Inspection on 14/07/06 for Pavilion Care Centre

This inspection was carried out on 14th July 2006.

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

Pavilion Care Centre 04/10/07

Pavilion Care Centre 16/02/06

Pavilion Care Centre 13/09/05

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

CARE HOMES FOR OLDER PEOPLE Pavillion Care Centre North View Terrace Chilton Moor Houghton-le-spring Tyne And Wear DH4 5NW Lead Inspector Mr Steve Tuck Key Unannounced Inspection 11:30 14 July and 6 and 12 September 2006 th th th 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 Pavillion Care Centre DS0000063779.V302898.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. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pavillion Care Centre Address North View Terrace Chilton Moor Houghton-le-spring Tyne And Wear DH4 5NW 0207 0343220 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) www.europeancare.co.uk European Care (England) Ltd Mrs Ann Marie Shillaw Care Home 40 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (40), Physical disability (2), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (6) Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may from time-to-time admit persons under the age of 65 within the OP category. 16th February 2006 Date of last inspection Brief Description of the Service: The Pavilion is a large detached building set in its own grounds in a small village near Houghton-le-Spring, near the boundaries of Durham. It was originally built in the 1960’s and is currently owned by European Care Ltd, an independent provider. The home provides personal care for up to 40 older people. The home is divided into 2 distinct units with 20 bedrooms on the ground floor, and 20 bedrooms on the first floor for older people with dementia care and mental health needs. The home is not registered to provide nursing care. Each floor provides a range of lounge and dining rooms, bathrooms and small kitchens. All necessary facilities are provided and are suitable for the people who live there. A staff call system, which is accessible to the service users, is provided in all parts of the home. Set back from the main road the home is close to local amenities and bus routes. There are well kept gardens around all sides of the home and the large front lawn has a wishing well and other garden features of visual interest for the people who live there. The laundry and staffroom are located on the second floor of the home. A place at this home costs £310 - £550 per week. Additional charges are made for toiletries, newspapers/magazines, private chiropody and manicurist (if required) and hairdressing. Items which are included in the cost are listed in the homes terms and conditions. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three days on 14th July, 6th and 12th September 2006 and was a scheduled unannounced inspection. Prior to the inspection site visit, the manager had completed a questionnaire in which she gave some of the evidence which was used to make judgements about the service The inspection process involved spending time talking to a number of the people who live in the home as well as the management team and staff. A sample of records were examined including care plans and rotas. The inspector joined some service users for lunch to talk about the service they receive and observe the way that people are supported at lunchtime and throughout the day. Several staff were interviewed to assess their care practices and their knowledge of service users needs. Time was spent examining the building, which included all communal areas and a selection of service users bedrooms as well as the kitchen and laundry. Observations were made of the support the staff offered to service users at mealtimes and throughout the day. Discussion also took place with visitors to the home and several relatives were interviewed. Ten service users and nine relatives/friends returned questionnaires which gave their views about the service. All of these have been used in this inspection and report. Service user comments included: “All of the staff are very caring and the home is well run.” “I like it here if I didn’t I would move out.” What the service does well: Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 6 This is a popular home amongst people who live in the areas which surround it. The people who live here had many positive comments to make about the service they receive. Service users and visitors described staff, as helpful and “calm, patient and sensitive to peoples needs,” One relative said that there is a “friendly atmosphere and good management style at the home. People talk to each other at this home, service users staff and visitors get on well which adds to the ‘homely’ atmosphere of the service. One relative described the home as having a “little community of its own.” The home offers service users a homely, clean and comfortable place in which to live. The accommodation is clean bright and cheerful. Service users and visitors praised the domestic staff who keep the home clean. All bedrooms are spacious single rooms with en-suite facilities. The home has a number of different lounges for people to use. There are also large gardens to the front and back of the house where residents and visitors can enjoy in good weather. Service users get the support that they need from staff to ensure that their personal, physical and emotional needs are met. And they work well as a team. All service users living at the home are supported by staff without prejudice to their level of need, preference or background. Staff training is good with almost all staff having achieved NVQ level 2 and over half at level 3. Additional specialised training takes place so that staff have up to date knowledge and practices to support the needs of people living at the home. There are few staff who leave this home, so they know each other and service users well. The manager and staff have good working practices with community healthcare staff such as district nurses, which helps to ensure that service users receive prompt medical attention or monitoring should these be required. There are activities both in and outside of the home are available so that people have the opportunity to lead stimulating and interesting lives and relatives and friends are encouraged to take part if they wish. The service is managed by a competent leader who successfully directs the way in which the home responds to the needs of service users. Service users and relatives were complimentary about the manager and felt that their views were listened to. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 7 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. Pavillion Care Centre DS0000063779.V302898.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 Pavillion Care Centre DS0000063779.V302898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 and 3 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A range of information about what life is like at the home is available to help people to decide if they want to move there. Each service user’s needs are assessed before they move to the home. This helps to make sure that their needs can be met at the home and inappropriate admissions are avoided. EVIDENCE: The home has written information called the service users guide, which gives all of the important information that people need to know about the home. This includes information about how to make a complaint and the most recent Inspection report. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 10 The manager prefers people to visit the home before they decide to move in and one service user said this was useful. He said, “you can’t really tell until you’ve moved in but the book (service user guide) is helpful”. Another service user said that there was “more than enough” information available. The manager changes the information in the guide to make sure that it is still up to date and accurate. Each service user’s needs are assessed before they move to the home either by a local authority social worker, the manager, or by both. This is so that the manager can be sure that the home is suitable for meeting the needs of people who are going to live there. The manager also finds out the cultural and lifestyle needs of people who wish to move to the home to make sure that these can be met. As a result of these measures, all of the people living at the home at present have been properly placed and the home is able to meet their needs. Where people have specialised needs or they are already having treatment the manager asks for advice and guidance from other healthcare specialists to make sure that these needs are best met. The home does not provide care for those people who have been admitted on a short-term basis to get special therapy while they recover from injury or hospital treatment. No one has been admitted to the home with these needs. One person said, “It was good to come here because I couldn’t cope at home. I met with the manager who talked to me and my daughter and when I moved in they knew what help I needed”. Pavillion Care Centre DS0000063779.V302898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Each service user has a care plan, which sets out their preferences and how their assessed needs will be met by staff at the home. The way that staff at the home store and give out medication should help to make sure that service users receive the medical treatment they have been prescribed. But there have been some errors made which could lead to service users receiving the wrong medication by mistake. Staff have a friendly and respectful approach towards service users, which empowers them and helps to keep in control of their lives. EVIDENCE: Improvements in the care planning arrangements have taken place since the last inspection. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 12 Care planning arrangements are now much clearer which helps service users to understand them and staff are better able to record the support they carry out. Care plans have detailed information about the healthcare needs of service users. This records how the health of service users is monitored and supported and how treatment is to be organised. Service users needs are reviewed by staff and any worsening in health is noted so that treatment can be arranged quickly. Records are clear, accurate and help the manager to monitor the effectiveness of treatment. Staff are diligent and routinely involve Doctors and community nursing staff so that healthcare needs are properly met. For example the observation of skin condition and the treatment of pressure sores. The manager confirmed that she is going to continue to develop the care planning arrangements at the home so that she can add more detail and further improve the format. Staff are also to receive additional support and training. All accidents and incidents are dealt with appropriately to ensure that service users remain safe whilst they are supported to maintain their confidence and independence. Due to their levels of need, most service users are not able to organise their own medicines, and appointed staff therefore help in this area. Staff at the home have taken training in relation to medication administration. Medication is securely stored but some records were not accurate and the amount of medication prescribed and administered did not match. When this was brought to the managers attention she took immediate action to ensure that service users had received the medication they are prescribed and records were put in place to ensure that and mistakes were minimised. Service users are treated with respect by staff, who know them well and the atmosphere at the home is supportive and good-humoured. There is a good rapport amongst service users and staff at the home. Visitors are welcomed and said that they are always treat well by the staff and manager at the home. Pavillion Care Centre DS0000063779.V302898.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. A variety of social activities are provided which help service users to make positive choices about how they spend their day and friends and families are encouraged and involved too. The meals provided offer a balanced diet and help service users to eat healthy food and service users and families are involved in planning the menu. EVIDENCE: Service users talked of the things that they do both inside and out of the home, in the local and wider community. For example games sessions, shopping visits, social events and entertainers. There are many photographs of celebrations, annual events and visits to places of interest and service users talked about these. The home has strong links with the local community, with groups who support service users and are keen to include people who live in the home in the opportunities available to all citizens in the area. For some of the people who are unable or do not wish to leave the building there is a range of activities taking place some of which have been suggested by service users. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 14 An activities co-ordinator works at the home and supports service users to take part in opportunities. Some staff have undertaken training so that they can improve the support they give to promote the lifestyle opportunities of people at the home who have dementia type illness. Staff relationships with relatives are good and visitors are made to feel welcome and supported. All relatives said that they felt they could talk to staff easily and would approach them first if they had any concerns. One relative said, “I know I can visit at anytime and the manager and staff are always pleased to see visitors.” Staff talk with everyone living at the home using a variety of skills to help include everyone in conversation and discussion. They are skilled at making sure that people who have dementia type illness or who are unable to communicate with language are supported to make choices and are included in discussions. Service users said that they like the meals at the home and that they are asked what they would like to eat. Staff were observed asking service users about their choice of meal, size of portion to ensure that the element of choice for service users is always followed. Staff were available during meals to offer support and assistance where needed and this makes meal times a relaxed and unhurried experience for service users. Menus were available which confirmed that a range of meals are provided which give service users a balanced diet and refreshments are available throughout the day and night. A range of fresh fruit and vegetables are used in the preparation of food at the home which increases the nutritional benefit for service users. Service users and their families are involved in choosing the meals which are included in the menu. The home has received an award from the local authority because the meals are good and provide a healthy diet for people living at the home. Menus have been prepared for display which include photographs of actual meals which helps service users who have difficulty with written lists to make informed choices. Where necessary and as identified in the individual assessment, special diets and food supplements are made available and, as part of an ongoing process of monitoring health, records of weight loss/gain are recorded in service users’ files. Pavillion Care Centre DS0000063779.V302898.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 inspected at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. The home has a complaints system which service users can use if they are unhappy, have a grievance or dispute. They also give feedback when they are happy with the service. The home has measures in place which protect service users from being harmed which helps to promote their safety and security. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 16 EVIDENCE: There have been few complaints at the home in the last twelve months. There is a complaints procedure which describes the actions and timescales the manager or owner must follow if a complaint is made. All service users said that they knew how to complain if they were unhappy about something. Service users said that they would let staff know if there were any complaints, even small things so that they could be sorted out straight away. Relatives spoken to said that they would not be worried about approaching staff or the manager if they were unhappy about the care of their relative. They were confident that their concern would be taken seriously and something done about it by the manager. One visitor said, “I’ve not had any complaints but her (the manager’s) doors’ always open if you need to see her about anything.” On a day-to-day basis staff encourage service users to make choices and service users were seen to actively express their wishes. In this way the home minimises the likelihood of service users being dissatisfied whilst also ensuring that their lifestyle meets their expectations. The manager also ensures that staff have sufficient time to talk to service users about how they are feeling and to ensure that they continue to be happy at the home. Whilst there have been no instances where abuse has been suspected or reported, the home has an adult protection procedure which is robust and complies with the Public Disclosure Act and the Department of Health Guidance. Information about the role of the local authority is available and included in the homes procedures. There is a staff guide which gives clear instructions about the actions which they must take if abuse is disclosed or witnessed. All staff spoken to are knowledgeable of these practices and have demonstrated that they know the actions they must take. Pavillion Care Centre DS0000063779.V302898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 23 24 25 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is clean, warm and comfortable offering service users a homely and safe environment in which to live. EVIDENCE: All communal areas and some service users bedrooms were viewed during the inspection. Some of the communal areas have been redecorated and refurbished since the last inspection. The flooring had been replaced in the downstairs corridors. New flooring has also been installed in the corridor upstairs and the manager has added a collection of local period photographs which are relevant to service users who have lived in the area. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 18 All service users have individual rooms most of which have been furnished with personal items to make them more individual and homely. Some people have brought in their own furniture. One service user said, “Just look at my room, I’ve got everything I need here and the staff help me to keep it tidy.” The garden areas around the home are well kept and are enjoyed by service users especially during the warm weather. One relative commented that it had been good to see people using the gardens this year because of the fine weather. The home has a thorough cleaning programme at the home which makes sure that there are no unpleasant odours and this maintains a healthy environment for service users. One service user described the cleanliness of the home as “brilliant”. There are several lounges around the home where people can spend their time however the upstairs lounge has worn out furniture and is also in need of general refurbishment to the décor and other fittings. There are sufficient bathrooms available to meet the requirements of all service users living at the home. However one bath could not be used because the hot water did not work and another was being used to store furniture. There have been several changes in the ways in which the home is maintained in order to improve the effectiveness of the maintenance, replacement and refurbishment programme. There were a number of areas where maintenance or refurbishment is required and the manager demonstrated that plans were in place to carry these out. All equipment used at the home to support service users or ensure their and staff safety, is regularly checked, serviced and maintained. Laundry facilities are well maintained and run to ensure that all laundry is properly cleaned. However one laundry practice was seen which does not minimise the risk of cross infection. Pavillion Care Centre DS0000063779.V302898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported by staff who know them well and are committed to their wellbeing, which makes sure that service users needs are consistently met. The ways that staff are employed is robust and record keeping gives enough information to make sure that service users are protected from people who are unsuitable to work with vulnerable people. There are sufficient staff working at the home to meet the needs of people who live there. Many of the staff have undertaken training to make sure that their care practice is good and the manager guides them to make sure that they support people properly EVIDENCE: There are sufficient staff available to meet the needs of service users at the home. Rotas, which organise when staff are working are well structured and arrangements are in place should staff need to take leave at short notice. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 20 Staff are also supportive of each other and their manager both in their practice and also in their willingness to remain flexible about their working practices so that service users will benefit. Staff can describe the needs of service users in detail, they get on well together and with service users and promote an inclusive and supportive structure at the home. The staff team maintain good relationships with service users, relatives and visitors who are complimentary about them and their approach. One service user said they are “very easy to talk to” and they are “ always on hand”. Staff were noted to spend quality time with service users, listening to their opinions and experiences and taking part in discussions and demonstrating good humour. Staff turnover at the home remains very low which gives service users and staff the opportunity to get to know each other and helps the manager to structure and train her team. Induction training is in place should new staff be required which will make sure that they have all of the training they need to carry out their role with skill and competency. The homes recruitment process helps to make sure that all staff have appropriate checks carried out prior to them taking up employment to ensure that they are suitable to work with vulnerable people. Almost all staff have now obtained NVQ at Level 2 and some have achieved level 3. There is a plan in place which describes the training that staff are to undertake and this is provided by training agencies who support the home and also by the company’s own trainers. The manager has also sourced training opportunities for senior staff from a national organisation which supports people with dementia and their families. Several staff at the home have now themselves become trainers and are about to begin work with the colleagues at the home about how they support people who have dementia type illness. The manager prefers to recruit staff from similar cultural backgrounds as the service users living at the home. In the majority of cases service users and staff have the same community and social links, which helps to ensure that service users are confident with the way in which they are supported. The manager meets with all staff on a regular basis to examine their work performance and give guidance and structured appraisal of their work. Pavillion Care Centre DS0000063779.V302898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The manager provides drive and commitment to maintain and improve the quality of care at the home. She offers clear leadership and direction to the staff and they have support and supervision from the manager to make sure that they carry out their role effectively which helps to make sure that their care practice meets the needs of service users. Arrangements to ensure that the health safety and welfare of service users and staff are in place and are usually successful. The steps which the home takes to makes sure that service users’ financial interests are safeguarded are effective and accurate records are in place. This supports service users to remain independent and helps if they or their families have a query. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Manager has attained NVQ level 4 in Care, a Diploma in Business Studies and has also completed the Registered Managers’ Award. She has been responsible for the day-to-day management of the home for around 7 years. She is assisted by a Deputy Manager and a team of senior staff and supported by a senior manager who visits the home regularly and carries out visits on behalf of the owner. There are clear lines of accountability within the home and within the organisation. The manager makes sure that formal one to one supervision takes place six times per year as well as effective day-to-day communication between herself, senior and care staff. The manager runs the home in a way that is clear, open and objective. She has an open management style and is approachable so that service users and relatives are consulted about issues affecting the home. She routinely joins staff to monitor their performance and always makes herself available to service users and families. She is outgoing, an active and creative manager who has introduced many new initiatives to the home. Staff said that they like the clear direction they get from their manager. There is a detailed quality assurance process for the home which includes finding out the views of service users and relatives and using this feedback to confirm or change the way in which the home works. Service users are enabled and supported to assert themselves and their opinions are valued by the manager. A number of types of meetings are organised including consultation with families and friends. The home helps some service users to manage their day-to-day spending and accurate records are kept of these transactions. The home is also regulated by the local authority for safe working and hygiene practices and the Fire Protection Authority to ensure that adequate arrangements have been put in place to protect service users and staff. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 23 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X 3 3 3 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 3 X 3 X 3 3 X 3 Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 24 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 OP9 Standard Regulation 13 Requirement The manager must take steps to ensure that accurate administration of medication takes place at the home. (Previous timescale 15/10/05) The premises issues must be addressed as reported to the Manager during the inspection. The manager must ensure that worn out and damaged furniture in the upstairs lounge is replaced and the room refurbished. The manager must make sure that all Bathrooms must be in working order and kept clear of stored items. The manager must make sure that hygiene practices in the laundry are improved so that the risk of cross infection is reduced. Timescale for action 01/10/06 2 OP19 3 OP20 4 OP21 5 OP26 23 15/10/06 23 01/11/06 23 01/10/06 13 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 25 No. 1 Refer to Standard OP7 Good Practice Recommendations The manager should continue to develop the care planning arrangements at the home so that she can add more detail and further improve the format. Staff are also to receive additional support and training. Pavillion Care Centre DS0000063779.V302898.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. 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