a system is in place for providing an audit trail, e.g. dating eye drops and creams when starting or recording a carry forward balance on the MAR chart for each medicine. DS0000003967.V327508.R01.S.doc Version 5.2 Page 14 Information is available on all of the medicines used within the home for staff reference. Staff were seen to knock at bedroom doors and to offer personal care discreetly. Staff interact with residents in a friendly and caring manner. It was clear from the time spent with residents that they feel comfortable and at ease with staff and appreciate their gentle approach. Staff were seen throughout the inspection to be treating residents with courtesy and kindness, with due regard for dignity and respect. Toileting activities are carried out with discretion and continence products are stored out of sight in bedrooms so that visitors cannot see them. Residents have their own single bedrooms, thereby offering an opportunity to be on their own if they wish, or allowing privacy for any visitors or personal care needs. One resident commented, It is nice to be on your own sometimes. DS0000003967.V327508.R01.S.doc Version 5.2 Page 15 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 Overcliff House. A range of social activities provides variation and interest for residents living in the home. Residents are supported to maintain contact with family and friends and the wider community and to choose their own lifestyle within the home, where their individual preferences and routines are respected. Overcliff House serves a balanced and varied selection of food that meets residents’ tastes and special dietary needs in surroundings of their choice and at times which are convenient to them. EVIDENCE: From the time of the original pre-admission assessment, as much information as possible is sought about the social history of residents. This helps to inform the home about hobbies and interests and assists in the planning of activities. An activities organiser provides a range of activities of three days a week. Some activities are spontaneous, such as “sing-a-longs” but residents also DS0000003967.V327508.R01.S.doc Version 5.2 Page 16 enjoy Memory Lane Bingo, quizzes, manicures, colouring and doing puzzles. On the morning of the inspection, the Extend coordinator was visiting the home to provide gentle exercise to music. Mrs Cooper and her staff take a flexible approach to the running of the home to fit in with residents needs and wishes. Some residents like to help with small tasks in the home and garden and this is encouraged. Important dates and events are celebrated, such as birthdays, Valentines Day, Easter, Halloween and Christmas. Summer barbecues take place in the garden and occasional outings are arranged, to which relatives are invited. Arrangements are made for clergy to visit individual residents if required. Residents like to watch the church services on television as well as Songs of Praise. The home has a number of pets. At present, Overcliff House is also home to two cats, two Cockatiels, a tortoise and two ducks. Mrs Cooper says that visitors are encouraged to visit the home at any time. Members of staff and a visitor confirm that visiting times at Overcliff House are unrestricted. Residents records and the visitors book demonstrate contact with family and friends as well as visits by professionals. A telephone is always available to residents so they may make or receive calls from family and friends. The home provides a daily newspaper for residents to read and five residents also order of their own newspapers. Residents are encouraged to choose their own lifestyle within the home and make choices wherever possible. These include choosing when to get up or go to bed, what to wear, what to eat or drink and freedom to come and go as they please within the home. They are able to bring their own possessions into the home to personalise their bedrooms. Observation confirms that staff respect the individual preferences and routines of residents. One resident said, Everyone is very nice. I go where I like in this place and nobody seems to mind. Lunch on the day of inspection was beef casserole, with boiled or creamed potatoes, cabbage and runner beans. This was followed by homemade rice pudding with jam, or ice cream. A wide range of alternatives is always available, such as omelettes, jacket potatoes with assorted fillings, a variety of soups and salads and this list of items is displayed in the dining room, next to the daily menu. Residents may choose where in the home they eat their meals, including the garden when weather permits. Meals are seen as social occasions and the lunchtime meal took place in a relaxed, unhurried and congenial atmosphere with discreet staff assistance provided wherever necessary. DS0000003967.V327508.R01.S.doc Version 5.2 Page 17 Mrs Cooper says that she and her staff strive to ensure that all residents eat at least five portions of fruit and vegetables a day. Fruit juices are always offered with lunch and fresh fruit salad is popular with residents. Fresh fruit is often liquidised to provide a fruit sauce for ice cream. Residents commented, I thoroughly enjoy my food. My mother used to make rice pudding just like this. I dont remember what it was, but it tasted very nice. (Speaking about lunch.) DS0000003967.V327508.R01.S.doc Version 5.2 Page 18 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Overcliff House. A complaints procedure is available which provides information on the procedure to follow for anyone wishing to make complaint. The home has an Adult Protection policy and procedure in place and staff have received Adult Protection training to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a complaints policy and procedure that is included in the information provided to residents or their representatives. The complaints procedure is also displayed on the notice board in the hallway and in the Service Users Guide. A complaints record is maintained, but since the last inspection, no complaints have been received. Most residents were not able to comment about the complaints procedure, but two said, I am not unhappy, I like it here. I have no complaints about anything. If something was wrong, I would tell them about it. Overcliff House has an Adult Protection policy in place to protect residents from possible abuse. This makes reference to the Department of Health No Secrets guidance, which is also available to staff. All staff have received Adult DS0000003967.V327508.R01.S.doc Version 5.2 Page 19 Protection training to ensure that they remain vigilant in protecting vulnerable residents from risks of abuse and know how to properly manage any allegation or suspicion of abuse. DS0000003967.V327508.R01.S.doc Version 5.2 Page 20 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 Overcliff House. Residents live in comfortable, safe and well-maintained surroundings where standards are constantly improving. Overcliff House is clean and there are no unpleasant odours, ensuring that residents live in a pleasant environment. EVIDENCE: Overcliff House is well maintained to ensure resident safety. All radiators except one are guarded to ensure residents cannot hurt themselves by coming into contact with hot surfaces. Because of the position of one radiator, it is not possible to fit any kind of cover, so the temperature is regulated to ensure it does not get too hot. Windows have only limited openings, to prevent any risk to residents. DS0000003967.V327508.R01.S.doc Version 5.2 Page 21 Maintenance records show that continual work is carried out to keep the home and gardens in good condition. Care staff confirm that prompt attention is always paid to any defects. Since the last inspection the car parking area has been improved and steps in the front garden have been replaced and new safety rails fitted. A new boiler has been recently installed which does not store hot water, so there is no risk from Legionella. Four bedrooms have been redecorated and carpets renewed. The communal areas have also been redecorated and the linen room floor replaced. A new commercial washing machine has been purchased and the laundry room retiled, redecorated with new cupboards and hanging space also being fitted. In the kitchen, a new cooker, fridge, freezer, two microwaves, crockery and a hot water urn have been purchased. The home has also provided new bedding and towels for residents. The home is clean and there are no unpleasant smells, making life within the home more pleasurable. Suitable facilities and procedures are in place in respect of laundry and the disposal of clinical waste. DS0000003967.V327508.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Overcliff House. The home employs sufficient staff to meet the current needs of residents and to ensure their safety and comfort. The home has exceeded the recommended ratio of 50 NVQ level 2 trained staff, to help ensure residents are in safe hands. Employment and recruiting procedures are in place, but some improvements must be made to ensure the protection of residents against the possible employment of unsuitable staff, who may place them at risk of harm. Staff are provided with suitable training, to ensure they have the skills necessary to meet the assessed needs of residents. EVIDENCE: Mrs Cooper works very much hands on within the home and is assisted by a team of experienced care, catering, cleaning, gardening, clerical and maintenance staff, including some members of her family. The weekly staffing roster shows sufficient staff on duty throughout the day, including two wakeful staff at night. DS0000003967.V327508.R01.S.doc Version 5.2 Page 23 Mrs Cooper takes staff training very seriously. Two staff have achieved National Vocational Qualifications (NVQ) at level 2 and two new staff have commenced their NVQ level 2. Eight staff have achieved NVQ level 3 and two staff have NVQ level 4, which far exceeds the required standard that 50 of staff achieve NVQ level 2. The home has a thorough recruitment procedure in place, based on equal opportunities and ensuring the protection of residents. The two staff files examined demonstrated that documentation was in place to ensure the protection of residents, e.g., Application form with employment history, proof of identity and two written references. However, one of the staff files showed that the Criminal Record Bureau (CRB) disclosure had been received some weeks after the employee had commenced working in the home. There was no record of any POVAfirst check being made prior to employment commencing. Mrs Cooper explained that this employee was supervised and never worked alone until the receipt of the CRB disclosure. This was confirmed by staff, but not fully documented. All care staff applying to work in care homes with adults are required to have a satisfactory Protection of Vulnerable Adult (POVA) check before taking up employment. Induction training is well documented. A range of policies and procedures is in place to assist staff and they sign to show they have read and understood these. Mrs Cooper then tests their knowledge to ensure staff have a full understanding of what is required. Staff undertake a range of training, such as dementia care, conflict management, moving and handling, first aid, health and safety, infection control, risk assessment and basic food hygiene. This is provided through a mixture of external and in-house courses, as well as distance learning. Staff commented, I have had lots of training opportunities since I came here. Mrs Cooper is very keen on training for all staff. DS0000003967.V327508.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Overcliff House. Mrs Cooper leads by example to ensure that residents receive a consistently high standard of care. She provides clear leadership and is well supported by a dedicated staff team. The home regularly reviews its performance and actively seeks the views of residents, staff and relatives to ensure the home is run in the best interests of residents. Residents are assured of sound management of their financial interests. Overcliff House works to ensure the general health, safety and welfare of residents. The premises and equipment are properly maintained and subject to ongoing improvements to ensure the comfort and safety of all in the home. DS0000003967.V327508.R01.S.doc Version 5.2 Page 25 EVIDENCE: Overcliff House is a well established home and Mrs Cooper has considerable management experience. She has successfully completed her NVQ level 4 in management and care and is also an NVQ assessor and mentor. A full range of policies and procedures is in place to offer advice and guidance to staff and these are regularly reviewed and updated as necessary. Discussions with staff show that they are clear about roles and responsibilities within the home. Staff commented, Mrs Cooper makes residents, relatives and staff happy. This is a good home. I think we make a good team, we all work well together. Mrs Cooper is good with staff. She gives thanks whenever it is due. I enjoy coming to work. Mrs Cooper always says that anything the residents need they can have. The residents must come first. Overcliff House has a “homely” and welcoming atmosphere, which is beneficial to residents, staff and visitors alike. Mrs Cooper has a good rapport with residents, visitors and members of staff and this was demonstrated throughout the inspection. Management of Overcliff House is a team effort, with senior staff encouraged to take responsibility for different aspects of the running of the home, such as medication, training and health and safety. The home has a happy, relaxed and welcoming atmosphere, which is beneficial to residents. Mrs Cooper and her staff frequently spend time talking with residents informally to obtain their views. Quality Assurance questionnaires are sent quarterly to residents’ relatives or representatives and any comments or suggestions are discussed and actioned wherever possible. Examples of suggestions from relatives that have recently been implemented include name badges for staff and nameplates on bedroom doors. Responses to questionnaires are also fed into the Annual Development Plan. A selection of Quality Assurance questionnaires were examined and the following comments are representative of those received: A very warm and friendly atmosphere. The staff are very kind to all residents. The meals are delicious. The staff and owner are very dedicated in their work. Mrs Cooper confirms that, in order to protect residents it is the policy of the home not to have any involvement in their personal finances. Therefore those residents who are unable to handle their own affairs, or choose not to, have a relative or other representative to deal with their finances etc. DS0000003967.V327508.R01.S.doc Version 5.2 Page 26 The home pays for services such as chiropody and hairdressing and this amount is then invoiced to residents, relatives or representatives for payment each month. The premises are well maintained and there are regular checks and tests of all equipment. Details of equipment servicing and maintenance were previously provided to the Commission in a pre-inspection questionnaire. A sample of records was checked to verify this information. All staff have received first aid and moving and handling training and further training is planned. All substances that could be potentially hazardous to health are handled and stored safely. Keypad locks are provided on some doors, for example the laundry, to prevent entry to unauthorised persons and ensure resident safety. Fire records show regular maintenance of the fire warning system, emergency lighting and fire fighting equipment and checks being carried out at the correct intervals. Each member of staff has an individual record of fire training and fire drills are held to ensure all staff know the action to take in case of fire. A fire risk assessment is in place. DS0000003967.V327508.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 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 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 DS0000003967.V327508.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES 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) Schedule 2 Requirement The registered person must operate a thorough recruitment procedure to ensure the protection of residents. New staff must not commence work in the home without evidence of suitable Criminal Records Bureau and Protection Of Vulnerable Adults disclosures. (Previous timescale of 30/04/06 not fully met). Timescale for action 01/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000003967.V327508.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000003967.V327508.R01.S.doc Version 5.2 Page 30 - 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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