Inspection on 10/07/08 for Pondsmead Care Home

This inspection was carried out on 10th July 2008.

CSCI found this care home to be providing an Good service.

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.

Other inspections for this house

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Pondsmead Care Home Shepton Road Oakhill Bath Somerset BA3 5HT Lead Inspector Justine Button Key Unannounced Inspection 10th July 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pondsmead Care Home DS0000070015.V363529.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. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pondsmead Care Home Address Shepton Road Oakhill Bath Somerset BA3 5HT 01749 841111 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) None Mimosa Healthcare (No4) Limited Miss Keren Elizabeth Kahan Care Home 76 Category(ies) of Old age, not falling within any other category registration, with number (76) of places Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 76. Date of last inspection Brief Description of the Service: Pondsmead Care Home is located on the outskirts of the Mendip village of Oakhill, close to a local pub and village shops. It was completed in 1993 as a nursing home and comprises of a conversion of a large house and additional modern extensions. The most recent addition was completed in 2001. This area is not currently in use although the beds remain registered with the CSCI. The home is registered to provide 59 nursing beds and 17 beds for personal care. All of the home’s bedrooms are single. There are two passenger lifts as the home has four different levels. The home has extensive gardens that are well maintained, with some areas easily accessible. It is owned by Mimosa Healthcare, a company with other homes in the north of England and Bristol. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key unannounced inspection was carried out over one day by one inspector. The Registered Manager Ms. Tara Kahan was available on the day of the inspection. The inspectors would like to thank the manager and the duty staff for their time and hospitality shown to the inspector during their visit. The home completed an Annual Quality Assurance Assessment, AQAA, prior to the inspection. A number of surveys were sent to the home, of which 23 were completed and returned to the CSCI. People living at the home, Relatives and staff all completed the surveys enabling us to get a broad view of the home. Comment cards about the service from visiting professionals were also forwarded to the CSCI at the time of the inspection. Service users who responded to surveys for the CSCI, all described their ethnicity as white/British. Residents are over 65 years of age. The inspector was able to see and observe staff interactions with many residents, meet several relatives, discuss care issues with staff and discuss the management of the home with senior staff. The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. These judgement descriptors for the seven chapter outcome groups are given in the report. Records examined during the inspection were five service user care and support plans as part of the case tracking process, medication administration records, maintenance records, the home’s Statement of Purpose, staffing rosters, menus, the home’s complaint’s file, staff recruitment files, staff training records, quality assurance processes and staff supervision records. The home forwarded examples of current menus, staffing and rosters when completing the AQAA. The inspector also conducted a tour of the premises. The current fees range from £422 to £680, which does not include hairdressing, toiletries, dental care, optician, physiotherapy, newspapers, transport or chiropody. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 6 The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: All prospective residents and their relatives/representatives are given written information about the home before they move and an individual reference copy if they decide to live at the home. They are encouraged to visit the home and their needs are fully assessed by a senior member of the nursing team before they move in to make sure the home can meet their needs. All residents are given details of the terms and conditions of residency that is clearly written in plain English. Residents’ rights to privacy and dignity are respected by staff. Visitors to the home are encouraged and made welcome by staff and are now invited to attend events. All the people spoken to were very satisfied with the standard of the food served at the home. Individual preferences were known and catered for by care staff and the cook. Residents could choose to have their meals in the dining room or in their own rooms. The kitchen records were well kept and the kitchen clean and tidy. The home has a clear complaints policy that residents and visitors are aware of. Policies and procedures are in place to protect residents from the risk of abuse, including staff training and robust recruitment policies. All staff is formally supervised to make sure their practice is good and they receive structured support from the manager. The home was clean, tidy and free from unpleasant odours. Residents are able to bring in furniture and personal belongings to personalise their private room Resident and staff meetings have been held and the views of those living and working in the home are being taken into account by the manager. The majority of relatives surveyed said the atmosphere at the home was warm, caring and friendly, people living there confirmed that they shared this view. Staff were observed to be courteous and appropriately friendly towards residents. One resident described staff as ‘supportive but not intrusive’. Residents are seen as individuals and the home tries hard to accommodate their individual needs and characters. One resident said that ‘nobody wants to be in a residential home but if you have to this is as good as it gets’. The home provides a good induction to all new staff to ensure that they are confident in their role and feel well supported. All staff have attended all necessary mandatory training. Both of these areas ensure that staff can meet the needs of people living at the home. Pondsmead Care Home DS0000070015.V363529.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. The summary of this inspection report can be made available in other formats on request. Pondsmead Care Home DS0000070015.V363529.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 Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has developed has a statement of purpose and service user guide, which sets out the aims and objectives of the home and includes basic information. Admissions to the home are not made until a full needs assessment has been undertaken by a member of the senior management team. The prospective residents and their families are fully involved in the assessment and are encouraged to visit the home before making a decision on residency. All residents are provided with a statement of terms and conditions of residency/contract that sets out in plain English what is included in the fee, the role and responsibility of the provider, and rights and obligations of the individual. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home produces a statement of purpose and service user guide that is readily available to prospective residents, their families and funding authorities. This is clearly written in plain English and a copy is available to all residents when they move into the home. All the relatives surveyed said that they had received enough information about the home. Some residents spoken to said that they had looked around the home before they moved in but others had been unable to visit and their family had chosen the home. The home produces a terms and conditions of residency that includes details of the room to be occupied and what is included in the fee but should make clear who is responsible for paying the fees, i.e. the resident or a funding authority. The home has an equal opportunity policy relevant to people living there which acknowledges peoples rights to be seen as individuals and makes clear that the home will make all efforts to meet individuals needs and aspirations. The homes pre admission assessment covers all the topics recommended in the national minimum standards. The inspector looked at the personal files of two residents who had moved into the home since the last inspection. Both files clearly showed that the homes manager, Ms Kahan, had undertaken a pre admission assessment, these are carried out at the prospective residents home, hospital or wherever they are staying. This gives the manager and prospective resident the opportunity to meet and make sure that the home can meet their assessed needs before they move. A copy of the funding authorities assessment had been obtained and kept with the care plan. We have been informed that fee levels have increased by 6 for the year 2008-2009. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Care planning practice was on the whole good. Staff need to ensure that all areas of the plan are specific and person centred. Evidence was seen of input from the resident and/or their representative in the plan of care. Staff need to ensure that people have access to fluids at all times and that all aspects of personal hygiene are met. Residents are able to have privacy in their own rooms. Personal support was offered in a way to promote the privacy and dignity of residents. Service users were treated with respect and looked well cared for. The management and administration of medication was good. EVIDENCE: Four people were case tracked during the inspection and their care plans reviewed. An additional care plan was viewed for one individual all the care was not case tracked. Case tracking involves identifying individuals at the Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 12 beginning of the inspection and comparing the care and support they receive with the needs identified in the care plan. The majority of the plans had been completed with the individual and/or their representative. All contained a range of appropriate assessments and associated care plans. The majority of the care plans were clear and detailed. Care plans contained up to date assessments, which included moving and handling, reducing the risk of pressure sores & falls. Likes and dislikes were well documented in all the plans seen. One plan was viewed for an individual who had a pressure ulcer. The care plan contained ambiguous statements such as “provide nutritional supplements if required” and “offer a well balanced diet and fluids”. People who have or are at risk of pressure damage may require increased protein in the diet to aid healing. The plan therefore needs to detail the individual’s dietary requirements and the amount of fluids required on a daily basis. The care plan for the treatment of the pressure ulcer was relatively clear with tools such as photographs and sizes being used by staff. These tools enable staff to assess the progress of the wound and ensure the appropriate dressings/ treatment is being used. The frequency that the dressing was to be changed was made clear on the care plan. A number of people at the home are frail and as such staff had introduced charts to record such things as amount of fluids taken and frequency of positional change. The charts viewed had been accurately completed and demonstrated that staff had delivered appropriate care and support. There was a good range of pressure reliving equipment, hoists and pressure mats available. Staff demonstrated a good understanding of how to promote privacy and dignity and examples of how they do this were seen. Health and social care professionals, through surveys received, and confirmed that they see their residents in private. Staff were seen interacting kindly to residents and were seen knocking on doors before entering. Residents spoken to confirmed that staff treated them with respect and helped to maintain their privacy when delivering personal care. Feedback received from residents indicated that the majority felt that they always got the care and support they needed. Comments included “this is a wonderful home” During the inspection it was noted that a small number of the toothbrushes and toothpaste were dry. This leads us to conclude that people living at the home had not been supported by staff to clean their teeth/dentures. In addition one person was seen to have food remnants on their clothing long after breakfast had been completed. Staff need to ensure that people are supported to change clothing after meals if this is necessary. This protects the dignity and self esteem of people living at the home. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 13 It was also noted that some people in the communal areas did not have access to fluids at all times. Drinks “rounds” are conducted throughout the day and no person appeared to be dehydrated. Staff however need to ensure that people have access to fluids at all times particularly in the warmer summer months. The home’s procedures for the management and administration of medication were examined at this inspection. The home uses the monitored dosage system (MDS) with pre-printed medication administration records (MAR). The registered nurse on duty administers medicines. Medicines were found to be securely stored. Creams in use, seen in service user bedrooms, had been marked with an expiry date and the MAR chart been signed to confirm that the creams had been applied as per the Prescription. Pondsmead Care Home DS0000070015.V363529.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. 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. Activities are well advertised. There is a range of social events and for the less able there are opportunities for one to one social contact. Comment cards indicated that not all people found the availability of activities adequate Families were seen to be welcomed and to be part of the home life. The menu is varied. The food on the day of the inspection was of a good standard. EVIDENCE: The care plans viewed during the inspection detailed the preferences of service users. People living at the home or their Relatives & friends provide information relating to their loved one’s social history, previous Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 15 hobbies/interests, preferences, likes and dislikes if the individual is not able to provide this information. Those staff observed on the day of the inspection appeared to have a good knowledge of the people living at the home and what they did and did not like. Those service users able to express a view informed the inspectors that their wishes were respected and that they could choose what time to get up or go to bed. Service users can choose where and how to spend their day. Any restrictions would be identified in risk assessments. Due to mobility difficulties, not all service users can move freely around the home. Throughout the day the inspector observed regular staff presence in each of the lounges. As previously mentioned, staff interacted with service users in a kind and respectful manner. The home employs two activities organiser at the home. The activities records were viewed as part of the inspection. These demonstrated that there is a range of activities on offer when the activities organiser is present. People living at the home particularly enjoy the gardening club which is run by the home’s gardener and also the cooking club. Other activities included bingo, art, outside entertainment and Holy Communion One person living at the home stated that they would welcome the development of a shop. This would enable them to purchase items such as toiletries, sweets and chocolate. The home welcomes visitors at any reasonable time in accordance with the wishes/preferences of the service user. Visitors spoken to during the inspection were extremely complimentary about the care and support afforded to people living at the home. All meals are prepared and cooked on the premises. Copies of a two-week menu were made available to the inspector. The menu appeared wholesome and varied. The main meal is served at lunchtime with a lighter cooked meal at tea time. This was evident at the time of the inspection. The inspectors were informed that milky drinks and sandwiches were offered in the evening. Special diets are catered for. The inspector observed soft diets being served to those with an assessed need. These were seen to be attractively presented. Sweets were available for those requiring a diabetic diet. Staff were observed assisting service users in a manner which was relaxed, unhurried and respectful. Service users able to express a view were positive regarding the meals available and stated that there was always plenty to eat. Drinks were served throughout the day. A range of cakes or biscuits was available. In one area a range of snacks was available for those with swallowing difficulties or those at risk of loosing weight. This was not seen in Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 16 one of the other areas. Foods such as yoghurts, milk shakes fruit etc should be made available to all. A choice of meal is available at all times. Staff ask people the day before what they would like to eat on the following day. Some people living at the home had forgotten what they had ordered. Some people may have difficulty in expressing a preference. Staff were observed to be showing the plates of food to those with communication issues to ensure that a choice could be made more readily. One individual stated that he did not like the choice of food that he had ordered. Staff were very quick to offer an alternative. The tables were set with linen tablecloths, napkins and appropriate condiments. A range of cold drinks was available through the meal. Menus are on display on the tables. Independence could be more actively promoted by, for example, allowing them to serve their own vegetables and gravy although it should be noted that portion sizes were varied according to people’s appetite. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with in line with the homes policy and procedures. People living at the home are aware and comfortable in expressing any concerns. People living at the home are protected by the home’s policies and procedures. Staff have received recent training in the prevention and recognition of abuse. EVIDENCE: Feedback forms to people living at the home asked do you know who to speak to if you are not happy? All people, with the exception of one stated that they would speak to a staff member or the manager if they had any concerns. One person stated that they would not be happy to raise concerns and stated that they would “be nervous of complaining in case of unpopularity” Comments from relatives included “A wonderful home no complaints”. The Home has a complaints procedure that is clearly written and contains the contact details for CSCI. All the complaints are dealt with in line with the homes policy and procedure. A range complimentary letters were also held on the file. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 18 The policies and procedures regarding protection of residents are of a good standard, which include complaints,recognising signs of abuse and whistleblowing. Abuse training is included in the new staff induction programme. The training matrix was viewed as part of the inspection process and this showed that staff had recived abuse training. Since the last inspection the manager has been proactive in welcoming complaints and suggestions about the service, using these positively and learning from them. The manager has raised issues with the local council, who have the lead accountability in all issues relating to safeguarding people from abuse, in identifying issues in the current local safeguarding policy. Staff recruitment files were veiwed during the inspection. These contained all necessary checks. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well maintained and meets the needs of the people who live there. Service users live in a comfortable & clean environment and have access to range specialised equipment. The bathroom facilities are good with a range of both baths and showers offering choice to people who live at the home. The home takes appropriate steps to reduce the risk of the spread of infection. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 20 EVIDENCE: All communal areas and the majority bedrooms were sampled at this inspection or recent random inspections. The home is on the whole well maintained. The majority of people living at the home are accommodated in single bedrooms, which are fitted with en-suite baths, wash hand basin and toilets. Bedrooms are situated on the lower, first and second floor and are accessed by two passenger lifts and stairs. There are a number of communal sitting areas throughout the home giving a choice to residents. Corridors are spacious with handrails throughout. Many bedroom doors have automatic fire door closures fitted. All bedrooms seen were individual and personalised. Residents spoken to were happy with their rooms. All rooms do have a lockable space to store valuables, medications or monies. The communal baths on the ground, first and second floors are ‘Parker’ type baths, which could not be accessed by some service users, have been replaced with wet rooms in the last 12 months. These have been completed to a high standard. Specialist equipment is available at the home to include profiling nursing beds, mobile hoists, and pressure relieving equipment and bathing facilities. Infection control measures were in place to include hand-washing facilities for staff. Staff spoken to were aware of the actions to take to prevent any infection spreading. Staff have received training in infection control. Domestic staff spoken to during the inspection felt that the budget was adequate to keep the home clean and tidy. New equipment was purchased on request. In the last 12 months the lower floor, which was used to accommodate people who had personal care needs only, has been closed. The people previously accommodated in this area are now accommodated on the top floor of the building. Some people who had been affected by the move remained unhappy with Mimosa Healthcare’s decision to close the personal care unit. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels appear appropriate to the needs of people currently at the home but these should be kept under review. The home promotes NVQ training for staff and ensures that all staff received training appropriate to their role. The home follows robust procedures for staff recruitment. EVIDENCE: As previously stated in the report surveys were received from a variety of people living and working at the home. The only consistent comments that were not positive related to staffing numbers. Comments stated that staff were very good and dedicated to the care and support of the people living at the home however staffing numbers did not always allow them to complete their Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 22 jobs effectively. This was confirmed by staff on duty on the day of the inspection. Staffing numbers were confirmed by discussion with staff and by viewing the duty rotas. On the ground floor, 20 people are accommodated. Staffing in this area consisted of one registered nurse and three care staff. However 13 people require the use of the hoist to change position or to access the toilet (a task that should be completed by two people), six people require help in eating and drinking and 18 of these people require the help of one and for periods to help them get washed and dressed in the morning and evening. On the middle floor there are 19 people accommodated. Three care staff are available. In addition there is a registered nurse who also works on the top floor. Staff stated that in this area nine people required the help of staff to use the hoist, five required support in eating and drinking and all needed the help of two staff to meet hygiene needs. On the top floor two care staff are available and the Registered nurse from the middle floor also supports this area. On this floor six people require the use of the hoist and two people require help with eating and drinking. Again all people require help to meet their hygiene needs. Whilst the outcomes for people living at the home remain positive and their needs are being met some people living at the home are experiencing delays at times when they ring the bell for assistance. The outcomes for people living at the home remain positive only because of the hard work and dedication of the staff. The company now need to review the staffing levels in line with these dependency levels as a matter of urgency. During the inspection a number of staff expressed concerns that they had not received a pay rise in over 12 months despite the fee levels increasing by 6 and occupancy rates at the home being high. Staff pay is not within the CSCI remit however to ensure the continued employment of high quality staff Mimosa needs to consider giving the staff at least a rate of inflation pay rise. On examination of a two week staffing rota made available to us evidenced that shortfalls due to last minute sickness had been covered by agency staff. Evidence of agency booking confirmations were also made available. Staff spoken with during the inspection confirmed that they had been provided with the training needed to care for people at the home including NVQ. Staff indicated that they felt confident in their skills and they stated that they were never asked to undertake a task that they didn’t feel trained to carry out. Staff confirmed that, apart from mandatory training, they had received ‘very good’ training. Staff completed comment cards for the Commission and the following comments were made; ‘Training is excellent, not just mandatory training but other training is encouraged with all levels of staff’, ‘we have very regular Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 23 training’. Also staff members identified training as something that the home does well. The home’s procedures for staff recruitment were examined. Records relating to two staff recently employed were viewed and there was evidence that the home was following robust recruitment procedures which also included appropriate checks with the Criminal Records Bureau (CRB) and Protection of Vulnerable Adults list (POVA). We were able to see evidence that newly appointed staff follow an appropriate induction programme. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37, 38. The quality in this outcome group is good. The home is well managed in an open management style. The home is run with the service users best interests safeguarded by policy, practice and procedures. Attention to the health and safety of service users and staff is of a good standard. A system of staff supervision is in place. Health and safety is well managed. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager, Ms Kahan, has been employed at the home for just over 18 months. During this time significant improvements have been made due to a stable management structure. The management style of the home is appreciated by staff and service users. All but one person was very complementary about her open management style. Staff described Ms Kahan as firm but fair. Ms Kahan and the staff should be congratulated on the hard work they have completed to bring what was a failing service to one in which a good standard of care is being provided. Ms Kahan undertakes quality assurance assessment of the home; surveys have been made to assess service user satisfaction. Regular staff and service user meeting are held. Minutes of these were seen. All records seen were stored appropriately and safely. Accident forms are completed and these are audited on a monthly basis. Staff supervision is ongoing and all staff receives regular supervision on a rolling programme. Annual appraisals are conducted for all staff. Servicing and maintenance records were sampled these were found to be in good order. COSHH (Control of Substances Hazardous to Health) advisory sheets are held at the home. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 26 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X X 3 3 3 Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP7 OP8 OP8 OP10 OP15 OP27 Good Practice Recommendations It is recommended that the service user plans are reviewed to ensure that they are specific and give clear guidance on the care needs of the individual It is recommended that staff ensure that people living at the home have access t fluids at all times It is recommended that staff ensure that people living at the home are supported to complete oral hygiene twice daily. Staff need to ensure that people living at the home are supported to change clothing if it becomes soiled. It is recommended that suitable snacks are available to all people in all areas. Staffing levels need to be reviewed in line with the dependency needs of the people living at the home. Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pondsmead Care Home DS0000070015.V363529.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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