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Inspection on 26/06/08 for Prince Edward Duke of Kent Court

Also see our care home review for Prince Edward Duke of Kent Court for more information

This inspection was carried out on 26th June 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Visitors are always made welcome. Relatives felt that staff communicated with them well and kept them up to date with any issues concerning their relative. Feedback from relatives of people living at the home was positive and included comments such as: "The staff treat the residents as individuals and with consideration and respect`" "The home gives the feel of a caring community. It is always well staffed". "The home provides a secure environment with good food and various entertainments and outings". "The food is excellent - the catering staff should be congratulated. The home is clean. The home smells fresh and clean". "I am very satisfied with all aspects of the care provided". "I cannot think of anything that would improve on the service". People living at the home were encouraged to maintain their independence, and had regular opportunities to express their views on the service.

What has improved since the last inspection?

The organisation has recruited a new manager for this service since the previous inspection visit. The manager operates an open door policy and makes herself available to the people living at the home. Medication training has been provided for the staff team and external pharmacy advice has been utilised at the home. This has brought about some improvement to the medication administration and recording practices.

What the care home could do better:

People can expect to be cared for well, and care planning is becoming more focused on peoples` individual needs. This process needs to continue to ensure that the necessary information is available for staff to follow as people become more dependent on care staff to support their personal needs. People or their families should have a greater involvement in care planning. Some issues relating to medication recording practices that had been raised on previous inspections were again noted on this occasion. It is essential that medication practices and records are well maintained, as poor practice in this area can potentially put peoples` health and welfare at risk. These issues need therefore to be urgently addressed: the CSCI will consider taking enforcement action if the home does not demonstrate improvements in this area.

CARE HOMES FOR OLDER PEOPLE Prince Edward Duke of Kent Court Stisted Hall Kings Lane Stisted Braintree Essex CM77 8AG Lead Inspector Jane Greaves Unannounced Inspection 26th June 2008 09:20 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 DS0000017912.V367200.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. DS0000017912.V367200.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Prince Edward Duke of Kent Court Address Stisted Hall Kings Lane Stisted Braintree Essex CM77 8AG 01376 345534 01376 343545 stistedhall@rmbi.org.uk www.rmbi.org.uk Royal Masonic Benevolent Institution 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) Tracey Nelson Care Home 47 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (34) of places DS0000017912.V367200.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 35 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 13 persons) The total number of service users accommodated must not exceed 47 persons 6th July 2007 Date of last inspection Brief Description of the Service: Prince Edward Duke of Kent Court is owned by the Royal Masonic Benevolent Institute (RMBI). It is a large period house set in extensive grounds adjacent to a golf course. Although the home is in a semi rural location with limited access by public transport, Braintree town is just a short drive away and the Home has its own transport. The home has several lounges, a library and a conservatory, and also extensive well maintained grounds and an enclosed courtyard. The home provides 24-hour personal care and support, and has a through-floor lifts and other equipment (e.g. mobile hoist, hand rails, etc.) to assist residents with limited mobility. It is registered to provide care to a maximum of 47 people, and its conditions of registration allow the home to care for up to 35 older people and/or up to 13 people with dementia. People are accommodated in single, en-suite rooms, and these are located on three floors of the main house and on two floors of the annex, a converted stable block that accommodates 18 people including up to 13 people living with dementia. The home refers to this unit as the DSU (Dementia Support Unit), and this term has therefore been used in this report when referring to this unit. Information about the service is available in the home’s service user guide, and the home makes a copy of the current inspection report available to residents. The home’s fees range from £536 to £848 per week, with additional charges for personal items (hairdresser, toiletries, papers, chiropody, etc.); residents funded by the Local Authority are also accepted. The charity currently pays the difference between the Local Authority rate and the Self Funded rate. The home also has a hairdressing salon, which is used by visiting hairdressers. A new home manager has been appointed since the previous inspection visit. DS0000017912.V367200.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced ‘key’ site visit. At this visit we considered how well the home meets the needs of the people living there and how staff and management support people to have a lifestyle that is acceptable to them. The level of compliance with requirements made at the previous inspection was assessed. The site visit took place over a period of eight hours. A tour of the premises was undertaken, care records, staff records, medication records and other documentation were selected and various elements of these assessed. Time was spent talking to, observing and interacting with people living at the home, and talking to staff. Prior to the site visit the manager had completed and sent in to the Commission for Social Care Inspection the home’s Annual Quality Assurance Assessment (AQAA). This provided detail of how the service feels they are performing against the National Minimum Standards, and how they can evidence this. Before the site visit a selection of surveys with addressed return envelopes had been sent to the home for distribution to residents, relatives, involved professionals and staff. The views expressed in survey responses have been incorporated into this report. Feedback on findings was provided to the manager throughout the inspection. The opportunity for discussion or clarification was given. We would like to thank the manager, staff team, residents and relatives for their help throughout the inspection process. What the service does well: Visitors are always made welcome. Relatives felt that staff communicated with them well and kept them up to date with any issues concerning their relative. Feedback from relatives of people living at the home was positive and included comments such as: “The staff treat the residents as individuals and with consideration and respect’” DS0000017912.V367200.R01.S.doc Version 5.2 Page 6 “The home gives the feel of a caring community. It is always well staffed”. “The home provides a secure environment with good food and various entertainments and outings”. “The food is excellent - the catering staff should be congratulated. The home is clean. The home smells fresh and clean”. “I am very satisfied with all aspects of the care provided”. “I cannot think of anything that would improve on the service”. People living at the home were encouraged to maintain their independence, and had regular opportunities to express their views on the service. 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. DS0000017912.V367200.R01.S.doc Version 5.2 Page 7 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 DS0000017912.V367200.R01.S.doc Version 5.2 Page 8 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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A throrough pre-admission process reassures people that the home can meet their needs EVIDENCE: The home’s Statement of Purpose was reviewed and some minor amendments were necessary to the contact details for the Commission for Social Care Inspection and where the service now refers to the Dementia Support Unit this was still indicating EMF. The manager was able to confirm that wherever possible prospective residents are visited in their own home and told about what the care home has to offer them, and can also visit the care home as many times as they wish prior to admission. DS0000017912.V367200.R01.S.doc Version 5.2 Page 9 The manager’s AQAA stated ‘Prior to admission time is spent talking with prospective residents, family and friends, showing them around the home allowing them to take their time and meet some agreeing residents. If they decide to live here each resident has a contract and statement of terms and conditions’. We looked at care plans for two people who had recently moved into the home, both care plans contained evidence of pre admission assessments being carried out in advance of the person moving into the home. This was so that the home and the resident could be sure the service could meet the person’s needs and individual preferences. The manager was very clear that given the information available, they would not let someone move in if they felt that their needs could not be met by the facilities or staffing levels. DS0000017912.V367200.R01.S.doc Version 5.2 Page 10 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are well cared for however their welfare is not safeguarded and supported by the home’s medication recording practices. EVIDENCE: People living at Prince Edward Duke of Kent Court made positive comments about the care and support provided. One person said, “Everything is fine here.” Surveys returned to us by relatives included comment such as “I sincerely feel that my relative could not be better taken care of”. People said that staff members always respected them. We could see peoples’ dignity being maintained throughout the day. We looked at 3 care plans to see what information was included to tell staff the support each person needed to meet their personal needs and maximise their independence and how this support was to be provided. The care plans were organised however the format did not make them easy to read. The care staff DS0000017912.V367200.R01.S.doc Version 5.2 Page 11 reported they did not feel the care plans were workable documents; the lines were too close together making them difficult to read. The registered manager reported that staff had raised concerns about the format of the care plans and had made suggestions to improve the layout to ensure they were the best tools to assist them in delivering person centred and holistic care for the people living at the home. The home is still dependent on agency staff and information in the care plans needs to be clear for them to read and quickly understand peoples’ individual needs. Care plans seen contained little detail to help staff deliver personalised and holistic care. In some cases this is because people were fairly independent and self caring and therefore not keen on providing this information. However as peoples’ support needs increase and their dependency on staff support increases the information must be developed to make sure their future needs can be met according to their individual preferences. The registered manager reported that residents ‘hate the care plans as they are too intrusive’. During a care plan review one resident noticed that there was a photograph of themselves and became quite upset about it. Care staff reported that residents felt that detail within care plans impacted on their dignity and privacy. 3 people spoken with said they were not aware if they had a care plan. The care plans had sections reflecting all areas of identified needs however these were not always completed. For example, one care plan indicated that a person’s weight should be monitored monthly however this person had not been weighed on admission to the home or since, so it was not possible to assess if this person’s nutritional needs were being met. Another care plan viewed had no photograph of the person, and had no information recorded under the sections medical history, past life or health and social care needs. There was evidence in the care plans to confirm that routine healthcare appointments and specialist appointments were attended as necessary. People we spoke with said, “ if you are not feeling well you only have to tell one of the girls and they sort you out” and “If I have any problems I just ask for help and they get me the help I need”. Risk assessments appeared to be more reactive than proactive. For example one risk assessment relating to the risk of falling took place 2 days after a person had fallen. There was no evidence in the care plan to show that this area of potential risk had been previously assessed. The registered manager reported that external medication training had been recently provided; records and staff members confirmed this. One staff member reported that some additional advanced medication training had been booked. It was reported that an external pharmacist had visited the home in recent months to undertake a pharmacy audit. DS0000017912.V367200.R01.S.doc Version 5.2 Page 12 Medication was stored in a locked trolley secured to a wall within a locked room. The trolley was clean and organised. The manager reported that the temperature of the medication room was regularly monitored however the room was over warm on this day. Controlled drugs were stored in a locked cupboard secured to a wall. Controlled drugs for three people were physically checked and agreed with the controlled drug register. There were two instances where the controlled drug register page had a comment written at the top ‘1/2 given. ½ destroyed’ with no date, signature or further detail. One Medication Administration Record (MAR) indicated that the persons dosage of the controlled drug had been reduced to ½ 10 mg tablet, however this was not dated and signed to indicate who had taken this instruction and when. The other MAR sheet contained no instruction at all about the reduction in dosage. The remaining half tablets were in named plastic bags ready for return to the pharmacy. The pharmacy returns book listed the ‘half’ tablets for return however the record indicated that no returns had been made since 07/06/08. This meant there should have been more tablets awaiting return than were present at the home. The manager was able to confirm subsequent to this visit that a pharmacy return had been made on 17/06/08 however records available on the day of this visit did not confirm this. MARs had list of staff signatures at the front so it was possible to identify members of the staff team signing for medication. MARS included photographs of the residents to be sure the right person was given the right medication. Some people were able to take responsibility for the storage and administration of their own medication, there were locked facilities in each room for this. The home needs to review its’ procedures relating to the recording of medication, and revisit staff training relating to this. Issues relating to medication recording practices have now been raised at the last three inspections. The need for clear, accurate and consistent recording of medication is important for the protection of peoples’ welfare: the failure of the home to adequately address these issues has therefore affected the overall judgement for this outcome group, and the home should take urgent action to address this. DS0000017912.V367200.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to enjoy a lifestyle that meets their expectations. EVIDENCE: Routines of daily living at Prince Edward Duke of Kent Court were flexibly arranged around individuals’ needs and preferences. People told us that they could come and go as they pleased, one person said, “It is like a hotel with care provided”. Another person told us how they were offered a hot drink when they returned to the home late in the evening after a day out with family members. There was a continuous plan of activities within the home organised by the full time activity co-ordinator. The activities Plan for the month showed us that the following were offered: Games, films, a ‘pat dog’ visited, bingo, coffee mornings, holy communion, discussion groups, Flower arranging, a special lunch and a trip to a show to celebrate father’s day, Yoga, cream tea Quiz, Tea dance, mead tasting and buffet to celebrate the summer solstice. At the time of this visit there was a great deal activity around the home’s forthcoming Fete on 13th July. DS0000017912.V367200.R01.S.doc Version 5.2 Page 14 It was reported that the provider Organisation has agreed to a further 25 hours dedicated activities time for the Dementia Support Unit, the manager has identified the importance of recruiting someone with knowledge and experience in this area to improve the quality of life for those people living with Dementia. The home had a well stocked library, it was a lovely wood panelled room with dual aspect views over the grounds Some books belong to the home and some are supplied by Braintree Council Library and were changed monthly. There was a Bar for residents’ use and a hairdressing salon with a hairdresser visiting two times per week. There was a list attached to the door of the salon for residents to put their name down if they wished to see the hairdresser at the next visit. The communal lounge contained a large Plasma screen television. Residents said “We go out quite a lot, Pub lunches and a tea dance last week”. And “I have no complaints, we get entertainment regularly, I am satisfied” The Organisation had an annual quality assurance system involving the residents, their families and staff members. The previous survey identified that residents were not always satisfied with the quality of the food provided. In response the registered manager formed a catering committee consisting of 4 residents, the catering manager and the manager. This group had been meeting monthly to identify areas of weakness and to make amendments to the menu. The manager reported that this committee would continue to meet however not as frequently as people have indicated their satisfaction with the changes made to the menus. We took lunch with the residents and we found it to be a very pleasant relaxed affair with polite discrete ‘restaurant style’ service. Good quality food with ample sized portions seemed to be enjoyed by all people in the pleasantly appointed dining room. There were cloth tablecloths and menus on each table and a happy hum of conversation throughout the room. Many people spent time after the meal was finished sat chatting over coffee. People reported that Breakfast was a very social affair, 2 people said they had come down for breakfast at 0830 and didn’t leave the dining room until 10am. The dining room in the Dementia Support Unit was a pleasant space with attractive wipe clean cloths and a cosy feel. It was reported that staff visited each person in the evening to ask what their choice of meal was for the next day. One person said” if you change your mind on the morning that is fine, I did today and they didn’t mind at all” Menus showed a different option of cooked breakfast each day, a choice of at least 2 main lunchtime meals and three supper choices with the daily added option of Jacket potatoes. Residents reported that visitors are welcome any time of the day and a tray of tea is always provided for them. DS0000017912.V367200.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can raise concerns about the service and be confident that their views are listened to. They can expect to be safeguarded from abuse. EVIDENCE: There was a record of complaints and compliments received by the home. All complaints had been appropriately responded to within the timescales stated in the home’s policy and procedures for dealing with complaints, there was a clear audit trail of any investigations undertaken and the outcomes of these. The file included a letter from a relative to the manager complimenting the service on the way a complaint had been dealt with. There was a copy of the home’s Complaints Policy and procedure on notice board in the Dementia Support Unit and in the entrance hall of the main house. This needed to have the address and telephone number of the commission inserted and this was immediately done. The service had a good record of dealing with complaints appropriately and the manager had an open and inclusive ethos that encouraged people to bring any concerns to her attention. The staff team had attended training in safeguarding vulnerable adults and recruitment practices within the home included obtaining an enhanced Criminal Records Bureau disclosure for all people before they started to work at the home. DS0000017912.V367200.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean and pleasant home that is suitable to meet their needs. EVIDENCE: We undertook a physical tour of the home looking at all communal areas, bathrooms and toilets and three peoples’ private rooms with their permission. Some people chose to leave their doors open so it was possible to view inside whilst passing. The communal areas of the home were clean, pleasantly decorated and felt very grand. The bathrooms were very bare and functional and not pleasant relaxing places to be. The registered manager reported that this was an agenda item for the next residents’ meeting but that people living at the home were very resistant to change. Peoples’ private rooms appeared clean but not decorated to individuals’ taste or preferences and in many cases were shabby in appearance. Some walls were damaged due to quite narrow corridors and confined spaces for the DS0000017912.V367200.R01.S.doc Version 5.2 Page 17 people using wheelchairs. People were able to bring in personal items of furniture and other items to personalise their space and make it feel more homely. Surveys returned to the commission as part of this inspection process included “My relative’s room is shabby. It needs to be redecorated. I do not consider that it would be difficult or too expensive to move a resident (if only temporary) while a fresh coat of paint was put on the walls. I have commented on this before in each survey I have completed for the RMBI. The room was not decorated before my relative moved into this particular room many years ago” In response to this issue being raised through the organisation’s annual quality assurance system the manager’s action plan states that there will be an audit of people’s rooms and in discussion with individuals there will be a programme of redecoration taking place in line with budgetary restraints During the tour of the building it was noted that a cleaning cupboard on the 1st floor was not locked, this could cause a potential hazard. Some signs were on individuals’ bedroom doors requesting that staff did not check on people during the night. The manager reported that the people insisted on the signs being left on the door as it gave them peace of mind that they would not be disturbed during the night. Care plans contained reference to the wishes of residents. Furnishings throughout the home were in good condition, and provided a well presented environment, the gardens and Dementia Support Unit courtyard were well maintained and provided a pleasant outlook. An upstairs lounge contained a model of a purpose built care home that the provider organisation was intending to commission to replace the service currently provided at this site. Residents and their families have been involved in consultation and one resident told of how they had been taken in the minibus to view the proposed site for the new home. People indicated concern over the impending move. One said, “I really don’t want to move anywhere, I had hoped that this would be my last home” and another said, “ A new building will not have the charm and elegance of this house, it will be so sad to leave here”. The registered manager demonstrated a good understanding of the residents’ misgivings and had plans in place to gradually work through individuals’ fears and concerns with them. DS0000017912.V367200.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are cared for by a team of trained and well-recruited staff. EVIDENCE: Three staff files were looked at so we could be sure that all the necessary pre employment checks were made to keep people safe. All three contained the information necessary information to be sure the right people were employed to look after people living at Prince Edwards Duke Of Kent Court. Application forms included dates of previous periods of employment however these needed to be more precise. For example just giving the dates 2006 to 2008 did not give an accurate picture of when the person was employed. The organisation did not have a policy of routinely renewing Criminal Record Bureau Disclosures. Records showed us that 37 care staff had achieved minimum of NVQ level 2 or above. 58 care staff were employed at the home in total including bank staff meaning that this relates to 64 of the staff team. People living at the home told us “The staff are very good” Basic core was training provided for the whole staff team, records provided showed us that there were very few gaps in attendance in areas such as moving and handling, safeguarding vulnerable adults and health and safety. DS0000017912.V367200.R01.S.doc Version 5.2 Page 19 The shift leaders undertake supervision of the care staff team; the deputy manager takes supervision for the shift leaders and monitors the shift leaders supervision of the care staff for effectiveness and to identify any training requirements. One relative commented “staff are not easily distinguishable/do not necessarily wear a name badge etc. It is difficult to tell who is in charge”. The manager reported being aware that “Not everybody has name badges, it is on my ‘to do list’”. The staff team wear specific colours of uniform to help people differentiate between the different roles. Shift Leaders wear Burgundy, Carers wear Blue, Senior Care wear Lilac and the Domestic team wear tabards. In surveys relatives said “A photo board on the notice board at Stisted would be a good idea.” The manager and the Business Operations manager were able to confirm during discussion that this was ‘work in progress’ throughout the group homes and a suitable cabinet had been identified and would be provided imminently. The staff had an established routine of having alternate weekends off meaning that there was still a dependency upon agency staff especially at weekends. The manager recognised that the rota needed to be arranged in the best interests of the people living at the home. The organisation had entered into a consultation process with the staff team via the Human Resources department to change the rota to reduce the dependency of agency staff thus providing more consistency of care for the people living at the home. DS0000017912.V367200.R01.S.doc Version 5.2 Page 20 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, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a well managed home and can be confident that management is continually working towards improving the service. EVIDENCE: Since the previous inspection visit the organisation had recruited a new manager who became registered with the Commission for Social Care Inspection in May of this year. The manager had previous experience of managing a care home and had achieved her registered Manager’s Award and NVQ level 4. The manager had introduced a positive focus on empowering residents to make choices and being active in influencing the running of the home. She reported this as being an uphill struggle as the people living there were content with the status quo but there was evidence of progress being made. DS0000017912.V367200.R01.S.doc Version 5.2 Page 21 The previous Quality Assurance survey identified a lack of management presence around the home. This was not noted at this visit, residents were seen to have warm exchanges with the manager when they met her about the home and all people spoken with had positive and affectionate comments to make about her. One person said, “The manager’s door is always open, we are lucky to have her”. The organisation used an external company to undertake an annual quality assurance assessment. The next one for this home was due in September 2008. The manager was able to show us the action plan developed as a result of the previous year’s Quality Assurance report. Reference has been made to this within this report. The service had safe arrangements in place for looking after any monies held on behalf of the people living there. Funds were maintained in a dedicated, non-interest bank account, with clear, computerised individual records showing all income and expenditure; receipts were kept for all purchases, with clear systems in place for recording any shopping done by staff on behalf of individuals. The home’s administrator checked individual records against the monthly bank statements received and a report was passed to the manager for monitoring purposes. Cash was accessible during office hours, the manager reported that arrangements were normally made with this in mind but if any person needed access to their monies at weekends or evenings then she and the deputy were on call and could easily be contacted. The manager reported that she found the process of completing the AQAA very useful especially in light of the fact that she had been at this service for just one year. The process identified that portable appliance testing had not taken place the home; this had been actioned by this visit. Servicing of hoists and fire extinguishers had taken place and care plans included individual evacuation plans for each person. Fire drills were scheduled 6 monthly but any event where a fire alarm was activated (Toast burning for example) was used as a drill opportunity. The deputy manager and 2 shift leaders were in house moving and handling trainers and the training matrix indicated that the vast majority of staff had attended recent training in this area. Areas of the home viewed during this inspection appeared well-maintained and safe. DS0000017912.V367200.R01.S.doc Version 5.2 Page 22 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 3 X 3 X 3 X X 3 DS0000017912.V367200.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Medication recording practices must protect residents from any risk of administration errors. Practices therefore need to be reviewed to ensure that: 1. Controlled drugs are consistently recorded in a way that meets legal requirements; 2. MAR shows accurate current administration instructions (e.g. when the dosage of a drug is changed); 3. All handwritten medication details or changes recorded by staff must be signed and dated. Issue no. 3 is a repeat requirement for the third time (last timescales 8/9/06 and 06/08/07). 2. OP7 15 To ensure that residents receive the care they require, staff must have clear information on how to meet residents’ needs. Care plans therefore need to contain sufficient detail of the action to be taken to meet each person’s DS0000017912.V367200.R01.S.doc Timescale for action 10/08/08 30/09/08 Version 5.2 Page 24 health and welfare needs (including needs relating to challenging behaviours and social activities). This is a repeat requirement (last timescale 30/09/07 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 OP12 Good Practice Recommendations It is recommended that care records include information on residents’ previous life histories and interests. This is particularly important in the case of those residents who suffer with dementia. This is a repeat recommendation. DS0000017912.V367200.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000017912.V367200.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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