Inspection on 04/09/06 for Saxonwood

This inspection was carried out on 4th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Saxonwood 15/01/09

Saxonwood 04/09/07

Saxonwood 01/11/05

Saxonwood 31/05/05

Saxonwood 14/12/04

Saxonwood 13/07/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Saxonwood Saxonwood Road Battle East Sussex TN33 0EY Lead Inspector Rebecca Shewan Key Unannounced Inspection 4th September 2006 09:15 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 Saxonwood DS0000021203.V304928.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. Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saxonwood Address Saxonwood Road Battle East Sussex TN33 0EY 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) 01424 774336 Sussex Housing and Care Angela Sims Clements Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users must be older people aged sixty five (65) years or over on admission. That the maximum number of service users to be accommodated will not exceed thirty six (36). 1st November 2005 Date of last inspection Brief Description of the Service: Saxonwood is a detached property situated in a quiet cul de sac in Battle. The town centre with its shops and access to bus and rail routes is a short walk away. The home is registered to accommodate up to 36 older people, the registered provider is a local housing association, Sussex Housing and Care. The home comprises of 36 single occupancy bedrooms. 18 of which have ensuite facilities. There are additional toilet and bathroom facilities throughout the home. Rooms are located over three floors, accessible by two passenger shaft lifts. There are extensive attractive gardens to the rear of the property that is accessible to service users. There are car-parking facilities to the front of the premises. Potential new service users can obtain information relating to the home via the internet, CSCI Inspection Reports, Care Managers, Placing Authorities, by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) were £325 - £508 per week, with additional charges made for newspapers, hairdressing, newspaper/magazines, transport and chiropody. Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the 4th September 2006. The CSCI Pharmacist (Suni Chotai) also inspected the homes medication stores, records and policies and procedures on 21st September 2006. The findings of which have been incorporated into this report. Incident reports, monthly unannounced monitoring visit reports, previous inspection reports and the home’s Pre-Inspection Questionnaire, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took eight and three quarter hours. A tour of the whole home was undertaken and the Registered Manager, two staff, four service users (known as Residents) and two relatives/representatives were spoken with. Records such as care plans, policies and procedures, maintenance records and medication records were also viewed. Ten Service User Surveys were distributed of which ten were returned. Comments received included: • • • • • ‘The carers are very supportive’ ‘Carers are very rushed’ ‘Very happy here, caring and friendly at all levels’ ‘Glad that our own manager is back as there has been a real atmosphere here since she has been away’ ‘Staff are friendly and compassionate’ 35 residents were accommodated at the home at the time of the inspection. One bedroom had been decommissioned as it was being utilised to accommodate two newly recruited staff from overseas. What the service does well: The home ensures that thorough pre- admission assessments are carried out on all new and potential residents with only those who needs can be met, being admitted to the home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 6 Staff provide personal support to residents in such a way that promotes and protects resident’s privacy and dignity. Activities are arranged according to resident choice. Mealtimes are unhurried and all meals are home cooked with an alternative option being available for each mealtime. The homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. What has improved since the last inspection? What they could do better: The home must ensure that action is taken to ensure that residents care plans and risk assessments are reviewed in order to provide staff with current information relating to residents needs, limitations and risk factors. The home must also ensure that action is taken to ensure that all medication policies and procedures provide clarity for the receipt, recording, storage, safe handling, administration, self-administration and disposal of medicines, specific to the home and that clear procedures are implemented around any deviation from the policies in individual care plans. Reviews must also be undertaken for any self-administration of medicines by residents, such reviews should include suitable risk assessments and monitoring of the health of service users. Staff must receive training in the handling of medication along with regular competence skills assessments. Security keypads must be applied to all sluice room doors, in order to reduce the element of risk to all residents and staff. The Registered Providers are required to monitor the concerns of staff and residents with regards to the management structure of the home and take any Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 7 action appropriate to address concerns raised, in order to provide residents and staff with the support they need during their period of concern and to promote good relations between SHC and staff and residents of Saxonwood. The home are also advised to ensure that a more recent copy of the British National Formulary is obtained, that a record is maintained of when a month’s supply of medicines is handed to self-medicating residents, that medicines are dispensed in the traditional packs if use is irregular, that staff are informed of the correct procedure to follow in the event of a complaint and that the information given is consistent with that of the homes Complaints Procedure and that minutes of all staff and resident meetings are maintained on a regular basis. 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. Saxonwood DS0000021203.V304928.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 Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has good processes for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. EVIDENCE: The home’s Registered Manager, Deputy Manager or a Senior Carer carries out pre- admission assessments. The Registered Manager stated that two staff conduct all pre- admission assessments. Records inspected showed that preadmission assessments are carried out on all new and potential residents. It was noted that the documentation allows the assessor to gain a good overview of individuals medical, social and personal care needs. The home also obtains a copy of a care management assessment from a placing authority where this exists. Any issues, which are highlighted within this assessment, are addressed by the home and documented records are maintained of all correspondence with the placing authority. Residents and representatives commented how they had ‘felt encouraged’ at the time of their assessment that they were entering a friendly home. Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 10 Intermediate care is not offered by this home. Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home. However improvements are required to ensure that care plans and risk assessments are reviewed on a consistent basis, in order to ensure that staff are aware of residents current needs and limitations. The residents receive medicines as prescribed. However improvements are required to ensure polices relating to medicines management need to be in detail to give clear guidelines to staff and to ensure a common approach, whilst self-medicating residents need reviews on a more regular basis. EVIDENCE: Three residents individual care plans were viewed and it was noted that these were detailed in content and covered all aspects of resident’s needs. Suitable risk assessments were in place for the complications associated with reduced mobility, trip/falls hazards and associated risks. Residents informed the inspector that care plans are devised with their involvement. However, from Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 12 the care plans sampled it was evidenced that monthly care plan reviews had not been conducted consistently with review dates evidencing that reviews had been completed for the months of January, April and June 2006. It was also evidenced that some, but not all, risk assessments had either not been completed or had been completed but had not been reviewed on a three monthly basis. Therefore requirements have been made. From the records sampled and from discussions with staff it was evidenced that the health needs of residents are well met with evidence of good multi disciplinary working taking place, on a required basis. Resident’s are encouraged to attend the GP surgery were able and home visits are conducted when necessary. Referrals to the Occupational Therapist, Physiotherapist and Audiologist are made via the GP or the hospital. CSCI Pharmacist Inspector Findings: Medicine storage facilities, All the MAR charts were inspected. The Pharmacy Inspector talked with one service user who manages their own medicines. Recording system around medicines management were inspected. The Pharmacy Inspector observed part of a lunchtime medicine administration process. Two members of staff were questioned. For medicines information the home keeps a file of patient information leaflets found as inserts in the medicine boxes. A British National Formulary (BNF) is available which was dated September 2002. Corporate medicines policies were seen. The corporate policies relating to medicines lacked detail and certainly needed additional local information. Only One additional detailed procedure around ordering relevant to the home was seen. There was no evidence of additional procedures for any deviations from the normal policy for individual residents in their care plan. [e.g. if medicine is left for able resident to take in their own time within a short time frame] This is vital to demonstration diversity. The home has a good relationship with the supplying pharmacist and the GPs and district nurses in the area. The medicine storage facilities are good including storage of controlled drugs. The fridge temperature was just above 9° C and this had been reported to the maintenance personnel. All records for audit of medicines are kept. Controlled drugs records were correct and accurate. There is no record of any medicines errors. Keeping this would complete the requirement of records relating to medicines in the home. Medicine in the trolley were placed according to residents and the blister pack were group according to resident name and arranged according to room numbers. The medicine administration chart had identification photos. The resident who self medicate complained that medicines were not given to them until the evening of the start date, resulting them not being able to have their morning medication. They were however, confused regarding days and believed it to be Thursday the 21st September when in fact it was Wednesday 20th September. The manager informed the inspector that this service users medicine had been given to them in good time. This highlights the need to sign for medicines when a full month’s supply is handed over to the resident. With regards to medicines training staff receive a 12-week distant learning course and some additional training from the local Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 13 pharmacist. There was no record of any on-going competence skills assessment although the manager informed the inspector that an induction period is observed before staff are allowed to handle medicines. This had somewhat slipped up during a recent absence on the manager’s part. Medicines prescribed on a ‘when required basis were in ‘blister pack’. As this may not be used it is very wasteful. There were no recorded incidents of error in recent months. Staff were observed providing personal support to service users in such a way that promoted and protected residents privacy and dignity. Of the ten service user surveys received six stated that they always received the care and support that they needed, whilst four responded that they usually received the care and support that they needed. Respondents commented that ‘care staff numbers are often low due to sickness or staff holidays’ and that ‘care staff are often rushed, which causes a delay in responding to call bells’. Residents spoken with commented that ‘care staff are caring and compassionate’ and are ‘always kind and friendly’. Saxonwood DS0000021203.V304928.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides good social, cultural and recreational facilities, including a balanced diet to residents, with resident’s choice and wishes being respected. EVIDENCE: The home does not have a published list of weekly activities. Resident activities are arranged and altered according to resident’s requests. Residents are free to participate in activities, held by the home or within the local community, or not as they wish. Activities held by the home include art and crafts, bingo, a visiting music man, a comprehensive library and a computer is available for residents who wish to utilise it. Trips to places of local interest are also arranged. The home recently held a fete, which was enjoyed by residents. Of the ten service user surveys received four responded always, one responded usually and three responded sometimes, to the question that asks ‘are there activities arranged by the home that you can take part in?’. One resident did not answer the question but stated that activities are provided but that they choose not to attend them. Two residents commented that ‘I am very grateful for the craft classes, having this opportunity has given me the confidence to be able to take up my art work again and I am being positively encouraged to do so’ and that ‘the craft group is run by a very caring member of staff’. Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 15 Resident’s religious wishes are observed and arrangements are in place for residents to receive Church of England or Baptist Holy Communion if they wish. Discussions with the Registered Manager highlighted that although many of the current residents fall into a specific age group and have similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. This was observed on the day of the inspection and confirmed by relatives/representative spoken with. Residents are treated with respect and there is a good rapport between staff of the home and residents. This was observed at the time of the inspection. Residents reported that the home assists them to maintain their independence with their daily living and daily routines. The home’s menus are devised on a four week rolling programme. The menus viewed showed that there is a variety of food and that the menus are varied. All meals are home cooked with an alternative option available for each mealtime. Medical, therapeutic or religious diets are provided as needed. Of the ten service user surveys received three responded always and seven responded usually to the question that asks ‘Do you like the meals at the home?’. Respondents commented that ‘presentation of liquidised food is poor and certain kitchen staff appear no to care’, ‘there are always good alternatives’, ‘the meals are well cooked and tasty’, ‘the meat is poor and the vegetables are boring’, ‘excellent cooking, service is very efficient and reliable’ and ‘there is a good choice and this is usually kept to’. Saxonwood DS0000021203.V304928.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: The home has an established complaints procedure in place. The home has received two complaints within the past twelve months, both of which have been recorded as addressed within the response time specified by the home’s policies and procedures. Each of the complaints has now been resolved and appropriate action was taken by the home to address the concerns raised. From the section in the service user surveys received relating to complaints, this showed that five ‘always’ knew who to complain to and two responded ‘usually’. Whilst one respondent entered ‘No’ in the comments box and one respondent entered ‘yes, if I need to make a complaint the manager or a carer will listen to me’. Two complaints relating to the management of the home have been received by the CSCI, one has now been resolved and one is currently being investigated by the Registered Providers. Care staff spoken with confirmed that during a recent staff meeting they had been informed by the Responsible Individual that all complaints (made by staff) must be directed to Sussex Housing and Care (SHC) and not directly to the CSCI, however this contravenes the homes complaints procedure. Therefore a recommendation has been made. Following the inspection the CSCI has also become aware that a letter of complaint has been sent to the Board of Directors of Sussex Housing and Care, regarding the management of the home during the Registered Manager recent absence. Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 17 Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Staff have attended training in the Protection of Vulnerable adults within the last twelve months. This was evident from the staff files that were viewed and from staff spoken with during the inspection process. Staff said that they were confident that in the event of an allegation of abuse, they would know the correct procedure to follow. The home has a copy of the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. There have been no Adult Protection alerts made by the home since the previous inspection. Saxonwood DS0000021203.V304928.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides a good quality of accommodation for residents that is hygienic and odour free. Whilst some improvements are required to safeguard sluice room areas. EVIDENCE: The home is well maintained and all areas of the home, including the garden, are accessible to residents. Of the ten service user surveys received ten responded always and one responded usually to the question that asks ‘Is the home fresh and clean?’ One respondent commented that ‘the cleaners are always cheerful but they arrive when I have breakfast and I don’t like the smell of cleaning products with my cereal!’ The home has an infection control policy in place and staff are trained in infection control procedures, this was confirmed by staff training records, by staff spoken with and by observation of staff adhering to procedures. The home was odour free throughout. It was evidenced that a clinical waste contract is in place. However, it was noted that keys to one of the sluice rooms Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 19 were located on the doorframe to the sluice, this matter has been addressed with the Responsible Individual who informed the CSCI that security keypad would be utilised, in order to safeguard all sluice rooms. In view of the fact that this action has occurred for one of the homes two sluice rooms, a requirement has been made. Saxonwood DS0000021203.V304928.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. EVIDENCE: A competent staff team, sufficient in number, meets the resident’s needs. There is a staff rota in place, which was made available to the inspector with the home’s pre-inspection questionnaire. Of the six service user surveys received six responded always and four responded usually to the question that asks ‘Are the staff available when you need them?’ The home has a permanent care staff team of twenty two care workers, eleven of which are trained in National Vocational Qualification (NVQ) level 2, or above, in care. Therefore the previous inspection recommendation that a minimum ratio of 50 of care staff have achieved a NVQ in care by 2005 has been met. Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001.The home has an Equal Opportunities policy in place and is an equal opportunities employer. The home has recently recruited a new Deputy Manager, who residents commented ‘is very likeable and approachable’ and two Senior Carers from overseas whom residents commented ‘sometimes there can be a language barrier due to their accent and our hearing difficulties’. All necessary Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 21 visa and Home Office documents were found to have been obtained and kept on file for these employees. Staff training records showed that over the last twelve months the home had provided a range of training, including Induction Training, Medication Training, Fire Training, Health and Safety, Moving & Handling, Infection Control and First Aid. Additional training has also been conducted in catheter care, continence, care of the dying, diabetes and dementia care. Care staff spoken with and individual training records confirmed this. Saxonwood DS0000021203.V304928.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The health, safety and welfare of residents and staff being protected at all times. The administration of the home is generally good, however improvements are required to ensure that consideration is being given to residents choice and opinion with regards to concerns that they may have relating to the management of the home. EVIDENCE: The Registered Manager has many years relevant experience in caring for older people. The Registered Manager has achieved the NVQ level 4 in Management. Therefore the previous inspection recommendation that the manager completes her required NVQ level 4 in Care training by the end of 2005 has been met. Residents, relatives and staff spoken with said that the Registered Manager is friendly, approachable and any issues raised are actioned quickly and efficiently. However, both staff and residents commented that they feel Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 23 that the Registered Manager is unsupported by SHC Directors and that they ‘fear that she will be made to leave due to unnecessary pressures from above’. Residents also commented that during the Registered Manager’s recent absence from the home, ‘the atmosphere in the home has been dreadful’ and ‘once upon a time we would have highly recommended this home to anyone but due to recent events, we’re not so sure we’d recommend at all’. Residents commented that they had approached the Board of Directors, with regards to this matter and felt that their concerns had not been appropriately addressed. Therefore there is a need for the Registered Provider’s to address these issues in order to reassure residents and staff that their concerns are heard and that any action will be taken, if appropriate. Therefore a requirement has been made. There is a Quality Assurance policy in place, that involves an annual development plan and continual self-monitoring of the home by the Organisation. Quality Assurance questionnaires are distributed to residents, their representatives and other interested parties on a six monthly basis. The results of which are not published but are made available to all upon request. Monthly unannounced (Regulation 26) visit reports are conducted and a copy of this report is sent to the CSCI Eastbourne Office. Both staff and residents meetings are held on a monthly or two monthly basis. Minutes of both s and residents meetings were viewed and these were found to be detailed in content and included actions taken to address previous issues raised by staff. However, minutes of meetings held in the Registered Manager’s absence had not been maintained, therefore it was difficult to ascertain whether issues raised by residents and staff had been addressed. Therefore a recommendation has been made. The Registered Manager reported that the home does not take any responsibility for resident’s finances. From the Pre-Inspection Questionnaire provided by the home it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had been carried out. It was evidenced that accidents are well documented in the home’s accident book and that fridge, freezer and food temperature probe readings are recorded on a daily basis. Saxonwood DS0000021203.V304928.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X N/A X X 3 Saxonwood DS0000021203.V304928.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. 2. 3. Standard OP7 OP7 OP9 Regulation 15 (2) (b) 15 (2) (b) 13 (2) Requirement That care plans are reviewed consistently on a monthly basis. That risk assessments are completed and reviewed on a three monthly basis. That clear and comprehensive policies and procedures for the receipt, recording, storage, safe handling, administration, selfadministration and disposal of medicines, specific to the home, must be produced. That the home are to have clear procedures around any deviation from the policy in individual care plans. That the home undertakes a review of any self-administration of medicines by residents, which should cover risk assessment and monitoring of the health of service users. That staff must receive training in the handling of medication and there must be evidence that this has taken place. There should be regular competence skills assessment, which must be evidenced. DS0000021203.V304928.R01.S.doc Timescale for action 04/11/06 04/11/06 31/12/06 4. OP9 13 (2) 31/12/06 5. OP9 13 (2) 30/10/06 6. OP9 18 (1) (c) (i) 30/10/06 Saxonwood Version 5.2 Page 26 7. OP26 13 (4) (a) (c) 12 (5) (a) (b) 8. OP31 That the security keypads are applied to all sluice room doors, as highlighted previous to the inspection. That the Registered Providers monitor the concerns (regarding the management structure) of staff and residents and take any action appropriate to address concerns raised. 30/09/06 30/09/06 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 OP9 OP9 OP9 OP16 Good Practice Recommendations That the home obtains a more recent copy of the BNF. That the home are to make a record when a month’s supply of medicines is handed to self-medicating residents. That the home are to have medicines dispensed in the traditional packs if use irregularly. That consideration is given to informing staff of the correct procedure to follow in the event of a complaint and that the information given is consistent with that of the homes Complaints Procedure. That minutes of all staff and resident meetings are maintained by the home. 5. OP33 Saxonwood DS0000021203.V304928.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Saxonwood DS0000021203.V304928.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!