Inspection on 02/01/07 for Sarah Ann Rest Home

This inspection was carried out on 2nd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sarah Ann Rest Home 26/01/06

Sarah Ann Rest Home 27/09/05

Sarah Ann Rest Home 18/03/05

Sarah Ann Rest Home 21/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Sarah Ann Rest Home 15 Abbotsford Road Blundellsands Liverpool Merseyside L23 6UX Lead Inspector Mrs Margaret Van Schaick Key Unannounced Inspection 09:00 2 & 17th January 2007 nd 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 Sarah Ann Rest Home DS0000005389.V311547.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. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sarah Ann Rest Home Address 15 Abbotsford Road Blundellsands Liverpool Merseyside L23 6UX 0151 476 8500 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) Mrs Pauline Joan Mary May Mr James Frederick May Mrs Pauline Joan Mary May Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 13 OP. Date of last inspection 26th January 2006 Brief Description of the Service: Sarah Anne is registered to provide personal care for a maximum of thirteen Older People of both sexes. The home has been opened for fifteen years and is privately owned by Mr James and Mrs Pauline May. There are 7 single and three double rooms, a lounge, and a dining room. A large basement contains the kitchen, laundry, office and a staff flat. The home does not have a ramp from the outside the building and limits access. There is a lift to all floors and alarm call systems in all rooms, toilets and bathrooms. Sarah Anne is a converted building in a quiet residential area, close to a number of amenities including easy access to public transport both trains and buses and local shops within walking distance. The home has a mini-bus for transport of residents where required. There are gardens at the front and rear, which are secure and accessible to service users when weather permits. Parking is available at the front of the building and there are double yellow lines outside the Home. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days and lasted 8 hours. This was the key unannounced inspection to be carried out as part of the regulatory requirements. As part of the inspection process all areas of the home were viewed including many of the residents bedrooms. Residents care records and other care home records were inspected also. Discussion took place with Mrs May who is the registered manager and provider. The inspector also had discussions with the deputy manager, and a one to one interview with one of the staff. Several residents were also spoken with. Residents were interviewed in private and their views obtained on how the home was run. The inspector spoke with one of the residents’ relatives on the telephone. A resident’s regular visitor to the home was interviewed also. Have your say about…questionnaires were sent out to the residents by the Commission prior to the inspection. These have been completed and returned and their views are included in this report. The weekly fees are £350. What the service does well: Sarah Ann is a family run, comfortable, homely and friendly environment for the residents who live there. Residents and their relatives/visitors have very complimentary views of the home and the service it provides. Management and staff are knowledgeable about the residents. Relatives’ comments about the pre admission progress include, “lovely owners and staff, they took so much time, ‘they’ didn’t rush answering all our questions”. Relatives canvassed for their views commented, “Sarah Ann Rest Home is a fantastic place, my aunts needs are always taken care of”. Relatives interviewed stated, “I am very pleased with the home, I am brought up to date and when my father is ill, I am kept up to date on a daily basis, I feel my father is well looked after and in excellent hands”. Residents interviewed stated, “staff are lovely, they help with my bath and check I’m alright, wash me well, always do my back and dry me well, we are looked after very well, I couldn’t ask for better”. An evaluation of care takes place and is recorded on file, which is good practice. Lifestyle profiles are in place, which is good practice as staff are then Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 6 aware of some of the residents lifestyle history. Residents interviewed stated, “it’s marvellous here, everything about this place is good, there’s nothing not good” and “I get up and go to bed when I want to, I like to go at 9pm”. The home provides a supportive and caring culture that encourages residents’ independence and to continue to maintain their family and friend contacts wherever possible. Relatives comments include, “my mother is so happy and well looked after, it gives us all peace of mind” Staff interviewed stated, “all the staff have been here a long time, it’s one of the nicest homes I have worked in, it’s really like a big family and friendly”. Relatives comments include, “staff are always so happy to talk to you” and “ I find staff very supportive” and “everyone is always happy to help”. Another relative canvassed for their views commented, “my family and I are so glad to have found such a wonderful home”. All appliances and services are checked and up to date including lift. What has improved since the last inspection? What they could do better: The pre admission process of assessment needs to be formally documented to ensure that all of the individual residents needs are identified to ensure the home is able to meet their needs. Care plans need to be improved to ensure all identified needs are addressed and managed. All prescribed medications must be signed for immediately following administration as this evidences medication is given as and when prescribed. Staff must not use tippex to correct any errors. A clear line through the error and an explanation on the rear of the medication sheet is sufficient. The home has an outstanding requirement with regard to staff training in abuse, policies and procedures with regard to whistle blowing, complaints and Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 7 protection of vulnerable adults and this remains so. This needs addressing so that staff are fully aware of how to deal with any issues raised. A complaints book is in place but there is no record of any to date. The home is advised to ensure any complaints/concerns from residents/staff relatives are documented as discussed and the investigation and outcomes are logged. Ramp access is required to the home to enable residents who have poor mobility to access the home easily. Pre employment checks are missing and this can place residents at risk. Mandatory training is out of date therefore this places the residents and staff at risk. 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. Sarah Ann Rest Home DS0000005389.V311547.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 Sarah Ann Rest Home DS0000005389.V311547.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): OP3 was assessed. OP6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission process of assessment needs to be formally documented to ensure that all of the residents needs are identified and that the home is able to meet their needs. EVIDENCE: Relative’s comments about the pre admission progress include, “lovely owners and staff, they took so much time, didn’t rush answering all our questions”. Residents’ files evidence copies of the social services assessment. One resident was admitted for respite on an emergency basis therefore there was not time for the home to assess this resident prior to admission. One resident admitted from hospital had visited the home for a couple of hours with her family so that she could meet with the residents and staff prior to admission. This is good practice. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 10 The assessment process has no formal documentation therefore the home need to record the pre admission assessment and include dates and signature of person assessing the resident prior to admission. Family friends interviewed confirmed that they were happy with the admission process stating, “It took me six months to find this home and we (resident and friend) visited the home twice and met the owner, we were shown the bedroom and then I returned to chat with the owner and agreed to accept the room on my friends behalf”. The social services assessment evidences all care needs were identified prior to admission. Sarah Ann Rest Home DS0000005389.V311547.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): OP7, 8,9,10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need to be improved to ensure all identified needs are addressed and managed. All prescribed medications must be signed for. EVIDENCE: Three residents care files were case tracked (all documentation including care plans are examined). Care plans are in place for two of the residents’ case tracked but there is insufficient detail contained with regard to residents needs. One care plan is blank. Discussion took place with the deputy manager with regard to what information should be included and how the care is managed. Through discussion with staff and management it is evident that the care needs of the residents are known and understood. Relative’s comments include “Sarah Ann Rest Home is a fantastic place, my aunts needs are always taken care of”. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 12 Relatives interviewed stated, I am very pleased with the home, I am brought up to date and when my father is ill, I am kept up to date on a daily basis, I feel my father is well looked after and in excellent hands”. The deputy manager advised that there are many residents in the home who are self caring therefore this needs to be reflected in care files and residents who do need support with personal care and other areas have to have this documented in care plans. Dependency levels are assessed on a regular basis. Risk assessments are in place but some are not signed or dated. There is documented evidence that residents have their eyes tested, this is good practice. The NHS chiropodist visits the home 8-12 weekly and a private chiropodist attends to residents who wish this service. The deputy manager has been advised that any residents who have diabetes are entitled to free chiropody also. Manual handling records are not up to date for some of the residents, which can place them at risk. Residents are not weighed on a regular basis. It would be of benefit to record residents weight on admission and on a regular basis throughout the year as this record will indicate any weight loss/gain. How often the residents are weighed is dependent on the weight loss/gain and the physical health of the individual resident. Advice could then be sought from the GP/Dietician if needed. An evaluation of care takes place and is recorded on file, which is good practice. Lifestyle profiles are in place, which is good practice as staffs are then aware of some of the residents’ lifestyle history. None of the residents in the home self medicate. The home has the blister pack system for medications. A list of staff signatures/initials of those trained to administer medication is recommended. There is evidence that ‘tippex’ has been used on the medication records. This is bad practice. If an error occurs, a line through the error and explanation recorded on the rear of the medication sheet is sufficient. Staff signatures are missing from some of the residents’ medication records. This is poor practice as it is assumed that the resident did not receive their prescribed medication. Some residents, who wish to, have signed an agreement stating they do not wish to have a key to their individual bedrooms. Residents who live in shared bedrooms have screens available to ensure their privacy and dignity. Relatives interviewed stated, “dad is always clean and well looked after, I feel very confident in the home and the staff”. Residents interviewed stated, “staff are lovely, they help with my bath and check I’m alright, wash me well, always do my back and dry me well, we are looked after very well, I couldn’t ask for better”. During the inspection visit staff were noted to be respectful in their approach to the residents. A family friend who visits the home regularly stated, “staff are very, very nice I have never heard any being nasty to the residents. Residents were well groomed and smart during this unannounced visit. Relatives comments include, “my mother is so happy and well looked after, it gives us all peace of mind” Sarah Ann Rest Home DS0000005389.V311547.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): OP12, 13,14,15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a supportive and caring culture that encourages residents’ independence and to continue to maintain their family and friend contacts wherever possible. EVIDENCE: Relatives canvassed by the Commission for their views are made to feel welcome at the home and confirmed that they can visit at any time. Family visitors interviewed also confirmed that they are able to visit the home as and when they wish. Relative’s comments include “my family and I are so glad to have found such a wonderful home”. Some of the residents in the home go out on a regular basis with friends and to shop. “I go out with my friend two days a week and “I visit church on a Sunday”. Residents, who wish to, can take part in Communion arranged by the local church, which visit once a fortnight. Residents are able to spend their time as they please where able. Meals are at set times but are flexible to fit in with residents’ daily activities. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 14 Residents interviewed stated, “it’s marvellous here, everything about this place is good, there’s nothing not good” and “I get up and go to bed when I want to, I like to go at 9pm”. The home does not have a programme of activities. The home have a mini bus and use it in the nicer weather to take residents out to various places of interest including, Burscough, the sea front and to musical events at the civic hall. The garden is in use in the summer months by many of the residents. Activities arranged include bingo, bowling, and old films/videos. Staff interviewed stated, “we play bingo, play your cards right, music, sherry afternoons and old films. The residents like to talk to you about their past”. One or two residents have commented that they don’t think they have enough suitable activities. Other residents’ comments are positive about the activities therefore it may be of benefit to all to try and ascertain what other activities may interest the residents who are unhappy with the present range of activities. Residents, who wish to, go out to vote, others use the postal voting service. The homes menus do not show choices with regards to many of the meals although residents interviewed confirmed that they were able to have an alternative when they wished. Residents interviewed about the meals stated, “the food is nice, I like it” and “the food is lovely, very good”. Staff interviewed stated, “I couldn’t fault the food, everything is cooked fresh and there are choices”. Relatives’ comments include “my mum says the food is always very good and tasty”. The inspector was able to observe lunch being served to the residents. The food looked appetising, well presented and wholesome. A separate dining room is available for meals. The kitchen was clean and organised on the day of the unannounced inspection. Sarah Ann Rest Home DS0000005389.V311547.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): OP16, 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to ensure all complaints/concerns are recorded, investigated and outcomes documented. EVIDENCE: The home has an outstanding requirement with regard to staff training in abuse, policies and procedures with regard to whistle blowing, complaints and protection of vulnerable adults and this remains so. The home do not have a copy of the Sefton Adult Protection Procedure therefore the inspector has given the deputy manager the contact number so that they can have a copy for their use. Management and staff interviewed understand the various forms of abuse that can occur. The home does have a complaints procedure. A complaints book is in place but there is no record of any to date. The home is advised to ensure any complaints/concerns from residents/staff relatives are documented as discussed and the investigation and outcomes are logged. The home does not deal with or hold any of the residents’ money. Relatives assist residents where wished with financial assistance. The home has a valuables record. Staff are advised during their induction to the home that they cannot become involved in residents wills. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 16 Residents and staff were noted to interact on a friendly and respectful manner. Residents interviewed had no complaints to make about the home. Relatives comments include “I’ve no need to complain, but I know how to” and “we have never had to make a complaint, the owners and staff are always there to speak to, we are always happy” Sarah Ann Rest Home DS0000005389.V311547.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): OP19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean and comfortable environment for the residents. There is no ramp access to the home therefore this may restrict the movement of residents. EVIDENCE: The home is fairly well maintained. The home do not have a maintenance book therefore the deputy was advised to start one, which will contain any areas of maintenance/repair with dates and to be signed off by the maintenance person when completed. Quotes and plans have been received from the builders with regard to the ramp access to the home and the proprietors are at present in the process of deciding, which would best suit the needs of the residents in the home. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 18 The inspector viewed these during this visit. The inspector recommended that an assessment of the premises take place to ensure that all areas of the home (for residents use) are easily accessed by the residents. Garden grounds are kept tidy and safe for residents. Following a fire inspection earlier in 2006 the home have improved and implemented recommendations made. Most of the home including many of the residents’ bedrooms was viewed during this visit. The kitchen was clean and organised with easily washed surfaces including the walls and floor. Plentiful dry foods are stored separately. The fridge/freezers were clean. Food stored in the fridge was covered and dated. The laundry has two washing machines and one tumble drier with easy washable surfaces to the floor and walls. Residents interviewed had no concerns about their personal laundry. The home is decorated in a homely style, which many of the residents confirmed they liked. Residents’ bedrooms and public areas were clean and tidy. Residents interviewed stated, “my room is nice” and “I like it, I like this home very much, I like my bedroom, it’s been cleaned today, it’s always clean”. Relatives comments “the home is always clean and fresh” and “my mum’s room is always clean and tidy when we come”. Sarah Ann Rest Home DS0000005389.V311547.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): OP27, 28,29,30 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Pre employment checks are missing and this can place residents at risk. Most of the mandatory training is out of date therefore this places the residents and staff at risk. EVIDENCE: The duty rota evidences three care staff are on duty throughout the day. One care staff is awake at night with the other care staff able to sleep but on call if needed. The cook works 8-4pm and a domestic is employed 10-2pm each day. Nine of the care staff has recently registered for the Level 2 NVQ with 3 care staff qualified already. Two staff are qualified to Level 3. One staff interviewed stated, “I have finished my NVQ Level 3 and waiting for it to be approved”. Three staff files were examined. All three staff has evidence of CRB (Criminal Record Bureau) checks at enhanced level. Two of the files have application forms but both are blank. One file has no application form. Personnel records have staff photos; job descriptions and some have signed contracts. Personnel files do not have start dates of staff. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 20 There are no references on file. Staff interviewed stated, “I was unable to supply references due to domestic reasons and I needed a job quickly”. The deputy stated, “we do have them and I think they are filed away”. All of the staff has worked at the home for many years and there have been no problems in all of that time. The manager is aware that all new staff has to have all the necessary pre employment checks in place prior to appointment. The manager is advised to review the staff files and ensure all information with regard to pre employment checks and training are in place and easily accessed. There is documented evidence that training has taken place to include healthy eating and hygiene, certificate in care practice, first aid, oral health, infection control, handling medication, working and operating equipment safely, manual handling and safety at work. Mandatory training is not up to date, which places residents at risk. Relative’s comments include “I am totally confident with the care and support the staff at the home offer to my aunt and myself”. There is no evidence on file of staff induction. Staff interviewed stated, “when I started, I had a tour of the home, fire exits, introduced to the residents and I worked with Sue (deputy), Pauline (manager) and Rachel (carer) for some time as part of my induction and I have had nine years experience in care”. Staff interviewed confirmed they had attended mandatory training previously. One staff interviewed confirmed they had attended fire drills last summer (2006). Staff interviewed stated, “all the staff have been here a long time, it’s one of the nicest homes I have worked in, it’s really like a big family and friendly”. Relatives comments include, “staff are always so happy to talk to you” and “ I find staff very supportive” and “everyone is always happy to help”. The home have been having discussions with the local pharmacist who has provided training handbooks for staff who administer medications and they are due to meet up next month to commence the training programme, this is good practice. Sarah Ann Rest Home DS0000005389.V311547.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): OP31, 33,35,38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The servicing and certificates of all equipment including fire appliances have been checked and are up to date in date, which contributes to the safety of the residents and staff. EVIDENCE: The registered manager/proprietor has owned and managed the home for approximately 18 years. The manager has the NVQ Trainer/Assessor D32/33 award. Mandatory training has been attended but is not up to date. Through discussion with the registered manager it is apparent that she is well informed with regard to the residents in the home. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 22 She understands the health and care needs of the residents and residents and relatives confirm this. Relatives interviewed stated, “my father is well looked after and in excellent hands”. Staff are very complimentary about the manager and through discussion it is apparent that they respect her, find her approachable and are confident in her managerial abilities. The owners’ daughter has applied for the registered managers position and has attained the RMA (Registered Managers Award) in April 2006. She is at present employed as the deputy manager in the home. The home has informal staff and residents meetings but there is no formal record of it or minutes held. The home have sent out questionnaires to families and these were viewed by the inspector with all having positive views of the home. Staff interviewed stated, “I do have regular informal supervision and I have had an appraisal, last summer, but can’t remember if I signed it”. The home does not hold any residents money. Although mandatory training has been attended much of it is out of date including, manual handling, infection control, health and safety and basic food hygiene. This has been addressed in the previous standard. Fire training/drills has been attended in October 2006. All fire equipment has been serviced in December 2006. The fire alarms at various points are checked weekly and emergency lighting monthly. All appliances and services are checked and up to date including lift (August 2006), gas servicing (December 2006), electric (July 2006) with portable appliances tested in November 2006 but no certificate yet received, Insurance expires in May 2007. The home has a contract for clinical waste from an approved contractor. Monthly risk assessments are carried out of the building with the most recent November 2006. There are risk assessments in place for the kitchen, fire risks and the manager also carries out regular checks of electrical equipment in the home. Records show that hot water storage and hot water outlets are checked with the most recent in December 2006. Thermostatic valves are fitted to baths. The manager advises that the home have been tested for Legionella but not recently therefore the inspector advises that the manager contact Environmental Health for advice re regular testing. Accident records are in place and completed. Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 23 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 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 (1) Requirement The registered provider must ensure that all residents have an agreed care plan in place that identifies all their health, care and support needs. The registered provider must ensure that risk assessments in place for residents are signed and dated to ensure that they are relevant and up to date. All residents must have a manual handling assessment in place with regular reviews to ensure their mobility needs have been addressed and met. The registered provider must ensure that all staff signs for the prescribed medication immediately following administration to the resident. The registered provider must provide staff with a copy of the homes policy regarding complaints, whistle blowing procedure and Protection of Vulnerable Adults. Training must be arranged for staff in recognising the signs of potential abuse and reporting them DS0000005389.V311547.R01.S.doc Timescale for action 01/05/07 2. OP8 13 (4) c and (5) 01/03/07 3. OP9 13 (2) 07/02/07 4. OP18 13 (6) 01/05/07 Sarah Ann Rest Home Version 5.2 Page 25 5. OP19 23 (2) (a) 6. OP29 19 (1) (5) 7. OP30 18 (1) (a) (c) 8. OP33 24 (1) (2) (3) appropriately. A copy of the Local Authority Protection of Vulnerable Adults policy must be obtained and the manager must be aware of her role and the role of external investigators in any potential Protection of Vulnerable Adults investigations. This is an outstanding requirement. The registered provider must ensure that ramp access is provided to enable residents who cannot use steps access to the home. This is an outstanding requirement. The registered provider must ensure that all new staff has 2 references, proof of identity, Criminal Records Bureau and Protection of Vulnerable Adults check prior to employment. The registered provider must ensure that she carry out an audit with regard to staff training needs, produce a training and development plan for each employee and ensure staff are trained to meet the needs of the residents. This is an outstanding requirement. The registered provider must ensure that she further develop the quality assurance system to enable residents, staff and relatives views to be obtained Their views can be used when setting up the annual development plan of the home. 01/08/07 07/02/07 01/05/07 01/08/07 Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP3 OP7 OP9 OP9 Good Practice Recommendations The inspector strongly recommends that the home should record the pre admission assessment carried out for each prospective resident with dates and signature in place. The inspector strongly recommends that all residents/relatives should sign and agree the care plan. The inspector recommends that a list of staff trained to administer medications should be in place with their signatures and initials documented. The inspector recommends that staff should not use tippex to cover errors made. A simple line through any errors with an explanation on the rear of the medication sheets is acceptable. The inspector recommends that the menus should be reviewed to evidence meal choices. The inspector strongly recommends that a maintenance book be commenced with records kept of all repairs/refurbishment. The inspector recommends that staff competency should be determined and reviewed in particular for those staff responsible for medications. All new staff inductions should be documented. 5. 6. 6. OP15 OP19 OP30 Sarah Ann Rest Home DS0000005389.V311547.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Sarah Ann Rest Home DS0000005389.V311547.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. 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