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Inspection on 14/06/06 for Pilton House

Also see our care home review for Pilton House for more information

This inspection was carried out on 14th June 2006.

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

The home has a homely and welcoming atmosphere and is a place where residents enjoy living. Emphasis is placed on it being `a home from home` and where staff considers "residents` come first". One health care professional commented that it has "a good local reputation". The home only admits residents whose care needs can be fully met at the home and residents commented that "the care I receive is excellent" and "the overall care is good". Residents are involved in the running of the home, with evidence that their views are sought. Residents are able to exercise choice and control over their lives. Staff ensure that residents are treated with care and respect at the time of their death and relatives are involved in their care. The home places a great emphasis on staff training. This ensures that residents receive care from staff that is skilled, competent and knowledgeable in their work and "all work to the same standards". Recruitment procedures are robust ensuring that residents are protected. Staff morale is high which results in an enthusiastic workforce that works positively with residents to improve their lives. Residents and staff benefit from the skills and experience of the manager. Resident`s benefit from being offered meals, which offer both choice and variety of food. The home is well managed where residents, relatives and staff feel that their opinion matters and that they will be listened to. "Staff and management are all able to be approached". Links with the community are maintained. The home organises a variety of stimulating and varied activities which are enjoyed. The home ensures it monitors its own performance through regular self-audit systems such as quality assurance questionnaires and meetings. It is "good at communication and handling criticism". The home, garden and grounds are safe, well maintained and furbished to a high standard with the home always "clean and tidy". Any monies relating to residents are correctly managed.

What has improved since the last inspection?

The staff recruitment procedure is robust and staff are only confirmed in post when the necessary pre-employment checks have been followed. When residents` monies are received into the home, they are safely and properly recorded.

CARE HOMES FOR OLDER PEOPLE Pilton House Pilton Street Pilton Barnstaple Devon EX31 1PQ Lead Inspector Victoria Stewart Unannounced Inspection 14th June 2006 09:45 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 Pilton House DS0000022096.V293486.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. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pilton House Address Pilton Street Pilton Barnstaple Devon EX31 1PQ 01271 342188 0870 1219766 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) Barnstaple Old People`s Housing Association Limited Mrs Gina Helen Rogers Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (27), Old age, not falling within any other category (27) Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: Pilton House is an extremely spacious and attractive listed Georgian manor house. It is situated in the Pilton area of Barnstaple. Barnstaple Old Peoples Association (BOPA) is the registered provider and a Committee play a regular and active part in the running of the home. The home is registered to provide care for 27 service users in the categories of old age (OP), Mental Disorder - over 65 years of age (MD, E) and Dementia over 65 years of age (DE, E). The home is situated in large, attractive grounds in a residential area and is close to the local facilities, amenities and services of both Pilton and the centre of Barnstaple town. It has an extensive parking area. Bedrooms are mainly en-suite, of varying sizes and are situated on two floors. Residents can access all areas of the building by a lift or staircases. There are a variety of communal areas in the building which includes a welcoming reception area, large sitting room, dining room, quiet lounge and a small library. The cost of care ranges from £320-360 per week at the time of inspection. Chiropody, hairdressing, personal toiletry items and newspapers/magazines are additional costs which are not included in the fees. Current information about the service, including the CSCI inspection reports, are readily available to those that wish to look at them including current and prospective residents, relatives, staff and professionals. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the normal inspection programme and took six hours to complete on 14 June, 2006. The registered manager, deputy manager, senior care officer, staff and residents all took part in the process. The inspector also met with a member of the management committee of the home. The home was full on the day of inspection and the inspector spoke or saw all of the residents in the home, either in the communal areas or in their private rooms. Prior to the inspection, a number of information surveys were sent out to residents, relatives, care professionals and staff to obtain their views on the service. Any direct comments made are included within the actual text of the report. Eight out of ten surveys sent to residents were returned with very positive comments. These confirmed that residents were happy at Pilton House and received the care they needed, that staff listened to what they had to say and were always available, that the home was always clean and tidy and that they liked the meals and activities offered. Three surveys were sent to relatives and all were returned. Two other relatives were contacted and spoken with by telephone. All confirmed that relatives were welcome at the home, that they were involved in the care of their relative/friend, that the home was well staffed and that they were satisfied with the overall care provided. Seven out of twelve surveys sent to health and social care professionals were returned. These confirmed that the home communicates and is managed well, that residents can be seen in private and that staff have a clear understanding of residents’ needs, including knowing when to ask for specialist advice. Thirteen out of seventeen staff surveys were returned. These confirmed that staff had been employed appropriately, they felt supported in their jobs and that they received good training to do their jobs. This report is written with information gained from the pre-inspection questionnaire completed by the home, by talking with residents, staff and management, by looking at a selection of records (including resident files, medication records, staff files, training records, fire records, quality assurance surveys and by undertaking a tour of the home. Finally the outcome of the inspection was discussed and agreed with the registered manager prior to leaving the home. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 6 What the service does well: The home has a homely and welcoming atmosphere and is a place where residents enjoy living. Emphasis is placed on it being ‘a home from home’ and where staff considers “residents’ come first”. One health care professional commented that it has “a good local reputation”. The home only admits residents whose care needs can be fully met at the home and residents commented that “the care I receive is excellent” and “the overall care is good”. Residents are involved in the running of the home, with evidence that their views are sought. Residents are able to exercise choice and control over their lives. Staff ensure that residents are treated with care and respect at the time of their death and relatives are involved in their care. The home places a great emphasis on staff training. This ensures that residents receive care from staff that is skilled, competent and knowledgeable in their work and “all work to the same standards”. Recruitment procedures are robust ensuring that residents are protected. Staff morale is high which results in an enthusiastic workforce that works positively with residents to improve their lives. Residents and staff benefit from the skills and experience of the manager. Resident’s benefit from being offered meals, which offer both choice and variety of food. The home is well managed where residents, relatives and staff feel that their opinion matters and that they will be listened to. “Staff and management are all able to be approached”. Links with the community are maintained. The home organises a variety of stimulating and varied activities which are enjoyed. The home ensures it monitors its own performance through regular self-audit systems such as quality assurance questionnaires and meetings. It is “good at communication and handling criticism”. The home, garden and grounds are safe, well maintained and furbished to a high standard with the home always “clean and tidy”. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 7 Any monies relating to residents are correctly managed. 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. Pilton House DS0000022096.V293486.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 Pilton House DS0000022096.V293486.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): 1,2,3,4,5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home provides good information to prospective residents to allow them to make the choice about whether they wish to live at the home or not The home ensures that a full assessment is made on each resident prior to admission to ensure that the home can fully meet his or her individual needs EVIDENCE: Four files of resident’s care were looked at. All files contained a preassessment of care need carried out by the home before being admitted. Files also contained a care assessment and plan carried out by social care and/or health care professionals. All files contained a completed contract and signed acceptance of terms and conditions of the home. The home’s statement of purpose and service user guide is available for all prospective residents and copies are available at the home. All resident surveys received confirmed that they had received enough information about whether to live at Pilton House or not and they were very pleased with the home. Typical comments were “”a Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 10 very homely home, with caring staff” and “I’m very pleased with the home”. Surveys also showed that some relatives had been involved in the choice of home. Trial visits are offered by the home and some residents confirmed that they took advantage of this opportunity. Some of the staff have worked at Pilton House for some time and others are new to the home. There is a wide range of training available to staff to equip them with the skills and knowledge needed to look after the residents. The staff group is motivated and all enjoyed the training offered. On the day of inspection, recognised dementia training had been organised for the majority of staff to attend as part of an eight-week training course. Pilton House DS0000022096.V293486.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): 7,8,9,10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Resident’s benefit from staff planning and delivering a high standard of health and personal care Medications in the home are well managed but some improvements are required in record keeping Staff ensure that residents are treated with care and respect at the time of their death and relatives are involved in their care EVIDENCE: Four residents care files were looked at. All had an individual plan of care in an easy to read and follow format and showed evidence of regular updating/reviewing with resident consultation. Residents’ preferences and choices were recorded. Risk assessments had been completed and regularly updated preventing unnecessary risk to residents. Files showed that the home contacts specialist advice from other professionals when needed such as the Parkinson’s specialist nurse, Diabetes nurse, speech therapist and incontinence Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 12 advisor. One health professional said that Pilton is a “very good home who know their limitations and ask questions when they don’t know”. Records also showed that residents received regular visits from the GP, district nurses, dentist, chiropodist and optician. All resident and relative surveys received confirmed that residents felt that they always received the care, support and medical attention they needed. Comments included “the care I receive is excellent”, “very caring staff” and “the overall care is good”. All professional contact surveys received stated that the home communicates clearly and works in partnership with them and one said “the home provides very good care”. The home has a satisfactory medication policy and procedure. All staff that dispense medication receive the appropriate training. Four residents Medication Administration Records (MAR) were looked at. These were generally satisfactory but it was noted that some medications were being given at a time different to that prescribed, which included one controlled drug, and that some changes in medication were not being recorded appropriately on the MAR chart which could both lead to unnecessary potential risk to residents. One of the medication records looked at showed a resident who wished to give her own medicines. A disclaimer and risk assessment had been carried out but this had not been properly reviewed for some time. It was not clear when one of this resident’s prescribed applications was opened or the date it needed to be discarded by. This could affect the potency of the medication. The home audits its own medication practice on a regular basis to highlight any improvements in practice, although this had not been carried out since March 2006. Staff displayed a very good understanding of meeting the privacy and dignity needs of residents both in their completed survey forms and in formal interviews carried out during the inspection. Training in this area is covered in new employee staff induction. Relative and professional surveys confirmed that they could visit in private. The inspector observed that privacy, dignity and independence was afforded to residents in the home during the inspection and residents confirmed that staff respected this. Staff informed the inspector that care and comfort are afforded to residents who are dying and their relatives included in this care. Drinks, meals and overnight stays can be arranged if desired to allow relatives to stay with the resident. Staff and management confirmed that there is enough staff on duty for one person to be with the dying resident and ensure they are not left alone for long periods. Staff confirmed that the local hospice is used for specialist advice if needed. One member of staff stated that on one occasion a specialist bereavement counsellor was asked to visit staff by the home to offer emotional support for those who needed it following one the death of one particular resident. One recently bereaved relative stated that the care and kindness she received from the staff was “superb” and that “great kindness and efficiency was extended to myself and my family”. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 13 One resident was being looked after in his room and evidence was seen of good personal care given by staff and good communication about his condition passed on to other staff. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Residents are able to exercise choice and control over their lives Residents’ benefit from being offered meals which offer both choice and variety of food Residents are encouraged to maintain contact with family and links with the local community The home offers residents a programme of social and recreational activities which residents enjoy EVIDENCE: The home has an activities organiser who provides 20 hours a week of various social and recreational activities. These range from the usual in house activities such as quizzes, bingo and musical entertainers to outings to the local coast and shops in the home’s minibus (for “proper” ice-cream or cream teas) or visits to local shows and displays (such as the theatre). One recent activity involved a selection of wild birds such as eagles and kestrels visiting the home which residents enjoyed. The annual Pilton Festival is shortly due to Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 15 take place when the home plays an active part in the festival by opening the grounds to the local community. Residents enjoy this time of year and have a choice to either participate in the proceedings or just watch from the garden. Residents confirmed that they enjoyed the activities programme in the home. One member of staff commented that they would like to see more hours spent on activities, as 20 hours a week is sometimes not enough to do everything. Relatives and visitors are made welcome at the home, with one request by the home not to visit at breakfast time. However, the manager confirmed that this is totally negotiable and by prior arrangements visitors can visit the home at any time. Relative surveys confirmed that they were made to feel welcome at the home and felt involved in the care of the resident. A new larger menu board had recently been provided which so that residents’ who have sight impairment are able to see it. Menus display that the home provides a wide and varied choice of meal. Residents liked the food but two surveys commented that they thought the breakfast and lunch times are too close together. When the inspection commenced the inspector noted that many residents had chosen to eat breakfast late, with lunch being served only approximately 2 and a half hours later. The timings of meals were discussed with the manager who promised to review this in the near future and seek resident choice and consultation. Special dietary meals are catered for. One resident was being fed in his room in a non-rushed and dignified manner. Resident and staff surveys confirmed that residents have choice and control over their lives in the home and are free to come and go as they please. One resident enjoys a daily trip to the local club, one enjoys a weekly trip to the local church of choice and another goes into the local town shopping. One staff member commented that the dining room is too small. The refurbishment programme confirms that the home has plans to extend the dining room to enable there to be more space for residents to dine together and provide improved access. However this takes longer than normal as the building is listed and requires special licence to make any improvements. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service The home has a good complaints system with evidence that residents, relatives and staff feel their views are listened to and acted upon EVIDENCE: No complaints have been received by the CSCI since the last inspection. The home has a good complaints system and residents, staff and relatives confirmed that they knew how this worked either in their surveys or in talking with them. Staff felt they would could use the complaints system openly and that they were also aware of outside agencies to contact if necessary. Residents and relatives wrote in their surveys that they thought the complaints system in the home worked well and felt that they are always listened to. They were very complimentary of the way in which complaints were dealt with and re-occurrence of the cause for complaint did not occur. Comments included: “the complaint we made was dealt with immediately and there was no repeat of the problem”, concerns “can always be discussed with the manager and dealt with” and “I had cause to complain on one occasion, it was dealt with promptly and the situation never happened again”. Professional surveys confirmed that they had never had cause to make a complaint to the home. All complaints are held securely in a file and contain details of full investigation carried out and any outcomes or changes in practice. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 17 The manager also uses the regularly distributed quality assurance questionnaires sent out to residents, relatives and staff to bring any concerns to the management’s attention. This enables any concerns to be dealt with before they become serious issues or complaints. Staff demonstrated a good understanding of what abuse is and said they would not hesitate to report it to a senior member of staff. Staff undertake the recognised Protection of Vulnerable Adults training and five staff spoken with were aware of adult protection procedures. The home has an adult protection procedure based on the Devon County Council Social Services Alerter’s Guide and management confirmed they felt confident to use it. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Residents benefit from living in an environment that is homely, well furnished and maintained to a high standard EVIDENCE: The home is well furnished, decorated and maintained to a high standard. The residents have the advantage of a maintenance man who is employed full-time to look after the home. He has built up good relationships with the residents and the inspector saw that one resident asked him to carry out a repair in her private room and then later in the day asked by another resident to remove an unwanted bird from outside of her private room which was causing much concern. There is a programme of refurbishment at the home both for indoors and outdoors. Evidence was seen of decoration since the last inspection to several areas of the home including the front hall, the hall to the dining room, new carpets to the stairs and the dining room and a new floor covering in one of the resident’s bedrooms more suitable to the resident’s individual needs. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 19 The type and colour of stair carpet was chosen specifically to reduce the risk of falls and prevent unnecessary risk to residents living at the home. When residents leave a room, the opportunity is then taken to redecorate the room as necessary. Resident surveys confirmed that the home was always fresh and clean that typical comments were: “the home is always clean and tidy”. Residents decorate their rooms with their items of personal and sentimental value and the inspector was invited to see a new addition to her collection of treasured possessions. The laundry area was clean and tidy and equipment was well maintained and operating. However, some fluids were found in both this room and the upstairs bathroom which could pose a health and safety risk to residents (refer NMS 38). Gloves and aprons are freely available for staff to use to maintain good hygiene practice. Specialist equipment such as mattresses, hoists, grab rails etc are used when needed and examples of these were seen in the home in both communal and private areas. Equipment is stored out of the way of residents when not being used. The gardens are maintained by a gardener and looked very appealing on the day of inspection. Residents sitting outside enjoyed the flowering hanging baskets and were anxiously awaiting the winner of the competition to grow the tallest sunflower. One resident comment was “the gardens at Pilton House are wonderful where we can sit and enjoy talking to each other”. Private rooms are decorated individually and one resident showed the inspector her most recent new addition to her sentimental possessions in her room. Residents are encouraged to bring in their own items of furniture and these were evident in their rooms. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is excellent. This judgement is made using available evidence including a visit to this service Staff morale is high which results in an enthusiastic workforce that works positively with residents to improve their lives The number and skill mix of staff is sufficient to meet individual residents’ needs Residents’ benefit from staff who receive all the training necessary to allow them to do their jobs well Recruitment procedures are robust ensuring that residents are protected EVIDENCE: The home always ensures that there is the right amount of staff on duty to meet the residents’ needs. With the exception of one or two, all staff have achieved or are working towards gaining an NVQ level 2, 3 or 4 in care. Training in the home is identified and promoted. The training records showed that staff take part in all the mandatory required training in the home, but also attended other training such as the NVQ assessor’s award, dementia, health and safety, safe administration of medicines, incontinence and infection control. Staff commented in their surveys and verbally that they enjoyed the training and that “residents have a good standard of care…that is what really matters”, training ensures “we all work to the same standards” and the home Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 21 “provides the training and back-up we need to enable us to do our jobs correctly”. The staff morale is high and staff spoke overwhelmingly about how much they enjoy working at Pilton House. Comments about their place of work included: “happy”, “lovely”, “smashing”, “warm” and “friendly”. Regular staff meeting take place every two months when staff can air their views and any changes in practice discussed. Four staff files were looked at all staff had been recruited using a robust procedure to ensure the protection of residents. This includes all the information required to be obtained and held on file before a person is employed at the home. Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 & 38 Quality in this outcome area is excellent. This judgement has been made on available evidence including a visit to the service. Residents and staff benefit from the skills and experience of the manager Residents are involved in the running of the home, with evidence that their views are sought Systems are in place to ensure that residents’ personal monies are correctly managed The health and safety procedures in the home are generally good but improvements need to be made to ensure residents are not put at unnecessary risk. EVIDENCE: Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 23 The manager is a qualified Registered General Nurse (RGN) and has other care and management qualifications to enable her to run and manage the home. She has most recently almost completed an NVQ 5 in training and development. Residents, relatives, staff and professionals all confirmed both in surveys and verbally that they have confidence in her, that she listens to them and that the door ‘is always open’. Comments included: “management staff are very helpful”, “staff and management are all caring and able to be approached” and they are “good at communication and handling criticism”. One overwhelming typical comment was: “they make sure that residents come first”. The home has an established quality assurance system to ensure that residents’ views are listed to and acted upon. Resident/relative meetings take place every two months and discussion and feedback is encouraged. Residents, relatives and staff have recently completed a questionnaire and the manager is currently looking at these. The manager is committed to improving the home and involves residents in this process. The quality assurance system may in the future include ‘mini inspections’ carried out by the manager who believes this will maintain the standard of the home. A regular monthly visit by a different member of the management committee takes place; with a focus chosen of care on each visit and these are monitored by the home. Staff and records confirmed that regular supervision takes place with a senior member of staff every two months to discuss their practice. Staff commented that they find this helpful but feel that the management can be approached at any time. An annual appraisal takes place for all staff which identifies. The home keeps some personal accounts of residents and the inspector looked at how these are kept. Each is kept secure and monies kept by the administrator of the home. Records, receipts and accounts held are kept in order. The pre-inspection questionnaire showed that servicing and maintenance of all equipment held in the home is carried out regularly and appropriately. Fire safety was randomly selected at the home and records, equipment and training was checked. These were all found to be satisfactory. Mandatory training of all staff takes place. Pilton House DS0000022096.V293486.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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X 3 3 3 2 Pilton House DS0000022096.V293486.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. 1. Standard OP9 Regulation 13, 2 Timescale for action The registered person shall make 14/08/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines into the care home. With regard to: • ensuring that all medicines are given at the prescribed time on the MAR chart • ensuring that any changes in medication are recorded appropriately on the MAR chart • ensuring that all prescribed medication used externally has an opening/discard date written on it • ensuring that all risk assessments relating to residents who selfmedicate are reviewed and up to date The registered person shall make 13/07/06 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; and unnecessary risks to the health or safety of DS0000022096.V293486.R01.S.doc Version 5.2 Page 26 Requirement 2. OP38 13 (2) a,c Pilton House service users are identified and so far as possible eliminated With regard to: • ensuring that all substances which are hazardous to health are stored securely and appropriately (bathroom and laundry areas) 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 OP15 Good Practice Recommendations It is recommended that the home reviews the times of meals served in the home with resident consultation Pilton House DS0000022096.V293486.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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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