Inspection on 05/10/06 for Overleat

This inspection was carried out on 5th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Overleat 01/10/07

Overleat 07/10/05

Overleat 06/05/05

Overleat 21/09/04

Overleat 04/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Overleat Derby Road Kingsbridge Devon TQ7 1JL Lead Inspector Judy Cooper Unannounced Inspection 5th October 2006 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 Overleat DS0000003768.V305485.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. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Overleat Address Derby Road Kingsbridge Devon TQ7 1JL 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) 01548 852603 Mrs Sharon Angela Hard Mr Richard Hard Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10), of places Physical disability over 65 years of age (10) Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th October 2005 Brief Description of the Service: Overleat is a small family run home situated near the centre of Kingsbridge. The home is a period property, and is set next to a small park on the level to the Quayside walk and the town centre. The home provides accommodation on two storeys, serviced by a chair lift, for up to 10 older residents with or without physical disabilities and/or with mild confusion. Accommodation is in single rooms, which vary in size, and some have en suite facilities. The home also has level easily accessible gardens and parking facilities. The home’s weekly fees range between £287.00 and £400.00. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place on a Wednesday between 10.30 a.m. and 4.00 p.m. Opportunity was taken to observe the general overall care given to current residents. The care provided for two residents was also followed in specific detail, from the time they were admitted to the home, which involved checking that all elements of their identified care needs were being met appropriately. A tour the premises, examination of some records and policies, discussions with one of the owners, manager (non registered), all residents and staff, as well as one visitor to the home, also formed part of this inspection, whilst staff on duty were observed, in the course of undertaking their daily duties. Other information about the home, including the receipt of several completed questionnaires from residents, staff, relatives and other interested parties including two G.P practices, has provided further feedback as to how the home performs, and this collated information has been used in the writing of this report. All required core standards were inspected during the course of this inspection. What the service does well: Overleat continues to provide a comfortable and caring environment, where residents’ individuality is encouraged and upheld. The homes real strength lies in the way that the required individual care is provided, with residents’ rights to privacy and dignity always maintained, by Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 6 staff both valuing and meeting a wide range of very diverse needs professionally and sensitively. Residents confirmed this themselves with many very positive statements received from the residents in relation to the good standard of care they received. The residents also felt that the home was run for their benefit and in their best interests. The residents continue to receive excellent meals, visitors are always welcomed, various informal activities and regular outings are made available and there are strong links with the local community The staff group remains very stable with several long standing staff remaining in post. The staff work well together as a team, supporting one another, and ensuring that the overall outcome is the provision of good care for all the residents. What has improved since the last inspection? Additional staff training has been made available. All care staff are now appointed first aiders having attended the required training. All staff within the home, except one, have achieved an NVQ training award in care. This also includes the home’s cook. This is an excellent achievement and should be commended. It is the owners’ intention to now fully concentrate their efforts on Overleat, having recently sold a second residential home that they owned. The owners are soon to put forward an application to this Commission, in respect of an extension to the home, which will create an extra seven bed places and upgrade existing facilities. The owners are hopeful that the work will commence in April of 2007. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 7 What they could do better: All prospective residents should be given documented information about the home prior to admission to help then make an informed choice as to whether the home can provide the services the prospective resident requires. The residents’ care plans should be further expanded to include a full assessment of need, how those needs are to be met and what the intended goals for the residents are in providing the identified care. This should be undertaken with the resident where possible. The staff at the home should record a day and night entry for each resident to ensure that the care provided to each resident is fully known by each member of staff on different shifts. The home’s medication polices should be adhered to. Any medication given must be signed for at the point of administration to help minimise any potential for error: An up to date list of those staff that are trained to give out medications must be easily available with the corresponding signatory for each staff member also available to allow quick recognition as to which staff member administered medication at any one time; A photograph of each resident should be placed on the home’s medication documentation to ensure all staff working at the home are fully aware of which resident corresponds to which name. All hot radiators and pipe work in the house must be guarded or have a low temperature surface, to ensure that residents are fully protected form the risk of sustaining a burn. (One radiator remains unprotected since the last inspection undertaken in September 2005). As a matter of urgency the two baths and the one shower within the home must be provided with a permanent, safe regulated hot water temperature (43 degrees Centigrade), as the risk of a resident sustaining a scald from hot water whilst being fully submerged in non regulated hot water is high. The current practice of removing the plugs to prevent such an incident occurring is not appropriate as it takes away the residents’ rights to choice, if a resident wanted to and was able to have a bath independently. All other hot water outlets, accessible to residents, i.e. wash hand basins must also be regulated to a safe temperature to further ensure that residents are fully protected from sustaining a scald. Some general day to day environmental upgrading needs to be undertaken. This includes ensuring all rooms are either named or numbered to allow easy recognition for each resident. All rooms should be free from any odour associated with incontinence and routine maintenance i.e. repainting/redecorating should be undertaken as required etc. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 8 The registered owners must proceed with the manager’s application for registration, which if successful, will to allow the current non registered manager to become the registered manager at the home and so take responsibility for the day to day management of the home. This is a requirement as the owners are no longer present within the home on a daily basis and are therefore not involved in the daily management of the home. 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. Overleat DS0000003768.V305485.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 Overleat DS0000003768.V305485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 (6is not applicable) The quality in this outcome area is good. The admission process continues to be mostly well managed. However more formal information (home’s statement of purpose, service user guide) should also be made available to prospective residents so that they, and/or their relatives/advocate, can make an informed decision as to whether the home provides the services they require. EVIDENCE: Since the last inspection the home has admitted two new residents. Both of these residents were spoken with during the inspection. Following discussion with the residents and the manager, and observing documentation in relation to the admission process, it could be concluded that both the admissions had been undertaken in such a manner as to allow the residents and/or their families/ advocate to be aware of what services the home could offer. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 11 The manager visits prospective residents, whenever possible, prior to admission and there was detailed evidence of in-depth pre admission assessments that had been undertaken at this point. The new residents and/or their families had been given access to necessary information including the home’s statement of purpose, but only on admission to the home. Prior to this the manager had verbally told prospective residents about the services the home could offer. It was concluded that any prospective resident would from now on be given details about the home for them to read/look at their leisure. Up to date and relevant contracts were in place for both the residents, which included a Social Service contract for one resident and a private contract for the other. The resident had signed this. The home does not provide an intermediate care service. Overleat DS0000003768.V305485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality in this outcome area is good. All residents are looked after very well in respect of their health and personal care needs, although staff may not be fully aware of all of the residents’ care needs as care plans did not contain full explanations. Residents’ privacy and dignity is fully upheld and their life style choices respected. EVIDENCE: The care plans inspected related to the residents whose admission procedure was previously inspected. The care plans were fairly detailed and contained relevant information appertaining to providing for the individual residents care. However it was noted that although there was a statement made regarding the care needs of the resident, there was little information as to why that care should be provided and what the hoped outcomes would be for the resident. Care plans should be enlarged to incorporate this further information. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 13 However it should also be noted that additional information was also available in the form of an individual falls risk assessment for each resident, as well as a nutritional screening form, a pressure sore assessment, and a personal risk assessment being undertaken for each resident. A record of any professional visits to a resident was also kept. The manager has just registered with the “falls nurse” at the local hospital. This is a venture that will help the home identify if any pattern can be identified as to why a resident may fall and, if so, what care/treatment could be made available to help prevent this. This was seen as a good example of how the home’s staff try to act proactively to ensure residents maintain a good quality of life and that their healthcare needs are fully addressed. Care plans are regularly reviewed; monthly by the home’s senior staff and annually by the manager with the resident, their representative and any other interested parties such as other professionals etc. Residents were aware of how their needs were being met and expressed confidence in the staffs’ ability to meet them, so it was concluded that this review system was in order. The manager and staff liaise with other professionals as required including District Nurses, community psychiatric nurses, continence advisor etc. During the day of the inspection it was noted that a visiting G.P was present in the home for one poorly resident, whilst another had been called to see a second resident with a routine ailment. Feedback received from a G.P practice stated that: “There is no doubt that Overleat is well run and residents receive appropriate care and attention at all times”. Another feedback comment made by a visiting professional stated: “I have had no recent contact but standards have always been high when I have visited” Appropriate handling and lifting devices were in evidence. Residents that require, or want one, are provided with a lever on their bed to aid mobility. An example of how the staff provide that “extra touch” was evidenced in the fact that a separate microwave has been installed in the laundry room to heat up wheat bags which provide a safe and comforting source of warmth for residents at night or when requested. The care given to a very poorly resident was seen and it was noted that the care was delivered with great kindness and gentleness. The resident was having some swallowing difficulties and a great deal of time and patience was being given to the resident to help the resident take some fluids. The staff’s daily written records were professional being concise and in-depth which provided a good understanding of what care had been needed/given throughout the day for each individual resident. However a night care record was only made if anything untoward occurred, and they were not written routinely. Nightly recording for each resident should take place to ensure all details/changes are noted. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 14 This is to ensure that all staff are aware of any resident’s possible changing needs. All residents were again very positive about the care received, saying that they felt well looked after and that the staff treated them well and were very kind to them, many stated that they had no complaints and examples of comments received were: “Overleat is a wonderful place”, “I am more than happy at the home”, “I am content with the home”.” Residents were again noted as being treated by the staff with kindness and due regard for the maintenance of their dignity and rights to individuality. Such evidence that supported this was noting the gentle way that staff spoke to residents, taking into account their individual levels of ability, all residents being nicely dressed, clean and well presented. Some residents had chosen to remain in their room whilst others were enjoying the communal lounge and the company of others. A feedback card from a resident’s family member stated: “My Mother is very happy with the care provided”. Medications were seen as being mostly well managed and securely stored. The home’s medication cupboard was inspected and noted as being locked and in order. Controlled drugs were also correctly stored and administered. All staff that administer medication have received training in the same, which should ensure residents are protected in respect of receiving their medications appropriately. Unfortunately on the day of the inspection the morning medications, given at 9.00a.m had not been signed for at 11.00a.m. Although this is not good practice it was noted that the senior carer responsible for this error had been busy attending to a very poorly resident and this is why the morning medications remained unsigned for at 11.00a.m. Other records that were inspected included the home’s accident book which was seen to be in order and detailed all the required information and action taken. Overleat DS0000003768.V305485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality in this outcome area is excellent. Residents continue to enjoy a peaceful, pleasant yet varied life at the home, with visitors and local community links encouraged and maintained. Various regular activities are made available. Varied good meals continue to be provided. EVIDENCE: The home continues to operate an open visiting policy and the visitor’s book evidenced that the residents continue to have many visitors at varying times throughout the day. One visitor spoken with confirmed that she visited regularly throughout the week and was always made welcome. Staff continue to undertake activities with residents both individually and as a group on a daily informal basis. This can involve in house activities, which are changed regularly to meet the residents’ needs/desires each day, for as there are only ten residents and only some choose to participate, the staff can individualise the activities accordingly. Residents also benefit from being taken out regularly to the local town or places of interest. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 16 The home has recently purchased a people carrier type minibus to allow the staff to take residents out more frequently. Two residents chose to go on a holiday to the Isle of Wight. Others did not want to go although they were offered the opportunity. The home recently held a summer fete and raised a substantial amount of money. This was split between a local organisation ,a G.P.’s support group and the home. The residents were responsible for choosing how the money raised was distributed. Once a week there is a craft session, which many of the residents very much enjoy. Their efforts have again resulted in the residents winning this years’ handicraft cup awarded by Age Concern, Plymouth for the best residential home entry. Congratulations!! Feedback received from the home’s annual quality audit survey resulted in residents scoring the home with a 100 satisfaction in respect of the amount and content of the activities provided for them to join in with. On the day of inspection some residents had enjoyed watching the day time T.V and being together in the communal lounge. The atmosphere in the home is very much a friendly, family atmosphere, which the residents at Overleat benefit from, being noticeably relaxed and calm within the home’s environment and with the staff. One resident stated: “I couldn’t wish for a better place. The staff are perfect, just like my own children, kind and caring for those that can’t do for themselves”. Residents continue to be encouraged to express their individuality as far as possible and to this end one resident has been enabled to purchase two pet birds, which give her, and other residents great pleasure. Another example of how staff provide for residents’ personal choices was the way that one resident’s choice to have a glass of wine with their lunch was facilitated and another to have a glass of sherry prior to lunch! The home’s cook has been at the home for a number of years and is very familiar with the residents’ individual needs, likes and dislikes. Although on the day of inspection she was off duty a carer, who is also very good at cooking, expertly prepared the meal. The resulting meal of Roast lamb, fresh vegetables and roast potatoes was followed by fresh fruit salad and was enjoyed by all. The home caters for the needs of four diabetics and one resident also has a gluten free diet. All are provided for, with the minimum of fuss, whilst recognising the need to ensure that dietary demands are adhered to. District Nurse input has been sought as to the most effective way of meeting these residents’ dietary needs Choice at mealtimes is always available. Feedback comments from residents regarding the food included such statements as: “The food is perfect, there is always a choice. The cook is a great cook. When she is off the one that helps out is also very good”. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 17 The cook is responsible for undertaking the home’s shopping list and creating the home’s menus. The routines within the home remain very flexible to ensure that residents can choose how they spend their time. Overleat DS0000003768.V305485.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 The quality in this outcome area is good. Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: The home’s complaint policy remains centrally displayed and is also contained within the home’s statement of purpose. The manager has completed “The Foundation Course for Vulnerable Adults” which was delivered by the local Social Services department. The manager has now undertaken the trainer’s course in this and so is now able to use this to further train the staff within the home. The staff already use video training sessions to raise their awareness of abuse issues and there are polices in place, within the home, regarding recognising and dealing with adult abuse. This ensures that residents are protected, and feedback from residents indicated that they were aware of the home’s complaint policy, which is communally displayed and contained within the home’s documentation. Residents stated that they would feel comfortable approaching the manager or any member of staff if they should have a problem they wanted to talk about. Although all said they had no concerns at all at the present moment! The home has not received any complaints either internally or externally within the twelve months prior to this inspection. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 19 Overleat DS0000003768.V305485.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The quality in this outcome area is poor. The home’s environment provides a relatively comfortable, well maintained home for residents to live in however residents’ safety is being compromised by the owners not having yet protected all hot surfaces within the home, or by ensuring that the hot water, supplying the home’s two baths, one shower and residents’ hand wash facilities is regulated to a safe temperature. The home’s odour control systems were such that they were compromising one resident’s right to be cared for in an odour free room as the room had a very strong odour associated with urine. EVIDENCE: The home remains comfortable and relatively well maintained with a very homely feel. Residents’ bedrooms had been personalised as required. Not all residents’ room doors had a lock provided, although these will be provided if required. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 21 Some further general upgrading needs to be undertaken to fully ensure that the home provides a good standard of accommodation. This includes such things as routine decorating etc as it was noted that some rooms had no names or numbers on the doors, some paintwork was scuffed (top of the stairs) and one room smelt strongly of urine. Although the majority of the radiators have been fitted with radiator covers, there still remains one that requires covering to minimise the risk to the resident, in whose room it is, sustaining a burn if fallen/leant against. Although the owner had stated, at the last inspection, that the home’s communal bath’s water temperature was suitably regulated, it was noted at this inspection that the hot water supply to this bath was not regulated to provide a safe temperature of approximately 43 degrees Centigrade. Also the taps on this bath do not make any distinction as to which is the hot tap and which is the cold tap. The regulator that had been provided to the one en-suite bath is not of a suitable type, having a large temperature gauge which is easily accessible to the resident, and which was very easy to turn up with little effort. This resulted in very hot water being available to fill the bath, should the resident choose to alter the thermostat before using the bath. This en-suite facility also had an electric shower fitted and was such that the temperature could be easily altered to provide very hot water. As such this poses a risk to the resident occupying this room and having access to the en-suite facility. The removal of the plugs for the two baths mentioned was not seen as being an effective measure to prevent the risk associated with running a bath of hot water, as this takes away a resident’s right to have a bath independently if they so choose and are able to so. Neither was the water temperature regulated to a safe temperature to any of the residents’ individual wash hand basins or to the wash basins sited within the communal toilets. The home’s fire precautions were inspected and the owner was seen as undertaking the required tests and providing the required staff training in fire awareness. All fire doors were noted as closed or being help open as required by an appropriate hold open devise. The home has a variety of aids and adaptations fitted throughout, such as grab rails and raised toilet seats and an assisted bath seat attached to the communal bath. There is level access into the home form outside. The home’s laundry room is sited internally and was noted as being suitable for purpose, as well as being very clean and tidy. Staff were noted as following routine infection control measures to help minimise the risk of spreading any infection, such as washing their hands and using aprons and gloves as needed. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 22 Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is good. The home’s recruitment programme is robust and protects residents by the appointment of suitable staff. Staff at the home are well trained and supported, and employed in sufficient numbers to meet the residents’ needs at all times. EVIDENCE: On the day of inspection there were ten residents in the home. Staffing rotas were discussed and it was concluded that there is sufficient staff on duty to care for the residents at all times and also sufficient time available to spend with the residents socially. All residents confirmed that the staff care for them well and are available whenever needed. Training is provided regularly including statutory training and NVQ training. All staff except one has an NVQ training award in care, this also includes the home’s cook. Induction training takes place for any new staff member and other recent training events have included first aid training for all staff members, undertaken with an external trainer. This level of training ensures that staff are both appropriately trained and consequently able to provide suitable care for the residents at the home. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 24 Staff on duty were spoken with and it was evident that they took pride in their role and felt that ensuring residents had a good quality of life, irrespective of need or diversity, was the most important part of their role. Comments received indicated that staff felt they worked well together as a team, were well supported by the home’s manager and felt that they could approach her whenever required. They felt there was always sufficient staff on duty and that they were encouraged and supported to attend training which they found valuable and helped them with their role. They attend regular staff meetings and minutes were seen of these minutes, where all aspects of working at the home were discussed. The staff felt that the residents do have a good quality of life and felt that respecting their individual lifestyles was important. The home maintains a very stable staff group. Minor changes that have occurred have been mostly on the night shift due to the owners no longer living on the premises and the home having to recruit some new sleep-in night staff. The home also employs a gardener/maintenance person two days a week and a general assistant on a Saturday and Sunday, in addition to the home’s regularly employed care staff. The home does not employ domestic staff as care staff also undertake these duties as part of their role. This overall staff stability allows residents to feel secure and confident of the carers’ ability to care for them. All of the four newly appointed staff records were inspected and it was noted that a thorough and robust recruitment programme had been carried out which had included the receipt of a detailed application form, two references, and in two instances the receipt of an enhanced CRB disclosure. This ensures residents are protected by the appointment of suitable staff at the home. Staff receive regular and relevant supervision sessions which are recorded. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 The quality in this outcome area is adequate. The management of the home, although not yet formally registered, provides the necessary support to staff and residents. Satisfactory quality auditing takes place to ensure that the home is run in the best interests of the residents. The home provides a mostly safe, secure environment. EVIDENCE: The owners do not have regular contact with the home but one of the owners visits at least weekly. An experienced and suitable qualified manager runs the home, however she is yet to be registered with this Commission. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 26 During the inspection several residents and visitors fed back how approachable they found the manager and how she is available within the home when they want to speak to her. Records that were inspected were noted as up to date, concise and containing appropriate information. The residents or the residents’ families/advocates mostly deal with any financial matter although the home does hold small amounts as requested by residents or their families. There were detailed records in respect of residents’ finances and one was checked at random which was seen as accurate. This ensures that residents’ can be sure that any monies the home holds are secure. As mentioned previously, although the home’s recording documentation was seen to be mostly in order, some further expansion of the residents’ care plans and the recording of the care given during the night needs to take place to ensure the home’s records are fully complete. The acting manager holds three monthly residents’ and staff meetings with the last one being held early in May this year. The home achieved “Investors in People” in 2001 and continues to maintain the necessary standards to keep the award current. Some windows were checked to see if window restrictors were in place and these were seen to be place on those windows inspected, with the manager stating that they were in place on all first floor bedrooms. Other routine health and safety measures were in place including an up to date building risk assessment for the home and up to date fire precautions including a fire risk assessment. The home’s stair lift was last serviced in August this year. The home undertakes routine quality auditing including issuing residents’ questionnaires, family questionnaires and other professionals questionnaires. The results were available for inspection and it should be recorded that there was a hundred percent satisfaction expressed in the following areas: staff being approachable, visitors made welcome, laundry service, provision of activities, residents felt well looked after and staff were adequately trained and experienced. Ninety two percent stated that they found the management approachable. The area that scored the lowest was in regards to the environment and it has been mentioned that the owners do have plans to address the shortfalls noted in this report. Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 27 Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 28 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 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x 2 2 Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 29 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 OP25 Regulation 15 Requirement The registered providers must continue to ensure that all pipe work and radiators, to which service users have access, must guarded or have low temperature services. (Previous timescale of 06/05/06 now expired). The registered providers must regulate the home’s hot water supply to a safe temperature of 43 degrees Centigrade, which supplies hot water to any baths or other full body submersion facility within the home. Water regulation must also be provided to any other hot water outlet to which resdents have access i.e. wash hand basins. The registered providers must apply to register the home’s manager with this Commission. Timescale for action 04/11/06 2 OP25 15 04/01/07 3 OP31 8 04/01/07 Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 30 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 OP1 Good Practice Recommendations All prospective residents should be given written information about the home prior to admission to help then make an informed choice as to whether the home can provide the services the prospective resident requires. The residents’ care plans should be further expanded to include a full assessment of need, how those needs are to be met and what the intended goals for the residents are. This should all be undertaken with the resident where possible. The record of medications administered to residents should be completed at the point of administration. A photograph of each resident should be placed on the home’s medication recording documentation. There should an up to date list of all staff trained to administer medication as well as an up to date copy of all the staffs’ signatures. The home’s environment should be free from any odour associated with incontinence. The staff at the home should record a day and night entry for each resident in respect to care given. 2 OP7 3 OP10 4 5 OP26 OP37 Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 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 Overleat DS0000003768.V305485.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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