Inspection on 06/09/07 for The Promenade Residential Care Home

This inspection was carried out on 6th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

The Promenade Residential Care... 25/08/09

The Promenade Residential Care... 13/09/06

The Promenade Residential Care... 21/02/06

The Promenade Residential Care... 08/06/05

The Promenade Residential Care... 04/02/05

The Promenade Residential Care... 10/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Promenade Hotel Marine Drive Hornsea East Yorkshire HU18 1NJ Lead Inspector Sarah Sadler Key Unannounced Inspection 6th September 2007 09:00 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 Promenade Hotel DS0000019709.V350154.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. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Promenade Hotel Address Marine Drive Hornsea East Yorkshire HU18 1NJ 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) 01964 533348 01964 537868 Continuing Care Services Limited Mrs Irene Phyllis Poole Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24) of places Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) named service user under 65 years of age may be accommodated within the maximum number. The condition is to cease when the named Individual ceases to live at the home. 13th September 2006 Date of last inspection Brief Description of the Service: The Promenade Hotel is a residential home that caters for the needs of 24 elderly people. The home is owned by Continuing Care Services Limited and was first registered on the 25th January 1994. Personal care is provided to all people in the home, along with meals and a laundry service. The home is located on the sea front at Hornsea, close to all town amenities and public transport. The home comprises of three houses that were originally converted into a hotel and restaurant. Accommodation is provided on three floors - the first and second floors are accessed via a stair lift. The environment consists of 2 lounges, 14 single rooms and 5 shared rooms. The home has an extensive garden at the rear and car parking is available at the front and rear of home. The weekly charges are £297.00 to £381.30 and there are additional charges for hairdressing, chiropody, toiletries, trips, newspapers and magazines. The administration person provided this information on the day of the visit. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit was undertaken on 6th September 2007. The site visit commenced at 09.30 and was completed at 17.00. The manager was available for all of the visit. There were several relatives and one professional who visited the home and were available to talk to. We also talked to some of the people living in the home and two staff members. A tour of the premises including people’s rooms was undertaken and people’s files; staff records, health and safety documents and other records were examined. The site visit forms part of this inspection, which includes a review of all information received relating to the home since the last visit or registration. As such this report reflects information from the site visit, views from people via surveys, the Annual Quality Assurance Assessment (AQAA) document provided by the registered person and referral to any other relevant letters or occurrences in the home. Other information we considered included the AQAA. This is a self-assessment document which is completed by the registered person to evidence how well the home is meeting the National Minimum Standards, and what if anything needs to improve. From this information formal surveys were sent to the relatives and professionals. No surveys were received prior to the visit. However, the service user and staff surveys were completed on the day of the visit, 5 staff and 8 service user surveys were received. Comments and responses from these were all positive and are included throughout the report. During the inspection process and again in preparation for the site visit we assessed other information received by the CSCI regarding the home, which included any letters from the registered person or others and any complaints, of which there has been none. What the service does well: In discussion and in surveys people told us that they were happy in the home and liked the staff team that support them. Relatives were all happy with the way people are supported and how they are welcomed into the home. Assessments of need are received from other professionals and completed in the home. This helps to make sure that the staff in the home are clear what the person’s needs are and that they can be met in the home. People have individualised plans of care that they have helped develop or agreed to. These provide staff with the information to help support them in meeting their needs, which people told us they are happy with. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 6 People’s health needs are well met. The people living in the home and the visiting professional were all happy with the support people receive for this. People living in the home and their representatives were happy with the activities provided. Relatives and friends felt that they could visit at any time and were always welcomed into the home. The home was clean, warm and welcoming, with a relaxed atmosphere. People living there said they were happy with their bedrooms and they can bring in their own possessions, making it feel more like home. The registered manager is experienced in managing the home. Maintenance certificates and checks were up to date, helping to make sure that people live in a safe environment. What has improved since the last inspection? What they could do better: The registered manager has made sure that there are a variety of risk assessments in place. These identify the risk to the individual and how this will be reduced or managed. However one person needs to use a bed rail and the risk assessment for this had not yet been completed. The registered manager knows that this must be completed to help make sure that the person is safe and that the use of the bed rails does not place them at further risk. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 7 In general the practices regarding medication are adequate. However, not all medication was stored correctly and there were small gaps in the recording of administration of medicines. New medication that had not been checked into the home was stored in a food cupboard. This was not locked ensuring safety and this is not an appropriate place to store medicines safely. The manager is aware of the Safeguarding policies and procedures, which provide guidance to support people if an allegation of harm or abuse occurs within the home. This includes a copy of the Local Authority’s policy The Protection of Vulnerable Adults, which people can refer to if an allegation is raised. However, although the registered manager had reported an incident to care management the Safeguarding policies have not been followed to make sure that the right actions are taken to help people keep safe. The manager should make sure that this and any future incident is. This will help to make sure that people are supported correctly if an incident occurs. There is a recruitment process in the home, which provides that each new member of staff supplies an application form, references and undertake a CRB check. However, the procedure needs to be improved to make sure that everyone provides a fully completed application form, showing their previous and relevant experience for this role. Staff told us that they have received training and about the different courses that they have attended. Although people were clear about what courses they had completed, there are several, for example, Safeguarding People which, they have yet to attend. These would help them to make sure that they have the skills to continue to meet people’s needs. The registered manager is available within the home and people in the home, their representatives and staff felt that she was approachable and would address issues. However, staff are not always offered formal supervision. Undertaking this would give staff more opportunities to discuss their roles, any worries and training needs they may have, helping them to be confident and trained in their role of meeting people’s needs. 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. Promenade Hotel DS0000019709.V350154.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 Promenade Hotel DS0000019709.V350154.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): 2, 3 & 6 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. People wanting to use the service undergo a full needs assessment, which tells staff about them and the support they need. People are on the whole provided with information about the home and the services provided, which helps them to make positive choices about moving into the home. EVIDENCE: Of the surveys received, the majority of people felt that they had received enough information about the home, to make an informed choice prior to moving in. Three people felt they had not received this information and two could not recall receiving a contract. Of the three files examined only one contained details of a contract held between the home and the individual person. The Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 10 registered manager should address this to ensure that people are as far as possible, always aware of the conditions for living in the home. People’s files all contained a copy of an individual assessment of needs completed prior to the person moving into the home. In addition two of the files contained a copy of the Local Authority’s assessment and care plan for the individual. These documents provide a picture of the strengths and needs of the individual and how these are to be met. The information contained in the AQAA detailed that information is collected from every available source, including the individual, their family or friends and staff from the health and social care sectors. This information had then been used to develop individual plans of care, which provide staff with the information they need to meet people’s care needs. The registered manager confirmed that the home does not provide an intermediate care service, so standard 6 does not apply to this home. Promenade Hotel DS0000019709.V350154.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 adequate. This judgement has been made using available evidence including a visit to this service. People’s health and personal needs are on the whole well met. But failure to ensure that all medication practices are correct could put people’s health and welfare at risk if not fully addressed. EVIDENCE: People have individual plans of care that include the details of their needs. This includes needs relating to personal hygiene, medication and diet. There are daily diary notes that reflect the level of support people have required and monthly evaluations completed by the home to make sure that the information is correct. The registered manager told us that should people need individual records of their nutritional intake then this would be completed, but that at present no one needs this. Annual reviews are held with the Local Authority again, reviewing the persons care plan and needs to find out how well these are being met and if there has Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 12 been any changes to this. This will help to make sure that the staff are provided with up to date information to continue to meet people’s needs. Wherever possible people have been involved with their care plans and have signed to say that they agree to these. People’s files include risk assessments, which identify possible risk and how these will be managed. These include the risk of the person falling, pressure areas and nutrition. These had been reviewed and kept up to date to make sure that staff were aware of the latest risks for individuals and how these could be managed in keeping people as safe as possible. Recently there has been the need for the use of bed rails and the registered manager was made aware of the need for a thorough risk assessment to help make sure that the use of this is safe. Details of people’s health needs were included within their plans of care. In their individual files were letters and documents that showed that they access chiropody, dental and optical services as well as the GP services. The professional visiting on the day of the visit was complimentary of the home. They confirmed that the home accesses their services as necessary, assists them with their role and follows their instructions to help ensure that the person’s needs are met. All of the people spoken to and who responded with surveys confirmed that they felt that their health needs are either always or usually met, with the large majority putting always. Records are kept of all medicines received, administered and disposed of. There were some small gaps in the recording of the administration of medicines and the manager is aware of the need to address this. In doing so it will help to ensure that people’s medication needs are fully met and reduce the risk of errors occurring. The storage and recording of medicines described as ‘controlled’ were found to be up to date and correct. There are a small amount of medicines that need to be kept cool and these are held in a labelled container within one of the catering fridges. There had recently been a delivery of new medication stock and this was found to be stored in an unlocked food cupboard. The registered manager was made aware that this practice does not make sure that medicines are secure and safe and that this practice must cease. Relatives and people living in the home told us that they were happy with the support they receive in the meeting of their needs. One relative commented that staff are: ‘ All brilliant – you never see them sigh if you ask for something’. Staff gave good examples of how to make sure people’s privacy and dignity is respected, this included making sure that bathroom and toilet doors are closed when in use, that people are offered a private room to see their relatives in and in making sure that confidential information is kept confidential. The information in the AQAA included that the privacy and dignity Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 13 of people is preserved and that the staff take particular care as to when is the best time for each person to have their bath or shower. Promenade Hotel DS0000019709.V350154.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. People have the opportunities to take part in varied activities and are supported to keep in contact with family and friends and people receive a nutritious diet, with choices, that helps to meet their needs. EVIDENCE: The people living in the home and their relatives are happy with the activities offered in the home. In the surveys all but one of the people living in the home said that there were ‘always’ activities in the home they could take part in. One person said ‘usually’. People’s comments included ‘ I like the bus trips out’. Relatives’ comments included, ‘There is always something going on and she loves it’ and ‘She loves the entertainer and they have a quiz every other Thursday’. People’s individual daily notes described mainly how their personal care needs could be met and did not contain much detail on which activities they joined in with and which they decided not to. This information would be useful when finding out about a person and which activities to provide in the home. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 15 Staff told us that activities include bingo, dominoes, quizzes, trips, going out into town and entertainment. The AQAA information told us that the staff in the home have altered their entertainment programme so that it takes place later into the evenings and this encourages people to socialise for longer. This was as a result of questionnaires completed with the people living in the home. We saw several different relatives and friends visit the home whilst we were there and spoke directly to four different visitors. One of these told us that ‘ We are always welcomed into the home at anytime and there is always a cup of tea and the staff are very friendly’. Staff told us that they make sure relatives are kept informed of any changes in people’s circumstances and are encouraged to visit the home with invites to social events including the summer fair and Christmas party. Also that if people wished they could spend time in private with their relatives. This would be in one of the lounges in the home. This helps people to maintain relationships that are important to them. People were observed to be able to make choices in their daily lives. Different people sat down for lunch at different times and one person told us that he could come and go from the home as he wishes. A relative told us that their relative chooses not to join in with activities and prefers to sit in their room and watch their television. Lunchtime was observed to be a pleasant and relaxing experience. People can eat in their rooms or later if they wish to. Staff were seen to give good support to people who required any assistance with their meal. The food was of a good quality and tasty, with salt and pepper being available on people’s tables if they required this. There are menus that are based over a two week rotation. These are sometimes basic and do not fully reflect the choices that people are able to have, also on one occasion the main course is the same of one of the optional choices, reducing choice. The registered manager agreed that the menus require updating. People responded in their surveys that the majority liked the food in the home ‘always’ or ‘usually’ with two people putting ‘sometimes’. Relatives told us that the food is ‘ Adequate, quite nice, quite good’ and ‘ she enjoys the food and she’s put some weight back on, she looks healthy again’. The AQAA information included that the home provides nourishing home made meals. There was a visit from the local Environmental Health Officer whilst we were visiting the home. The registered manager told us that they had met the requirements and the only work from their visit was to complete some paperwork. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints system was in place and people living in the home, staff and others were confident that complaints and concerns will be listened to and acted upon. But failure to ensure that Safeguarding procedures are followed correctly could put people’s health and welfare at risk. EVIDENCE: No complaints about the home had been referred to the Commission since the last inspection. A complaints procedure was on display in the home. Records showed there has been one complaint made direct to the home. However, discussion with the registered manager and review of the complaint found that this is an allegation that should be dealt with under Safeguarding polices. The registered manager told us that she has already informed the Local Authority representative of this situation and that actions are being taken. However, the incident that occurred and resulted in the complaint was not the first time that such an incident had taken place and the registered manager must now ensure that this is dealt with correctly under the Safeguarding procedures, informing the CSCI of the actions taken and keeping appropriate records. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 17 Relatives and people living in the home were confident that if they raised a concern then the registered manager would deal with this correctly. The large majority of people who responded in the surveys confirmed that they knew how to make a complaint, although not all of the relatives were aware of the complaints process. Information from the Annual Quality Assurance Assessment detailed that there is a Safeguarding Adults policy in the home and this was also provided at the time of the visit. When we spoke to staff they told us how they would respond to someone who was talking in an abusive manner to someone living in the home. Although staff have not all undertaken training in the Safeguarding of Adults their responses were appropriate. Information from the AQAA and in talking with the registered manager it was found that one Safeguarding Adults referral had been made to the Local Authority, although as discussed it is required that this is now followed up. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 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 comfortable home that is well maintained. EVIDENCE: The home is clean and comfortable throughout. The majority of the communal and personal areas are well maintained although some areas are in need of minor repairs and are nearing the time for refurbishment. The shower area is cold and badly designed, leaving only a small area for people to dry after their shower, which may in turn compromise their privacy. One service user told us that it is not easy to get dried after using the shower. There is a staff call system available within the home and this was tested and found to be working at the time of the visit. There were records to show that this had been maintained and people told us that they could ring their bell to Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 19 get staff assistance. There were records in place for maintenance of this to help make sure that it is in good working order. There is a conservatory to the front of the home that people were seen to use. The rear gardens are well maintained and the registered manager told us that there are plans to develop these further with the replacement of the old ‘summer house’ at the rear of the property. People’s rooms were all personalised and some people had brought objects from their own home including furniture to help them feel more comfortable. There were records in place to show that the equipment to assist people with mobility, including the hoist and chair lift were regularly maintained and in working order. However, the chair lift had recently broken down and this had resulted in one person having to sleep in the lounge, as they could not get upstairs. There is not a second chair lift to the higher rooms and the registered manager may wish to address this. Records were kept of a fire risk assessment; fire checks, drills and maintenance of fire equipment, to make sure that the home continues to work to both reduce the risks of fire and to help to keep people safe. The registered manager told us that there are now pre-set valves, which have, fail safe devices fitted to hot water outlets throughout the home. These help to make sure that water is provided at temperature close to 43° centigrade to help protect people from the risk of scalding. In addition weekly checks of the bath temperatures are taken. The registered manager also told us that the washing machines in the home meet with the Water Supply (Water Fittings) Regulations 1999, but that no evidence was available that all of the water supplies in the home meet this. The laundry is situated outside of the home and this is locked, as is the adjacent room where all COSHH (Control Of Substances Hazardous to Health) products are stored, to help ensure safety. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. People are happy with the staff that supports them. However, improvements need to be made to the recruitment and training practices to make sure people’ s needs continue to be met safely. EVIDENCE: There are duty rotas planned within the home that reflect that the staffing levels vary throughout the day. This helps to make sure that there are more staff at busy times when more people need support. Of the six staff surveys received the majority felt that there were ‘sometimes’ enough staff on duty. The registered manager may wish to address this further with the staff team. People were on the whole happy with the staff team. They told us that people were polite, friendly and ‘brilliant’. Three staff files were looked at. All of these had evidence that two written references and a CRB (Criminal Records Bureau) check is undertaken on staff prior to them commencing in the home. Also that a POVA (Protection of Vulnerable Adults) first check is completed. These checks help to ensure that potential staff are suitable for the position they are applying for. Also that they Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 21 do not hold a criminal conviction which may prevent them from working with vulnerable people. The CRB guidance is clear that a POVA first check is only undertaken in exceptional circumstances when there is a particular shortness of staff and there is a need for people to commence work urgently. However, the registered manager had completed this check on all of the new staff in the home. This was discussed with the registered manager and she was made aware of the guidance. Not all of the staff had an application form or when they did it was not always fully completed. These help to show the previous experience and qualifications of the staff member, when helping to decide if they are suitable for the post. Without these in place it will be more difficult for the registered manager to make sure that the correct people are employed. Two people’s files included evidence that they had completed an induction into the home. Although the registered manager has registered with Skills for Care to help make sure that the staff team are trained to the latest standards. There was no evidence that the induction met these standards. The AQAA information also told us that over 50 of the staff team now hold a National Vocational Qualification (NVQ) to level 2 or equivalent in care, and certificates were on display throughout the home. The registered manager has completed a staff matrix of all courses undertaken and the required date for renewal. Staff told us that over the last year they had completed courses in First Aid, Palliative Care, Medication and Fire Training and that they are about to commence a course on Dementia care. They further told us in their surveys that they felt they had been given training relevant to their role, that helped them understand their role and which keeps them up to date. However, on the day of the visit individual staff records relating to training were sparse with only limited information and little evidence of staff training. The registered manager later provided further evidence of staff training. These records must be kept up to date to make sure that there are clear audit trails of all training and that this training is kept up to date. Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced manager runs the home and systems are in place to ensure people are consulted about the home. However, these systems need to be used more to ensure people are involved in the continuous improvement of the service. The health and welfare of people using the service is protected and promoted. EVIDENCE: The registered manager has managed the home for some time and is experienced. She told us that over the last year she has continued to update her skills and has undertaken training in Continence Management, Fire, First Aid, Safer Food, Better Business and Drugs Management. As the manager of Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 23 the home she completed the AQAA and returned it to the CSCI. Information about the home and any occurrences that are required to be notified under regulation 37 is normally forwarded. This helps to make sure that the CSCI is kept up to date on incidents in the home and how these are managed. However, no notification was received regarding the breakdown of the chair lift and the registered manager was made aware of the need for this. The information in the AQAA told us that there is a wide range of policies and procedure within the home to support people and that these are reviewed and kept up to date. There continues to be a quality assurance system in the home. However, this has not been fully used to find out information and to complete reports and development plans for the home over the last year, and it is recommended that this takes place. This will enable the people who live in the home and their representatives to be involved in the development of the home. The administration person in the home is the appointee for only a few of the people who live in the home. Only personal allowances are kept in the home and there are receipts and regular checks made for these to help ensure that these are managed correctly. Of those examined these appeared to be in good order. Staff told us that they felt well supported; in the surveys they completed approximately half said that they received support regularly or often and half said that they received support sometimes. Staff records did not hold details that regular supervision/support sessions are taking place. This was a recommendation from the last visit to the home and this must now be addressed. Without formal and regular support ( a minimum of 6 times a year) staff may not be clear in their roles, know what training they require, or receive the support that they require to ensure that they continue to meet people’s needs. Maintenance certificates were in place, which showed that the home is kept well maintained to protect people’s safety. These included the emergency lighting, electrical installation, portable appliance testing, gas safety and the chair lifts. The manager has completed risk assessments in relation to people’s safety, which include the outside of the premises and the sloping footpath. The manager has addressed the risk of the use of using steradent in relation to safe storage. Each person is now provided with the necessary amount of steradent, in water on a daily basis. Promenade Hotel DS0000019709.V350154.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 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 3 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 X 3 Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 13 Requirement The registered person must make sure that risk assessments are in place for the use of bed rails. This should include how any risks will be managed to help keep the person safe. The registered person must make sure that medication is stored safely, in a suitable locked container, which cannot be removed from the home. The registered person must make sure that any incidents that may be regarded as abuse are reported within the Safeguarding Adults procedures. The registered person must make sure that all staff undertake Safeguarding Adults training. This will help to make sure that hey are aware of the systems and able to support people if an incident occurs. The registered person must make sure that all staff fully completes an application form as part of their recruitment process. This will help to make sure that the appropriate people are DS0000019709.V350154.R01.S.doc Timescale for action 15/12/07 2 OP9 13 15/12/07 3 OP18 13 15/12/07 4 OP18 13 30/12/07 5 OP29 19 15/12/07 Promenade Hotel Version 5.2 Page 26 6 OP36 18 employed in the home. Formal supervisions should be provided for all care staff at least six times a year, so that they understand the policies and ethos of the home and are supported in their role. 15/12/07 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 2 Refer to Standard OP2 OP12 Good Practice Recommendations The registered person should make sure that people are kept aware of the terms and conditions for living in the home. The registered person should make sure that there are records kept of people’s level of involvement in the activities provided in the home. This would help both in the individual and group planning of activities in the home. The registered person should make sure that the menus accurately reflect the food and choices provided within the home. The shower facilities should provide adequate private space for people to dry themselves after taking a shower. There should be evidence that the home meets the Water supply Water Fittings) Regulations 1999. This would show that the water supplies are safe to this standard and reduce the risk to people in the home. The registered person must ensure that individual staff training records are kept up to date and are easily accessible. This helps to make sure that staff have the necessary skills to continue supporting people safely. The registered person should ensure that there is evidence that the staff induction meets the requirements of Skills for Care. This would show that the induction meets the National Standards in care. The registered person should make sure that the Quality Assurance system is fully utilised to support people to be involved in the development of the home. 3 4 5 OP15 OP21 OP26 6 OP30 7 OP30 8 OP33 Promenade Hotel DS0000019709.V350154.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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