Inspection on 12/12/06 for Ponsandane

This inspection was carried out on 12th December 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 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

Ponsandane 14/01/08

Ponsandane 11/10/05

Ponsandane 10/05/05

Ponsandane 09/02/05

Ponsandane 05/08/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Ponsandane Chy-an-dour Penzance Cornwall TR18 3LT Lead Inspector Stephen Baber Key Unannounced Inspection 12th December 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ponsandane DS0000009091.V305847.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. Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ponsandane Address Chy-an-dour Penzance Cornwall TR18 3LT 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) 01736 330063 01736 332343 Swallowcourt Limited Mrs Penny Hicks Care Home 58 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (58), Physical disability (18), of places Terminally ill (22) Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Accommodation may be provided for one service user from the age of 55 years for respite care. 11th October 2005 Date of last inspection Brief Description of the Service: Ponsandane is a private care home providing personal care and accommodation for fifty-eight elderly people in need of residential and nursing care. The home is registered under the terms and conditions set out in the Care Standards Act 2000 and Care Homes Regulations 2001. The home is situated on the outskirts of Penzance town and is a short distance away from the main London to Penzance railway station. The bus route out of Penzance runs past the home and this makes reaching to the home easy if you haven’t got a car. There are panoramic views of St Michaels Mount and the bay from the front of the home. Some of the rooms have ensuite facilities and there is one shaft lift that serves ground to first and second floor as well as two chairlifts to aid the more dependent service users who find getting to their room difficult. The home provides a spacious communal space and there are several rooms where people can meet with their visitors including their own rooms. The home has its own mini-bus, which is enjoyed by the service users especially when trips out are arranged. This service is free to the service users. Medical care is provided by several General Practitioners practices with the manager and staff working closely with all community professionals to provide a high quality nursing and residential care experience for the service users. The Managing Director who is the Responsible Individual for Swallowcourt company visits daily and offers support, guidance and supervision to service users, management and staff. As representative of the Company she writes a monthly report on the conduct of the home in line with her responsibilities under regulation 26 of the Care Standards Act 2000. Current weekly fees range from £293 to £650 per week. Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission are making changes to the regulations and inspection of social care agencies. Inspecting for Better Lives (IBL). We are modernising the way we inspect all social care services and will be more proportionate, more focused on the experience of people using services and focus on providers to ensure quality. This was an annual key inspection, which took place over two days and was unannounced. It lasted for approximately 13:5 hours. The Commission received information about the home prior to the inspection in the form of a pre inspection questionnaire. The purpose of the inspection was to ensure that service users’ needs are appropriately met in the home, with particular regard to ensuring good outcomes for all who use the service. Throughout the two-day inspection interviews with service users and observation of the daily life and care provided were undertaken. There was an inspection of the home’s premises and of written documents concerning the care and protection of the service users and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with the home’s manager. The principle method used was case tracking. This involves inspecting the care notes and documents for a select number of service users and following this through with interviews with them and/or their relatives and staff working with them. This provides a useful, in-depth insight into how service users needs are being met in the home. At this inspection, four service users were case tracked. Overall there was evidence of ongoing improvement in care standards at this inspection and work is continuing to improve it further to provide service users with a safe and comfortable home in which service users can feel comfortable and safe. This was the first inspection for Mrs Hicks the registered manager who assisted me throughout the inspection and was very helpful. The inspection was a very positive inspection and I thank the manager and staff for their helpful manner to complete the inspection. The service users and staff stated they are reliably and well supported by the manager who is always available to offer advice and guidance when required. This is the management style of the manager who wishes to be available to service users, relatives and staff throughout the day. The Commission have recived an application to register 9 beds in the category of learning disability from the age of 18 to 65 years of age. In addition to this we have recived a variation application to register five beds for people from age 50 years of age for respite and permanent care. The central registration team is currently processing the applications and the home is waiting for the applications to be approved in the New Year. Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 6 What the service does well: Prospective service users are provided with good written information so that they and their representatives can decide whether the home is suitable for them before they move in. Admission to the home is based on detailed assessments of their health, social and personal care needs, including needs relating to their religious, ethnic and cultural backgrounds, to ensure they can be met in the home’s setting. The manager stated that the company are committed to promote equal opportunities, prevent dicriminationand value diversity, which is fundamental to building a strong service. All of the service users have detailed written care plans, based on their assessed needs, which set out their personal goals and are regularly reviewed. Service users are encouraged to make choices about their daily activities and menu plans and other aspects of their lives that are important to them. Staff supports service users to achieve their goals. Any necessary restrictions to protect their best interests are included in detailed written risk assessments. Service users are helped to access a wide range of activities provided by the activities co-ordinator so that opportunities and wishes can be met. Throughout the two-day inspection service users it was noted that visitors and professionals were constantly visiting. The service users I spoke with were very complimentary about the catering arrangements at the home and said that they receive choice at all meal times. Varied well balanced diets and special diets are catered for. There is a formal complaints procedure, contained in the home’s statement of purpose and service users’ guides, which has been provided to service users in formats that they can access directly, should they feel the need to do so. The manager attempts to directly resolve issues at an early stage before they develop into formal complaints. The home is warm and comfortable, set in its own grounds with picturesque views of St Michaels Mount. It was clean and tidy throughout at the time of the inspection and service users are encouraged to personalise their own rooms. There are systems in place to ensure that only people who are suitable to work with the vulnerable elderly in a care setting are employed. Staff have good access to ongoing training so that they develop their knowledge and skills in the best ways of caring for the service users. The home’s manager has been in post for five months. Mrs Hicks is registered with the Commission, qualified and experienced and wants to manage the home well and provide positive outcomes for service users who live there. Records are well maintained, securely stored and ensure that service users’ confidentiality is protected. The home is well maintained and kept safe for service users, with regular tests and checks of safety equipment and systems and detailed risk assessments to protect them from fire and other hazards. Ponsandane DS0000009091.V305847.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. Ponsandane DS0000009091.V305847.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 Ponsandane DS0000009091.V305847.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, 6. 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 service considers carefully the needs assessment for each individual prospective service user before agreeing admission to the home. Prospective service users always have the opportunity to visit and spend time in the home prior to agreeing admission. A variety of positive methods may be used to enable people to experience the home and what it has to offer e.g. arrangements to have a look around, enjoy a meal and talk to other service users. EVIDENCE: The Statement Of Purpose and Service User Guide has recently been amended. The new information enables service users to have information they need to make an informed choice about where they wish to live. All service users have a written contract of care with the home. Service users stated to me when I spoke with them that they received relevant information about the home prior to admission and their contract specifies the services and facilities they can Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 10 expect when the reside in the home. The manager assesses each prospective service user and the assessments also take account of the views of any professionals that are involved with the person concerned. This is undertaken to ensure the persons needs can be met by the home. Wherever possible the manager consults with the prospective service users and their relatives or representatives about the care and support required. The manager uses recognised assessment tools where nursing care is required. The nursing team and staff collectively have the skills to deliver the services and care, which the home offers to provide. Intermediate care is not provided. Ponsandane DS0000009091.V305847.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. 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 service has a strong belief that it is essential to involve service users in the planning of care that affects their lifestyle and quality of life. Each service user has a plan, which is written in plain language, is easy to understand and considers all areas of the individual’s health, personal care needs. The plan also includes risk assessments. Areas have been identified where staff are willing to support service users take some risks which may have an impact on their rights. Staff have the skills and ability to support and encourage service users to be involved in the ongoing development of their plan and make the process interesting and worthwhile using a variety of ways E.g. appointing key workers who build up special relationships with service users and work on a one to one basis. EVIDENCE: Four service users were case tracked. The service users have detailed written care plans, which address all their personal, health and social care needs, including needs relating to their disability, religion, culture and ethnicity. There Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 12 is evidence that service users are consulted on key aspects of their care planning, which directly affect them. It is recommended that service users or their representatives should be encouraged to sign the care plan to evidence that agreement has been reached on the care to be given. The service users choose to register with any one of the seven surgeries, which visit the home. The full range of health care professionals visit the home. The manager has forged positive links with them so that the service users receive quality health care. I noted the district nurse, doctor visiting on the days of the inspection. Dental, ophthalmic and chiropody are arranged on a domiciliary basis or by visiting the relevant surgeries with the home providing free transport. There are suitable procedures and systems in place to protect service users from harm through medication errors. The home has reverted to The Boots Monitored Dosage System with the nursing team being very pleased with the effectiveness of the new system. Medication is dispensed by the trained and competent nurses. Storage, administration, recording and disposal of medication satisfy the guidance stipulated by legislation and regulations. The home is going to be a totally non-smoking home Service users interviewed confirmed that they are well cared for and staff treats them respectfully. Relatives visiting the home confirmed this. There are records to indicate that they are consulted on important matters relating to their care, privacy and dignity. The Statement of purpose clearly sets out the importance of privacy, dignity, independence and choice. I observed the staff going about their business and noted that they were helpful, kind and caring towards the service users and friendly and hospitable towards the visitors. Ponsandane DS0000009091.V305847.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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. . Family and friends are welcome and know they can visit the home at any time. Staff always makes time to talk to visitors and share information with the agreement of the service users. The layout of the home provides seating areas within the communal areas of the home where service users can entertain visitors, in addition to the privacy of their own rooms. It is clear that the home encourages individual and groups from the community to visit the home. Food and mealtimes are treated as an occasion and something to be looked forward to. Experienced chefs are responsible for providing quality nutritional meals that meet the cultural and dietary needs of the service users. EVIDENCE: The home employs a recreational coordinator who works five days a week. At the time of the inspection, service users family and visitors enjoyed the candlelit supper provided for them by the company. There are notice boards, listing activities available and service users views are sought through the home’s quality assurance programme. The recreational coordinator showed me all the individual evidence of the outings and activities that some service users Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 14 enjoyed doing. The individual records evidenced that because people come into care their social, cultural, recreational characteristics, which have taken a lifetime to emerge suddenly, disappear. The degree to which, social life is organised within the home, along with the range of activities available is clearly detailed in the Statement Of Purpose and Service User Guide Service users’ assessment and care records indicate their social and recreational interests, which they are encouraged to pursue following admission. There are no restrictions on visitors and service users are able to go out with relatives whenever they wish. Service users confirmed that they are able to choose whether or not to join in with activities and some chose to remain in their rooms rather than go to the party. All those interviewed and their relatives stated that they are satisfied with the care and services provided to them at the home. There are records on their personal files relating to important decisions about their care. The Environmental Health Officer inspected the home on the 9th October 2006. He identified that the home needs to comply with Hazard Analysis Critical Control Points (HACCP). I spoke with the chef who showed me the new records in place. The manager is also working with the chef to ensure full compliance with the Food Safety legislation. The home’s menu plans indicate that there is a choice of home-prepared meals at every meal and there is plenty of variety in the food served. The meal on the day of the inspection looked very appetising. Service users are able to choose where they eat, either in the home’s communal dining room or their own rooms. Staff are available to provide them with assistance if necessary. Their individual care plans indicate their dietary needs and preferences. All of the service users interviewed stated that they are very satisfied with the food provided to them. Ponsandane DS0000009091.V305847.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): 16,18. 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 promotion of the individual’s rights is central to the aims and objectives of the service. Policies and procedures and the homes documentation reflect the rights of the individual. Ponsandane has an up to date complaints procedure, which is very clearly written and is easy to understand. The policies and procedures regarding Adult Protection of service users are very detailed and are reviewed and up dated. The manager is clear when incidents need external input and who to refer the incident to. EVIDENCE: The manager stated there is an open approach to complaints and she is keen to resolve concerns as quickly as possible. Service users said they felt able to discuss any complaints/concerns they have with the manager and staff. There has been one complaint to the Commission following the last inspection, which has been resolved through the homes complaints procedure. The manager has taken steps to make sure that any complaint is satisfactorily documented and logged. A suitable policy and procedure is in place that is understood by service users and their representatives. The home has written policies and procedures to guide staff on how to recognise and prevent abuse of vulnerable adults. This includes copies of the local multi-agency procedures and guidance from the Department of Health. The two internal training officers come senior care staff have attended local multi-agency training and passed this onto staff working in the home. Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 16 Recruitment procedures demonstrate how staff should be recruited on the basis that they are safe to work with vulnerable elderly people with Criminal Records Bureaux checks (CRB), proof of identification and two written references on staff files. The company have a suitable whistle blowing policy and procedure in place. The managing director holds clinics where staff can see her privately to discuss any thing that concerns them. This provides service users with further protection from abuse. Ponsandane DS0000009091.V305847.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): 19,26. 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 management and staff encourage service users to see the home as their home. It provides a very well maintained, safe, comfortable, attractive home, which has all the specialist equipment and adaptations needed to meet individual’s service users needs. There is evidence that they meet the changing needs of all service users, especially where they have different cultural and specialist care needs. EVIDENCE: The company have recently invested in the redecoration and refurbishment of the home. The environment is very well maintained and provides a good standard of accommodation. I inspected the home and noted that some rooms would benefit from bedspreads which would make the beds look more cosy and homely, the carpets in some rooms require replacement due to some being badly stained and of poor quality and the bedside tables and some units are in Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 18 need of replacement. The grounds are well maintained and recently the manager has created a raised flowerbed for the service users to grow their own flowers for the home in the better weather. She has relied on donations to purchase bulbs and other items. The care home is maintained to an excellent standard of hygiene. Service users said they were very satisfied with the standard of cleanliness throughout the care home. A laundry is located on the ground floor and service users said they were pleased with the standard and service provided. I talked with the laundress who said to me that she had received training in the control of substances hazardous to health (COSHH). Sheets, table cloths, pillowcases go out to contactors. Protective clothing and anti bacterial hand wash is provided as well as alcohol gel. Ponsandane DS0000009091.V305847.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): 27,28,29,30. 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 have confidence in the staff that cares for them. Rota’s show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the service users. Management encourage staff to undertake qualifications beyond the basic requirements and recognise the benefits of a skilled trained workforce. The service clearly defines the roles and responsibilities of staff through accurate job descriptions and specifications. Service users report that staff working with them are very skilled in their role and consistently able to meet their needs. EVIDENCE: The staff rota showed that on a daily basis in the morning there are 9-care assistant son duty, 6 care assistants in the afternoon and 6 in the evenings. There are qualified nurses on duty throughout the day to support the staff. At night there is a qualified nurse and 3 care assistants on duty to offer comfort and reassurance to service users. Staff recruitment is based on written procedures that fully address equal opportunities for job applicants. Records reviewed at the time of the inspection demonstrated that staff are selected on the basis of written application forms, formal interviews and checks to ensure that they are suitable to work with vulnerable elderly people in a care setting. Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 20 Service users said they were satisfied with the manner in which the staff undertook their duties and provided the care and support they need. It is clear the staff treat service users with dignity and respect and that positive relationships have been established. Staff said there was a good communication between the staff group and the manager and nursing team maintain a good level of staff morale and mutual support. The manager has established arrangements to recruit vet and select new staff in line with the detailed policies and procedures as laid down by the company. The recruitment documents that were sampled for new staff showed that an application form was always completed and two references obtained. There was evidence that CRB and POVA checks had been carried out before the staff commenced their duties. There was evidence that new staff undertake a period of induction when they commence employment. An experienced member of staff takes a lead role in the induction arrangements under the guidance of the manager and steps are taken to make sure the new staff member concerned has the skills and abilities to meet the needs of the service users. The current induction training is not based on the revised Skills for Care specification, which was introduced with effect from September 2006. Information about the revised specification may be obtained on skillsforcare.org.uk. Staff have received recent training in moving and handling, health and safety and adult protection. There are individual staff training records/training profiles, which set out the worker’s qualifications, training completed and training required, and include supervision and appraisal records. Ponsandane DS0000009091.V305847.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): 31,32,33,34,35,36,37,38. 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 has the required qualifications and experience and is competent to manage the home. She works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being open and transparent in all areas of running the home. The manager is service user focused and leads and supports a staff team who have been recruited and trained to a good standard. The manager is aware of current developments both nationally and by CSCI and plans the service accordingly. EVIDENCE: The registered manager is Mrs Penny Hicks. She has been in post for five months as the registered manager but was a senior nurse at the home previous to this. Mrs Hicks is a qualified nurse and has thirty years experience as a nurse/ midwife. She is currently undertaking her management award. Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 22 The manager works to high professional standards, which is underpinned by a sound service user, centred value base. Her management approach of the home creates an open, positive and inclusive atmosphere The manager would like to communicate a clear sense of direction and leadership to the staff team and provide positive outcomes for the people who live at the home. The home has carried out a quality assurance survey in November 2006 for service users, staff and relatives. On this occasion surveys were not sent to health and social care professionals. The questionnaires have been completed and returned to the home. It is recommended that the information be consolidated into a graph identifying the areas for further development based on a systematic cycle of planning-action-review reflecting aims and outcomes for service users. The accident records were satisfactorily completed but reviews, oversight and action from management is required where further action is required. The record complies with the Data Protection Act. The staff records showed that staff received regular supervision sessions, some as individual sessions and some as small group meetings. The manager, nurses and senior care assistants are responsible for supervising a number of staff. Since the manager has been in post the frequency of supervision has increased but needs to consistently achieve the six sessions a year recommended in the standard. Staff generally receives annual appraisals. Staff were satisfied that informal and formal supervision supported them to do their jobs well. They stated that if they sought guidance and information, this was always provided. Staff felt that they worked well together to ensure the well being of service users. The last visit by a fire officer was in October 2006. The senior care assistants/ training officers give fire training to all day and night staff. The records evidence that all staff attend fire training regularly. I discussed the new fire regulations (The Residential Care Premises) with the manager, which came into force in October 2006. I advised the manager that all external contractors and visitors to the home would have to receive fire instructions. The manager discussed this with the managing director and plans have been put into operation to address this at a company level. The manager submitted the list of required maintenance and safety records on the pre-inspection questionnaire. A sample was checked against the original documents and were accurate. There are clearly written suitable policies and procedures for the home, which are established to promote safe working practices for service users, and staff. This ensures that staff have up-to-date guidance to support the best interests of the service users. Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 23 Service users’ personal records are held securely and their confidentiality is maintained. Records reviewed demonstrated that there is clear communication across the staff team and service users’ best interests are protected. Ponsandane DS0000009091.V305847.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 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 4 X 3 X 3 3 X 3 Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered person should encourage whenever possible all service users or their representatives to sign the care plan to evidence has been agreed on the care to be given. The registered person should ensure that Hazard Analysis Critical Control Points (HACCP) is maintained to ensure full compliance with The Food safety Act 1990. The registered person should provide induction training for all new staff that meets the revised Skills for Care specification The registered person should consolidate the outcome of the quality assurance exercise identifying the areas for further development based on a systematic cycle of planning-action-review reflecting aims and outcomes for service users. 2 3 4 OP15 OP30 OP33 Ponsandane DS0000009091.V305847.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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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