Inspection on 19/07/07 for Puddavine Court

This inspection was carried out on 19th July 2007.

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

Puddavine Court 14/07/08

Puddavine Court 18/07/06

Puddavine Court 17/01/06

Puddavine Court 20/04/05

Puddavine Court 12/10/04

Puddavine Court 27/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Puddavine Court Ashburton Road Dartington Totnes Devon TQ9 6EU Lead Inspector Unannounced Inspection 09:00 19 & 20th July 2007 th 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 Puddavine Court DS0000003783.V342859.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. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Puddavine Court Address Ashburton Road Dartington Totnes Devon TQ9 6EU 01803 866366 01803 866366 courtgroup@btinternet.com 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) Manor Collection Ltd Mrs Valerie Hilda Austin Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Old age, registration, with number not falling within any other category (38), of places Physical disability (38), Physical disability over 65 years of age (38) Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD Category is from age 55 yrs only Date of last inspection 23rd January 2007 Brief Description of the Service: Puddavine Court is a large detached house on the edge of Totnes, substantially extended a few years ago. Accommodation is provided over three floors and there are thirty-six single rooms (the majority of which are en-suite) and one double en-suite room. There are two lounges and the main dining room on the ground floor, and also lounge and dining areas on the other two floors. All floors are accessed via a shaft passenger lift. The garden is large, accessible and attractive. There is ample car parking space. The home is registered to care for people aged sixty-five years and over, who may or may not be, suffering from dementia. The home also provides care for service users from the age of fifty-five years who have some form of physical disability. The current fees charged range from £350-£450 per week. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place on Thursday 19th July and Friday 20th July and totalling 10 hours. Opportunity was taken to observe the general overall care given to the people living in the home. The individual care provided for four individuals was also followed in specific detail, which involved checking that all elements of their identified care needs were being met appropriately, and obtaining feedback from staff and relatives and or their representatives. A tour of the premises, examination of some records, discussions with the Responsible Individual for Manor Collection Ltd. (who was present for part of the inspection), the registered manager, a sample of people living in the home, relatives and visitors and staff all formed part of this inspection. Staff on duty were also observed, in the course of undertaking their daily duties. Other information about the home, including the receipt of five completed questionnaires from relatives and seven staff at the home. The registered manager provided the CSCI with a completed Annual Quality Assurance Assessment which was completed at the beginning of July 2007 and has also provided further written evidence and sources of information post this inspection. All of this collated information has been used in the overall writing of this report. All required core standards were inspected during the course of this inspection process. An incident, dating back to June 2005 that was being investigated by the police, has now been passed to the local authority. This was in relation to the death of a resident falling from a first floor window of the home. It is understood that the local authority is currently undertaking an investigation under the Health and Safety at Work Act legislation. What the service does well: Puddavine Court continues to provide a comfortable and well maintained environment, where residents’ care is provided for by a relatively stable and well trained staff group. There were some good examples of good practice in Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 6 relation to people living in the home who have some confusion and associated needs. The home continues to maintain a welcoming, comfortable atmosphere, where residents are freely able to choose how they spend their time. Visitors are welcomed and encouraged to the home. The staff maintain individual choices for those living in the home, to good effect, which facilitates the pursuit of interests and choice of lifestyle. The Responsible Individual and manager endeavour to encourage community contact, with both considering Puddavine Court to be an extended part of the local community. The staff training programme is very good with continual training on offer and new training opportunities being sought. What has improved since the last inspection? What they could do better: The Statement of Purpose displayed in the main hallway needs to be updated to include the most recent findings of the Quality Assurance Audit obtained from people living in the home and their representatives and the most recent inspection report. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 7 The registered manager needs to obtain current guidance and good practice guidance in relation to the care of persons living with dementia and introduce these to staff and working tools with which to improve knowledge and good, current and recognised practice. Daily records need to be more descriptive and include details of the individual’s emotional well being. There needs to be care taken in the use of language in relation to daily records to ensure that some phrases cannot be misinterpreted or cause offence to the person to whom they belong or any relative that may have permission or cause to read it. The use of the home’s minibus for outings needs to be re-instated as promised. The cleanliness of all rooms alongside the needs of individuals should be closely monitored, and any cleaning routine needs to be fitted around these needs to avoid an unnecessary anxiety or concern for individuals, particularly those who may be spending a considerable amount of their time in their rooms. The staffing levels need to be closely monitored to ensure that they continue to be maintained at the level observed on the day of inspection and adjusted according to the needs of the people living in the home at any one time. The practice of staff leaving the premises at night to conduct checks on residents through their bedroom windows needs to cease to ensure the safety of themselves and all those in the home. 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. Puddavine Court DS0000003783.V342859.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 Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is good. The admission process is managed appropriately and prospective residents and/or their next of kin/advocate are given the necessary information regarding the service prior to admission so that they can make an informed decision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the home’s Statement of Purpose was viewed and found to be comprehensive, clear and written in plain English. It gives clear information to prospective residents and/or their representatives about the level of service they can expect to receive from this home. There was some information in relation to a quality assurance survey carried out – but this was from 2005. There has been more recent surveys carried out. The last inspection report contained in the document displayed in the main hallway was from 2004, when again there have been more recent inspections. The registered manager made re-assurances that these documents would be updated immediately and that documents given to prospective residents do contain the more up to date information as required. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 10 Several new persons have moved into this home since the last key inspection in 2006. The most recently admitted person was spoken with in detail about their admission process and records for this person were looked at in detail. The individual confirmed that she had moved in only two weeks previous and had previously lived in another care home. A senior staff member from this home had visited her to discuss her needs and talk to her about Puddavine Court. She confirmed that her family had been able to look around this home on her behalf prior to her admission. She stated that she had been made to feel welcome and on the whole her needs are being met and in particular health care needs were assessed and addressed promptly upon her arrival. Pre-admission assessments are clear and comprehensive and give a clear indication as to whether the needs can be met at this home. A letter is sent to the prospective resident and or their representative or placing authority confirming that a place will be offered if the manager feels their needs can be met. There is additional information and referral documentation on files from placing authorities, GP’s or previous care homes. Quality Assurance questionnaires are issued to all newly admitted persons and those who stay in the home on a short–term basis. Puddavine Court does not provide rehabilitative or intermediate care. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. Residents are looked after well in respect of their health and personal care needs. Residents’ privacy and dignity is upheld and their life style choices are respected, This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were seen in respect of four persons living in this home. The care plans examined were thorough and covered all required care needs. Residents who wish to are involved in both the drawing up of their care plan and the regular monthly review process of the care plan. Full risk assessments are carried out in relation to falls, medication control and self medication where appropriate, moving and handling and pressure area care. Individual’s weights are recorded and when required food and fluid intake records are implemented. People moving into the home are given the choice of G.P. wih whom to register and referrals to other health care professionals are sought where necessary. There is a visiting hairdresser and chirpodist and sight and hearing Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 12 tests are arranged as required. The home maintains a comprehensive list of any health care visits which ensures all staff are easily able to be aware of what each professional may have prescribed/suggested. Staff have received training in relation to personal care and specifically in pressure area management, catheter care, diabetes and nutrition. Daily records were up to date and recorded a good level of evidence of personal and health care needs as having been met or monitored when required. However, these records did not on many occasions give a full picture of the individual’s emotional well being or of any level of detail in relation to their social care or interaction. For example, the fact that an individual had received a visitor was recorded or that they went out with a visitor – but there is frequently no record of who the visitor was, where they went (where appropriate) and if they had enjoyed the experience or any other issues arising from this visit. An example of poor use of language was discussed with the Responsible Individual and registered manager and this will need to be monitored in all records. The registered manager has implemented new person centred care planning documentation in the form of a “My Life” book, which will be written with the people who live in the home with support from their relatives and/or representatives and staff members. This is currently awaiting the completion of a printing process and will be implemented fully in the next couple of months. The medication system was found to be stored, administered and recorded appropriately. All staff responsible for the administration of medications have received training and ongoing monitoring and supervision from the registered manager. A six monthly drug audit has recently been introduced and is carried out and recorded by the company’s Health and Safety Officer. People living in the home that were spoken with confirmed that they were addressed as they wish, that staff treat them as individuals and with respect and that they feel they are free to do as they wish within the confines of living in a care home. One relative stated that they feel Puddavine Court is more like a hotel than a home for older people as she had imagined it. Staff members were observed being patient, kind and empathetic with people, knocking on doors before entering a bedroom and giving people the freedom to spend time in their rooms when they wished and ensuring that at the same time they did not feel isolated, taking meals and drinks to them and popping in to make sure they were ok. One staff member was observed dealing with a person who was confused, anxious and upset in a particularly understanding and empathetic way. Puddavine Court DS0000003783.V342859.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, 15 Quality in this outcome area is good. Residents enjoy a peaceful life at the home, with visitors encouraged and welcomed. Choices are made available to residents regarding their day to day living and these are respected and upheld by the management and staff. Links are also encouraged and maintained with the local community. Residents are able to participate in various informal activities when offered. The home provides nutritious and varied meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home stated that they were free to choose where they would like to spend their time, with whom and doing whatever they choose. With some this meant that they spent time in their rooms watching TV, listening to music, doing crosswords, reading or with hobbies such as knitting. Others chose to spend time in one of the communal areas chatting with friends, reading the newspaper or books or watching the TV. There is an activity plan that is displayed on the home’s notice board, whereby informal group activities are organised on a daily basis. The staff on duty explained that this remains very informal and can be changed according to the groups’ wishes. People living in the home stated that they often go out for walks locally or are free to come and go with family members if they wished. Some Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 14 people were making use of the extensive gardens to the front and side of the home. Four of the five relatives who responded to surveys, three additional relatives spoken with on the day of the inspection and three people living in the home raised concerns that the weekly outings that once occurred have now ceased. They were told that the mini-bus belonging to the home had failed its MOT, but that this would be remedied soon. The registered manager confirmed this was the situation, but telephoned the Responsible Individual, who confirmed that a new minibus would be in position and ready for use again from the 26th July. This was an activity that seemed to be enjoyed and indeed expected by a good number of people in the home and has obviously been missed. Records of activities that have taken place are said to be recorded in a book with a list of participants and the outcome of the group. However, this book could not be located on the day of this inspection. Relatives confirmed that there is an open visiting policy in the home, and that many feel free to visit at differing times of the day and evenings and that they are always made to feel welcome. One relative was due to take her mother to her own home for the afternoon and for tea and welcomed the support she receives in doing this. The home has good links with the local community, with regular events and social occasions organised within the home whereby members of the local community, some of whom are from specific groups or organisations, are invited. There are a small number of people living in the home that are supported in attending church services outside of the home. There is a rolling menu in place that offers a good level of choice, variety and nutritious and well balanced meals. People living in the home confirmed that they are always told what is on the menu in advance and asked for their choice, which is then cooked in house. They stated that the meals provided are plentiful and offered a good level of choice. One person stated they had been unhappy with the quality of meals recently, but this was the only person to raise this as a concern. The meal on the day of this inspection was displayed on the board in the lounge. Staff were observed going to people in their bedrooms and asking for their choice of meal and for evening tea. People were seen to be served meals as they had requested. They were well presented and plentiful and the main meal was hot. People are supported in having their meals in their rooms if they do not wish to take their meals in the main dining area. Condiments, sauces and drinks were available to people to use independently where they were able to manage this. The registered manager stated that everyone is supported in maintaining skills of independence wherever possible, particularly around meal times. Puddavine Court DS0000003783.V342859.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): 16,18 Quality in this outcome area is good. Arrangements for protecting residents and responding to their concerns are satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaint policy remains communally displayed in the home’s hallway and is also contained within the home’s statement of purpose. It was noted that any in-house complaints are treated and recorded; clearly evidencing what action has been taken to resolve them. Formal complaints have been received and these too have been recorded in detail giving evidence of how the complaint has been resolved. People living in the home and relatives spoken to or who responded to questionnaires stated that they were aware of the complaints procedure and were confident in raising concerns with the manager or staff on duty when required. There was however an exception to this in relation to one particular concern experienced by and raised by four relatives and four people living in the home. It was reported that bedrooms are not cleaned as often as necessary, resulting in carpets being unclean and excessive dust. On the day of the inspection the inspector identified that four rooms in particular had not had the carpet hovered, for what looked like a few days. It should be noted that these four people living in the home were people who are more dependent and are spending most of their time in their bedrooms. All persons spoken to about this stated that this situation has been ongoing for some weeks. The registered manager stated that the cleaner was on leave, and although a Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 16 replacement cleaner was working, it may be that the level of cleanliness is not of a usual standard. However, when going back to check this with relatives and the people living in the home, they were insistent that this had been for some time prior to the regular cleaner being on holiday. The registered manager and Responsible Individual acknowledged that this issue was of concern, and stated their intentions to monitor this and discuss with the regular cleaner on their return from holiday. An investigation dating back to June 2005 that was being investigated by the police has now been passed to the local authority. This was in relation to the death of a resident falling from a first floor window of the home. It is understood that the local authority is currently undertaking an investigation under the Health and Safety at Work Act legislation. The Protection of Vulnerable Adults from Abuse, forms part of the staff training programme that has been attended by all existing staff. The home has in place the local Adult Protection policy, which is accessible to all staff. Puddavine Court DS0000003783.V342859.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. Puddavine Court is very comfortable, generally clean, well maintained and provides a safe standard of accommodation for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The tour of the home confirmed that the owner and manager maintain very good environmental standards within the home, which makes Puddavine Court a pleasant place to live in. Routine general upgrading continues to take place as required. Since the last inspection the owner has upgraded a further two shower rooms, as well as the ongoing refurbishment of bedrooms as they become vacant or when required. One ground floor bedroom has been taken out of use whilst a damp problem is addressed. The registered manager stated that the gravel to the front of the house is due to be removed and replaced with tarmac and some new fencing, that will extend the accessibility to the garden for all people living in the home. This work was due to commence on the 30th July. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 18 The manager ensures that the home’s fire precautions are maintained in line with the requirements of the local fire department, whilst a member of the company’s staff is employed specifically to ensure this, and all other areas associated with the health and safety of the residents, are maintained in accordance with the requirements associated with each area in all Court Group homes. There is a log of the Court Group’s health and safety officer’s monthly visits to Puddavine, detailing any remedial work that needed to be done to maintain the required environmental standards. The home’s fire logbook was also inspected and found to be in order. Privacy locks to all residents’ bedroom doors have been fitted. Each resident has had a room risk assessment undertaken. It is reported that all windows in the home are now fitted with opening restrictors. As stated earlier, some people living in the home and four relatives raised concerns about the level of cleanliness in bedrooms. This was raised with the registered manager and Responsible Individual, who gave their reassurances that this would be addressed immediately. Staff receive regular cross infection training as part of the Manor Collection Ltd’s statutory training programme. Puddavine Court DS0000003783.V342859.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, 30 Quality in this outcome area is good. The home’s recruitment policies are in order and protect people living in the home. Staff at the home are appropriately trained and generally employed in adequate numbers so as to meet the needs of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas indicate that there are five members of staff on duty in the morning and four in the afternoons, reducing to three from 7pm to 8pm. There are two waking night staff. The current staffing levels are differing to those found at the key inspection in July 2006, where there were six carers in the morning, and four carers in the afternoon and into the evening. There is additional ancillary and kitchen staff on duty Monday to Friday. The registered manager reported that in the main holidays and other leave is covered by existing staff. The registered manager works from 8.00a.m until 5.00pm Monday to Friday as well but her role does not involve “hands-on” care. People living in the home stated that staff were always attentive and answered call bells promptly, and from observation on the day of this inspection, this was found to be the case. The registered manager confirmed that new staff are currently being taken on and this it is hoped will bring the staffing levels back to that of last year. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 20 One person reported that a male member of staff had requested that her curtains be left slightly open during the night (ground floor room), thus allowing the carer to check on them from the outside of the building. This person didn’t understand the purpose of this. Staff on duty confirmed that this was the practice for two people who they felt required checking on during the night and who were occupying ground floor rooms. This issue was raised with the registered manager and Responsible Individual, who were not aware of this practice. Concerns about the health and safety implications of practice were discussed. The Responsible Individual and registered manager offered their reassurances that this practice would cease immediately. Seven members of staff responded to pre-inspection surveys for the CSCI. Of these, six stated that they work well as a team, which they feel is essential when working long shift patterns, as they currently do. There was evidence that there was good communication and good working relationships amongst the staff on duty at the time of this inspection. Staff recruitment records were seen to be in good order and up to date with all expected checks in place for two newly recruited staff. A new member of staff started work on the first day of this inspection visit and was seen to be reading the newly introduced induction package with some policies and procedures to read. The staff training programme within the company is consistently comprehensive and a continual rolling programme. All staff are encouraged to undertake NVQ training. The registered manager has an NVQ 4. The head of care has NVQ 4 and the Registered Managers Award, and one senior carer has an NVQ 4. 50 of the care staff have NVQ 2. Training in last year includes; Communication skills, pressure care, first aid, POVA, dementia, confusion and mental health, death, dying and bereavement, medication, challenging behaviour, food hygiene. Training planned for the near future includes; Effective Communication Skills, Food Hygiene, Manual Handling and Safe Administration of Medications. A discussion was held with the registered manager about the need to obtain current guidance and good practice guidance in relation to the care of persons living with dementia and introduce these to staff as working tools with which to improve knowledge and good, current and recognised practice. Staff meetings are held quarterly and staff are requested to complete quality assurance surveys annually. Records for both were observed on this inspection visit. All staff receive regular supervision and annual appraisals to allow them to fully understand their role/performance within the home. Puddavine Court DS0000003783.V342859.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. The management of the home provides the necessary support to staff and people living in the home to ensure the home is well run and managed. Good quality auditing takes place to ensure that the home is run in the best interests of the people living in the home. The home provides a safe, secure environment where individual’s safety and well being is maintained. This judgement has been made using available evidence including a visit to this service. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager has been in post for several years. She is therefore well acquainted with the day to day running of Puddavine Court. She has completed her NVQ level 4 in care. During the inspection people living in the home and relatives gave good feedback in relation to the approachability and support they get from the manager. Records inspected were up to date, concise and contained appropriate information. The people living in the home or their families/advocates mostly deal with any financial matter although the home does hold small amounts if requested to do so. There were detailed records in respect of these and the Court group senior management team undertake a monthly review of all monies held. This ensures residents’ monies are secure. A member of Manor Collection Ltd’s senior management team undertakes a formal monthly in-depth review of the service and provides the manager with a written record of this visit. Three monthly residents’ meetings are held, with minutes kept, as are staff meetings. The home continues to operate thorough internal quality monitoring systems with feedback invited from people living in the home and their relatives as part of the overall process. The home obtained “Investors in People” in February 2005. People living in the home and staff both receive a copy of the “Court Group newsletter”, which allows all to know what is going on within the Court Group generally. The company have a quality audit officer who oversees the whole quality assurance process within the home. The home’s annual development plan was seen at the last inspection for 2006/2007 and it was noted that it contained relevant and realistic plans and appropriate time scales. The manager and the owner both confirmed that health and safety issues continue to be well managed within the home and records inspected supported this. The manger, in conjunction with the company’s appointed health and safety representative, undertakes all required routine health and safety management including fire awareness and ensures all health and safety standards continue to be met. The home’s hot water supply is regulated throughout the home to a safe temperature and all hot surfaces are covered or have low surface temperatures and it is reported that all windows are fitted with restrictors. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 23 Puddavine Court DS0000003783.V342859.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 X 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 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 25 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. 1 Standard OP26 Regulation 23(2) Requirement The cleanliness of all rooms alongside the needs of individuals should be closely monitored, and any cleaning routine needs to be fitted around these needs. The practice of staff leaving the premises at nights to conduct checks on residents through their bedroom windows needs to cease to ensure the safety of themselves and all those that live in the home. Timescale for action 30/08/07 2 OP27 13(4) 30/08/07 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 OP1 Good Practice Recommendations The Statement of Purpose displayed in the main hallway needs to be updated to include the most recent findings of the Quality Assurance Audit obtained from people living in the home and their representatives and the most recent inspection report. DS0000003783.V342859.R01.S.doc Version 5.2 Page 26 Puddavine Court 2 3 4 OP7 OP12 OP27 5 OP30 Daily records need to be more descriptive and include details of the individual’s emotional well being. There needs to be care taken in the use of language. The use of the home’s minibus for outings needs to be reinstated. The staffing levels need to be closely monitored to ensure that they continue to be maintained at the level observed on the day of inspection and adjusted according to the needs of the people living in the home at any one time. The registered manager needs to obtain current guidance and good practice guidance in relation to the care of persons living with dementia. Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Puddavine Court DS0000003783.V342859.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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