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Inspection on 20/06/07 for Overdale

Also see our care home review for Overdale for more information

This inspection was carried out on 20th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People living in the home said that the care they were receiving was excellent. They made comments such as "I have been here for six years and from the first day I have been very happy". "It is recognised as one of the best homes in Sheffield and the only Christian one". The information received from questionnaires and from talking to a relative and people was very encouraging. Health professionals made comments such as "we are made aware of any nursing problems immediately", "the home provides excellent care for patients" and "we have encountered no problems in this home". One Relative said "Dad always looked well cared for when we visit" and "I would be able to speak to the staff and managers if I had any concerns". The inspector observed that people were well dressed in clean clothes and had received a very good standard of personal care. Care plans were in place for all. These were well set out and easy to read. They set out all aspects of personal, social and health care needs and recorded the staff action required to ensure all identified needs were met. People`s health care was monitored and access to health specialists was available. People confirmed that staff were always respectful towards them. Medication at the home was stored securely. Senior staff that administered medication confirmed that they had undertaken training in medication administration; to equip them with the skills needed to carry out the procedure safely. People said they enjoyed the activities available at the home. Activities available included quizzes, epilogues, gentle exercise and coffee mornings. People also spoke about their trips outside the home and the entertainers that visit the home to perform a variety of music and instruments. People said that they had a choice of food and that the quality of food served was "well cooked with just the right amount" and "good with lots of variety". There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. The home was clean and tidy. No unpleasant odours were noticeable in the home. People living in the home and their relatives said that the home was always kept "immaculately clean" and "very tidy". Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. A recruitment procedure was in operation to ensure the safety of people living in the home. Staff supervision took place, to support and give guidance to staff on an individual basis. Mandatory training took place, to equip staff with the essential skills needed. Records within the home were stored securely, to safeguard confidentiality. Health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment.

What has improved since the last inspection?

Medication administration records were checked and found to be fully completed. Staff supervisions were taking place at the minimum frequency of six times each year. All staff had participated in a practice fire drill a minimum of twice each year. The home had continued to carry out decoration and refurbishment work, which had improved the aesthetics of the home and helped to make the home very welcoming and homely. A business manager had been recruited to be responsible for building and maintenance and health and safety. This was of great significance for the registered manager who would benefit from having more time to focus on care and staffing matters. The homes trustees and manager continue to be open to suggestions for any improvements to the care offered at the home. There was evidence of internal auditing of the homes environment, services and records. The manager had continued to send out questionnaires to people and their relatives to ask for their views of the home.

What the care home could do better:

The service provided at Overdale is of a very high standard and everyone involved with the home should be proud of this. This report does not contain any requirements, the inspector acknowledges that the trustees and manager continue to evaluate and monitor the service and make any changes necessary to ensure that the home continues to provide the excellent service that is presently offered.

CARE HOMES FOR OLDER PEOPLE Overdale 29-31 Kenwood Park Road Sheffield South Yorkshire S7 1NE Lead Inspector Sue Turner Key Unannounced Inspection 20th June 2007 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000002996.V331124.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. DS0000002996.V331124.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Overdale Address 29-31 Kenwood Park Road Sheffield South Yorkshire S7 1NE 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) 0114 255 0257 0114 255 0257 none Overdale Trust Ms Ruth Helen Brown Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places DS0000002996.V331124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: Overdale is a care home providing personal care for up to twenty-five older people. The home is situated in the Nether Edge area of Sheffield, close to bus routes and local amenities. It is a detached Victorian villa, set in its own pleasant gardens. Accommodation is provided on three floors, all accessed by a passenger lift. All of the bedrooms are single, a proportion have en-suite toilet facilities. Communal lounges and a dining room are provided. Sufficient bathing facilities are available, with aids and adaptations in place. The home is served by a central kitchen and laundry. Overdale is a non-profit making voluntary care home run by a committee of Christian people from various churches. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from 1st April 2007 were £380 - £420 per week. Additional charges included newspapers, hairdressing and private chiropody. DS0000002996.V331124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Sue Turner regulation inspector. This site visit took place between the hours of 8.00 am and 2:30 pm. Ruth Brown is the registered manager and was present during the visit. The manager had submitted a pre inspection questionnaire and five people living in the home, five professionals and five staff members had returned care home surveys to the CSCI prior to the actual visit to the home. Their views and some information from the questionnaires are included in the main body of the report. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to eight staff, one relative and six people living in the home. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: People living in the home said that the care they were receiving was excellent. They made comments such as “I have been here for six years and from the first day I have been very happy”. “It is recognised as one of the best homes in Sheffield and the only Christian one”. The information received from questionnaires and from talking to a relative and people was very encouraging. Health professionals made comments such as “we are made aware of any nursing problems immediately”, “the home provides excellent care for patients” and “we have encountered no problems in this home”. One Relative said “Dad always looked well cared for when we visit” and “I would be able to speak to the staff and managers if I had any concerns”. The inspector observed that people were well dressed in clean clothes and had received a very good standard of personal care. Care plans were in place for all. These were well set out and easy to read. They set out all aspects of personal, social and health care needs and recorded DS0000002996.V331124.R01.S.doc Version 5.2 Page 6 the staff action required to ensure all identified needs were met. People’s health care was monitored and access to health specialists was available. People confirmed that staff were always respectful towards them. Medication at the home was stored securely. Senior staff that administered medication confirmed that they had undertaken training in medication administration; to equip them with the skills needed to carry out the procedure safely. People said they enjoyed the activities available at the home. Activities available included quizzes, epilogues, gentle exercise and coffee mornings. People also spoke about their trips outside the home and the entertainers that visit the home to perform a variety of music and instruments. People said that they had a choice of food and that the quality of food served was “well cooked with just the right amount” and “good with lots of variety”. There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. The home was clean and tidy. No unpleasant odours were noticeable in the home. People living in the home and their relatives said that the home was always kept “immaculately clean” and “very tidy”. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. A recruitment procedure was in operation to ensure the safety of people living in the home. Staff supervision took place, to support and give guidance to staff on an individual basis. Mandatory training took place, to equip staff with the essential skills needed. Records within the home were stored securely, to safeguard confidentiality. Health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? Medication administration records were checked and found to be fully completed. Staff supervisions were taking place at the minimum frequency of six times each year. All staff had participated in a practice fire drill a minimum of twice each year. DS0000002996.V331124.R01.S.doc Version 5.2 Page 7 The home had continued to carry out decoration and refurbishment work, which had improved the aesthetics of the home and helped to make the home very welcoming and homely. A business manager had been recruited to be responsible for building and maintenance and health and safety. This was of great significance for the registered manager who would benefit from having more time to focus on care and staffing matters. The homes trustees and manager continue to be open to suggestions for any improvements to the care offered at the home. There was evidence of internal auditing of the homes environment, services and records. The manager had continued to send out questionnaires to people and their relatives to ask for their views of the home. 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. DS0000002996.V331124.R01.S.doc Version 5.2 Page 8 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 DS0000002996.V331124.R01.S.doc Version 5.2 Page 9 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): Standards 1 and 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided sufficient updated and relevant information to inform people about their rights and choices. Trial visits were encouraged to enable people to look around the home, meet other people living there and give them the information needed to make informed choices. EVIDENCE: The homes combined Statement of Purpose and Service User Guide was available and on display in the entrance hall. In each bedroom there was a Service User Guide, which gave lots of useful information about the home and the services offered. The Statement of Purpose had been recently updated to incorporate staff changes. DS0000002996.V331124.R01.S.doc Version 5.2 Page 10 Professionals and staff from the home prior to admission taking place assessed people. This either took place at Overdale or at peoples own homes if they preferred. The manager said that assessments in hospitals were also possible if needed. This enabled staff to be aware of individuals needs and to ensure that they could be met. One person said, “my daughter visited the home and told me how nice it was and then I came and had lunch”, another said, “my friend said this was a lovely home so I came and spent the day here and I love it very much”. This home does not provide intermediate care services. DS0000002996.V331124.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the 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’s health, social and personal care needs were well documented in the care plans and a range of health care professionals visited the home, which meant that individual needs could be fully met. Medication storage and procedures protected people’s health and welfare. People and their relatives were very complimentary about the way staff cared for them and the ways they promoted their privacy and dignity. EVIDENCE: Three plans of care were checked. Care plans contained a full range of information, in a concise and easy to read format. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs DS0000002996.V331124.R01.S.doc Version 5.2 Page 12 were met. Staff were aware of the contents of care plans and were knowledgeable about peoples individual needs. The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. District nursing services visited the home as necessary to attend individual health needs. People said that GP’s, dentist, opticians and chiropodists also visited the home as requested. One relative said that staff were very good at informing them if their loved one was ill or had had an accident. People and/ or their relatives were asked to be involved in drawing up and reviewing care plans, some participated others chose not to. Staff were updating risk assessments and care plans on a monthly basis and the manager was auditing care plans regularly to measure their quality. Relatives said that the staff were “helpful”, “friendly” and “nice” and provided a “good” or “excellent” standard of care. One person said “the home gives you as much service as you need”. Medicines were securely stored around the home in locked trolleys and cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Senior staff administered medications. They said they had received in house medication training and the pharmacist had also provided some more in depth training. People said that staff at the home respected their privacy and dignity in a number of ways, for example, by knocking on their doors and waiting for a response before entering. The inspector observed this practice and many other good practise actions. Staff spoke to people in a respectful way and showed empathy and patience when providing personal care to them. DS0000002996.V331124.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home, a range of activities was on offer, contact with family and friends was supported and people continued to be involved in community life. Meals served at the home were of a very good quality and offered choice, which ensured people received a healthy balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was offered hospitality and staff took time to make sure friends and family were made to feel comfortable whilst visiting their loved one. Some people said they preferred to stay in their room at certain times of the day and that the staff respected their decision. DS0000002996.V331124.R01.S.doc Version 5.2 Page 14 A friendly and welcoming feel was very evident in Overdale. People said that there were a number of activities at the home, which appealed to their preferences and abilities. Activities particularly enjoyed were massage, quizzes and visiting entertainers. People said that local churches came and offered bible study, prayer meetings and epilogue, all of which were very popular. Two people said they particularly enjoyed going out for trips into the countryside and stopping off for coffee. There was a variety of books available for people to choose and read at their leisure, these were swapped over on a regular basis. One person said since coming into the home she had started to paint, the manager had provided a table for her painting and she said “I’m so busy now I don’t even get time to watch television”. The inspector sat with some people at breakfast. The tables were pleasantly arranged with cloths, and matching crockery and cutlery. The ambience in the dining room was pleasant and relaxed and people were seen coming into and leaving the table as they wished. Staff were asking people their choice of breakfast, almost everyone requested something different, these individual preferences were provided for without any hesitation and staff remained relaxed and sociable, nothing seemed to be too much trouble. A number of people had requested breakfast to be served in their rooms and this was provided. People said that the meals at the home were always of a high standard with plenty of choices available. When talking about the food people said such things as “its well cooked and good”, “there’s lots of variety” and “they cater for all my little fads”. DS0000002996.V331124.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and staff were aware of these. People and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their representatives had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and informed the reader of who to contact outside of the home to make a complaint should they wish to do so. All of the people said they had no concerns about the home, staff or service provided. They said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home had not received any complaints since the last inspection. The CSCI had not received any complaints DS0000002996.V331124.R01.S.doc Version 5.2 Page 16 about the home. Staff spoken to were clear how to respond and record any complaints received. An adult protection procedure was in place, which contained information on the Department of Health guidance `No Secrets’. Staff undertook training on adult protection to equip them with the skills needed to respond appropriately to any allegations. All people spoken to said that they felt safe living at the home. DS0000002996.V331124.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was maintained to a high standard. The environment was very clean and fresh smelling. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and people’s bedrooms were well decorated and personalised. Controls of infection procedures were in place, which promoted people’s health and welfare. EVIDENCE: The home is on a suburban road surrounded by gardens and has a pleasant patio area with seating and shelter. Many rooms overlook these grounds and people said they got great pleasure from sitting outside in the nice weather. DS0000002996.V331124.R01.S.doc Version 5.2 Page 18 The home was very clean and tidy. Lounge and dining areas were domestically furnished to a good standard. The manager had a programme of refurbishment and redecoration that ensured that the home was very aesthetically pleasing and free from hazards. The manager said that any work deemed necessary for the comfort and well being of the people living in, working and visiting the home was undertaken with the support of the trustees. Since the last inspection the kitchen floor had been refitted, a number of bedrooms and bathrooms ad been redecorated and a bathroom had been totally refurbished. People were able to bring personal items with them into the home. All of the bedrooms seen were individually personalised and very homely. One person said, “my whole lifetime is in this room” another said “I have glorious views from my very own balcony”. One person said the only thing that could make them any happier would be a bigger room, she said “the manager is aware of this and is trying her best to sort this out for me”. No unpleasant odours were noticeable in the home and relatives said that the home was always kept “immaculately clean”. Infection procedures were in place and staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. DS0000002996.V331124.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers, recruitment procedures promoted the protection of people, staff had completed training, including induction which ensured that they had the competences to meet people’s individual needs. EVIDENCE: Staff and relatives said that there was enough staff working at the home to ensure that people’s individual needs were met. The manager confirmed that staffing levels were above the agreed minimum and this was monitored according to people’s needs, if there was a need to increase staffing levels then the manager said that this would be implemented immediately. When describing the staff people were very positive and complementary, saying such things as “staff are very friendly”, “staff listen to me and their aware of my needs, likes and dislikes” and “staff are lovely, all different which makes them interesting”. DS0000002996.V331124.R01.S.doc Version 5.2 Page 20 Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, Adult Protection, First Aid and Fire. Some staff had also undertaken more advanced training in essential topics, for example palliative care. Over 50 of the staff team had achieved their NVQ Level 2 or above and others were eager to start this training. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Two staff files checked identified that the member of staff had received induction training when they commenced work. The recruitment records of three employed staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them, these were satisfactory. Protection Of Vulnerable Adults (POVA) checks had been made and Enhanced Criminal Record Bureau (CRB) checks had been obtained for the staff members. DS0000002996.V331124.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36 and 38. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager’s leadership approach benefited people and staff. Quality Assurance Systems, staff supervision and people, relative and staff meetings meant that the home was run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. People’s health and safety had been promoted and protected in all areas. DS0000002996.V331124.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager was very hard working, competent and carried out her role to a very high standard. She was clearly very committed to ensuring that people living in the home were consistently well cared for, safe and happy. Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. The service provided at Overdale is of an excellent quality and it is clear to see that people benefit greatly from the ethos, leadership and management approach of the home. The manager and trustees are very dedicated to providing a service of this standard. Monthly monitoring visits by the responsible individual took place. Records of these visits covered all aspects of the home and staff said that the provider “took time out” to speak to them and ask their opinions as part of this process. The manager and provider had a number of ways in which to assess the quality of the service and make improvements. Relatives and people said they had completed questionnaires, giving their opinions of the home, these were sent out yearly and a summary of the results was incorporated into the Statement of Purpose. Senior staff and staff meetings took place on a regular basis. Resident and relative meetings had not taken place recently as the home believed there were better ways to listen and obtain information, however the manager said this was under constant review as new people moved into the home. The home handles money on behalf of some people. Account sheets were kept, receipts were seen for all transactions and a second individual witnessed all transactions. Formal staff supervision, to develop, inform and support staff took place at regular intervals. All staff, with the exception of the registered manager were offered formal supervision and staff said that they found this useful and beneficial. The inspector believes the registered manager would also benefit from formal supervision, as it is important that the manager is given the opportunity to express her views and also be formally recognised for her achievements in providing and maintaining an excellent care service. DS0000002996.V331124.R01.S.doc Version 5.2 Page 23 The equipment at the home was serviced and maintained. Fire records evidenced that weekly fire alarm checks took place. Staff said fire drill training took place on a regular basis. Following a visit from The Environmental Health Services recommendations made had been actioned. DS0000002996.V331124.R01.S.doc Version 5.2 Page 24 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 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X 4 X 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 X 3 DS0000002996.V331124.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 The manager should be provided with formal one to one supervision. DS0000002996.V331124.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000002996.V331124.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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