Inspection on 14/08/07 for Scaleford Retirement Home

This inspection was carried out on 14th August 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

Scaleford Retirement Home 17/11/09

Scaleford Retirement Home 03/03/09

Scaleford Retirement Home 10/09/08

Scaleford Retirement Home 02/08/06

Scaleford Retirement Home 02/02/06

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

CARE HOMES FOR OLDER PEOPLE Scaleford Retirement Home Lune Road Lancaster Lancashire LA1 5QU Lead Inspector Mrs Joy Howson-Booth Unannounced Inspection 14th August 2007 09:30 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 Scaleford Retirement Home DS0000064565.V342699.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. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scaleford Retirement Home Address Lune Road Lancaster Lancashire LA1 5QU 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) 01524 841232 Scaleford Care Home Limited Mrs Lynette Anne Owen Care Home 32 Category(ies) of Dementia - over 65 years of age (32) registration, with number of places Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to service users of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Dementia over 65 years of age - Code DE (E) Up to 3 named service users can be accommodated in the category of OP. The maximum number of service users who can be accommodated is: 32 Date of last inspection 2nd August 2006 Brief Description of the Service: Scaleford Residential Home is owned and managed by Mr & Mrs Owen who have over 15 years experience of managing a care home. The home is registered as a limited company. Scaleford is situated in a residential area of the Marsh in Lancaster and overlooks the River Lune. It is close to local amenities. There are three lounges and a dining room, these are used for a variety of purposes and provide residents with a choice of where to sit and who to sit with. There are 32 single rooms, 7 of which have ensuite facilities. Bedrooms are situated on both the ground and first floor and the upper floor can be accessed either by stairs or by a stair lift. Residents are encouraged to retain links in the community and every effort is given to ensuring that relationships are maintained. A range of activities are organised within the home for those residents who wish to participate. Relatives, friends and visitors are made welcome at any reasonable time. All personal needs of residents are catered for by staff who have received training. All residents have their own General Practitioner who are responsible for medical needs. Those residents requiring nursing input have the services of the District Nurses made available to them and other healthcare professionals as required. The current weekly fees range from £374.00 to £384.00. Further details regarding fees can be obtained from the owner/manager on request. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Scaleford Care Home has recently changed its registration so that it now only accommodates people who have a diagnosis of dementia This is the first site visit and was unannounced so the registered provider/managers, staff and residents were not aware of he visit. The inspector for the service carried out the site visit. The site visit forms part of the overall inspection for the home which makes sure people are being cared for properly and to make sure the home is a safe place for people to live in. As well as the site visit, judgements have been made about the service based on information supplied by the registered provider/managers. Comment cards were made available to residents, their relatives, GP surgeries and healthcare professionals who are involved with the home. Responses were received from residents and their relatives who were very satisfied with the service provided. Responses received from GP’s and healthcare professionals expressed satisfaction with the service provided. The site visit took place over one day and included taking time to sit and speak with residents, spending time observing staff on duty performing the day-today care tasks, speaking with staff and speaking with the registered provider/managers. The home’s registered provider/manager was available during the inspection to answer questions and provide additional information. The inspector looked around parts of the home, including communal rooms, a number of personal rooms, bathrooms and toilets to see first hand if the home was a comfortable, clean and safe for people to live in. Every year the registered persons are asked to provide us with written information about the quality of the service they provide and to make an assessment of the quality of their service. This information, in part, has been used to focus our inspection activity and is included in this report. The site visit was enjoyable with everyone welcoming, friendly and cooperative during the visit. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Some changes to the management of the home have taken place, with the registered provider/managers having strengthened their input and monitoring. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 7 For example, the managers are now working at different times of the day to ensure residents and staff are supported. In the last inspection report, a number of repairs, improvements and issues of cleanliness were raised with the registered provider/managers and these have been satisfactorily addressed. The improvements that have taken place have greatly enhanced the environment for the residents. Concerns over the laundry in the home going missing and not been returned correctly to residents has been addressed – no issues over laundry were raised at this inspection. Staff mandatory and National Vocational Qualification training programmes continue with 79 of staff now trained to NVQ Level II. This means that the residents are looked after by competent staff. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Scaleford Retirement Home DS0000064565.V342699.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 Scaleford Retirement Home DS0000064565.V342699.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): Standards 1, 2, 3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home continues to have good arrangements to assess people who may like to live at the home. This means that only people whose needs can be met will be accommodated. EVIDENCE: Confirmation received that the homes Statement of Purpose has been amended to reflect the home’s new registration of accommodating only people with a diagnosis of dementia. The owner/managers are also looking at providing pictorial information (e.g. photograph album) so that people who have dementia can have visual information about the home. This is something that can be extended to the Service User Guide (information about the home that the resident can use). Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 10 In addition, relatives are encouraged to come and visit, bring their relative so that prospective resident can stay for a while, meet other residents and staff, see around the home, stay for tea, etc. Comment cards received from residents and relatives all confirmed that they had been given enough information about the home before admission. All residents are provided with either a contract or terms and conditions for the home. The owner/manager confirmed that copies of all contracts are kept for residents. The Office of Fair Trading advice was given to the owner/manager so they can check they are providing all the required information. Comment cards from residents were unclear if they had received a contract or not – given the needs of the residents this is usually something their relatives deal with. A formal record or copy should be kept of any contracts/terms and conditions issued. The owner/manager confirmed that she now visits the prospective resident at their own home or in hospital to undertake an assessment so that an informed decision can be taken over whether the home can meet identified needs. In addition, the home works closely with other healthcare professionals, who also provide in depth information about individual needs. Assessments examined during the inspection noted that these are comprehensive and include personal preferences and needs. Staff spoken with were able to confirmed that they get to know new residents by spending time and talking with them and by both written and verbal information passed on by the owner/manager or senior carer. The home does not offer an intermediate care facility Scaleford Retirement Home DS0000064565.V342699.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): Standards 7, 8, 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A good level of care is provided to the people which means their health and personal care needs are generally met and people are treated with dignity and respect. Medication systems are generally good but some improvements are needed to ensure people are fully safeguard. EVIDENCE: Care plans were examined for several residents and all confirmed that the information is comprehensive and sufficiently detailed to enable staff to know individual needs and how these are to be met. Risk assessments are also carried out and advice given that any risk assessment should clearly state the risk and how staff are to address this. Care plans are also reviewed on a monthly basis. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 12 Information provided by the home confirms that they try to involve the resident in their own care plan, but due to their needs it is not always possible. Relatives are also involved in care planning, although some are reluctant to take part. This is an area for further development and could be looked into as part of the admissions process. The home has a key worker system in place. This means there is a dedicated member of staff for each resident whose role is to build up a special relationship with their named resident, and work with them on a one to one basis to ensure they receive a good level of care. Care plans evidenced healthcare needs are met, with involvement of healthcare specialists as needed, including optician, dentist, chiropodist, Community Psychiatric Nurse and Consultants. Positive comments made included – “they took a great deal of time and care to cater for peoples individual needs, working together we lessened any management problems and protected clients safety”; “supports EMD clients very well” and “treats patients as individuals. Genuinely cares about users”. Some very good interventions by staff were noted including the care taken by staff to reassure one resident who was upset about their missing cat. Staff spoken with were able to describe individual residents’ care needs and how these are addressed by them, including specific strategies put in place to reassure more anxious residents. Personal care records and weight monitoring records were seen. Generally these are satisfactorily maintained although some gaps were noted. Advice was given that the home could look at a system whereby personal care records are more accessible for staff to maintain, e.g. held in residents’ own rooms. Medication records and stocks were examined and generally found to be accurately maintained. The administration of medications for one resident was discussed and further advice is to be sought by the owner/manager and will also be requested from the Pharmacist Inspector. Observations over the administration of medications was also discussed, including the current practice of putting the medications to be given out on the same table where people are eating, as this does not ensure residents’ privacy and dignity. The owner/manager advised she intends to address this. Comments from GP’s confirmed that the service usually supports individuals to administer and manage their own medication or manage it correctly where this is not possible. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 13 Observations during the inspection noted that all the residents were treated with dignity and respect. Staff were caring and took the time and trouble to sort out issues and concerns. Staff spoken with were also able to describe how they maintain residents’ privacy and dignity. Relatives raised no concerns about how staff care for their relatives and all felt staff maintain their relatives’ dignity and privacy at all times. Comments included - “Scaleford always seems to provide a friendly, professional and caring service to the residents” and “the staff are extremely kind and caring. This is extremely important to old people who are mostly in a confused and disorientated condition.” Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Social contact and meals are good which means the people are provided with a good quality of lifestyle. Individual activities should continue to be developed to ensure people receive social stimulation. EVIDENCE: Care plans evidenced that individual routines and wishes are noted and respected. Activities records evidenced that a range of activities have been developed and are provided, including – birthday party celebrations, table top skittles, organ music, quizzes, games, music, walks, physio games, sing-along-a-Geoff (twice a month), drawing, craftwork, use of musical instruments, bingo, 1 to 1 work (manicures, hand massages). For one resident family communion is offered once a week. The evening before the inspection site visit a harpist had visited the home – according to both residents and the owner/manager this was enjoyed very much. The owner/manager feels that resident enjoy the activities provided as there is “always a good turn out”. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 15 There remains a need for the home to look at offering outings to residents, possibly through 1 to 1 time rather than larger group outings which are not always preferred. Staff spoken to were able to evidence their knowledge of their individual preferences and interests of residents and confirmed that activities are offered twice a day – usually the morning times are for 1 to 1 work, the afternoons being for planned activities – group work, crafts, music, games. Importantly, staff were also able to confirm that residents are fee to join in activities or not and their decision is respected. Residents are able to maintain community contacts and the home tries hard to maintain these within safe parameters. Relatives confirmed that their relatives are supported to keep in touch. Relatives are free to visit at any time and no issues were raised regarding contact with the home. The home encourages people to manage their own finances as much as they are able to do so but as the home now accommodates people with dementia this is usually done by either a family member or an appointee. It has already been noted that residents are encouraged to bring in personal possessions with them and access to personal records is in accordance with the Data Protection Act 1998. Residents who completed survey forms confirmed that they are satisfied with the meals provided. Staff confirmed that meals and menu choices are discussed as part of the care plan review, and any changes or ideas are put forward at that time. A meal was taken with the residents which was nutritionally satisfactory. A sweet was provided but there was no evidence of choices being offered. Residents were encouraged and supported to eat in a relaxed and homely environment and no one was rushed or hurried to finish. Discussion with the chef took place who confirmed that there are sufficient stocks and good quality food made available to meet the nutritional needs of the residents. The menus examined appeared to provide a good nutritional and balanced diet. There are no special diets needed at present. Further information was sent to the chef over nutrition for future use in menu planning. According to the owner/manager, one resident is provided with a menu and outings to meet her cultural needs. However, none of the records examined evidenced outings to specialist shops had taken place nor had any specialist food been provided. Advice given that better recording should take place over this. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Concerns can be voiced and staff are trained in safeguarding adults which means that people are protected. EVIDENCE: The owner/manager confirmed that one complaint has been received by the home and this was not upheld. The complaints procedure remains the same and is on display in the hallway. Residents confirmed that they knew who to speak with if they were not happy with any aspect of their care – “see the boss”. Relatives, GP’s and other healthcare professionals all confirmed that the home has responded appropriately if they have raised any concerns. Advice was given that the complaints procedure could be produced in a format for people with dementia, particularly those people who are no longer able to comprehend written information. Information provided by the home confirmed that they “listen and act” on what residents say. The commission has not received any complaints regarding this home since the last inspection, although concerns were raised by a relative following receipt of a relative survey form. This was discussed with the owner/manager and records seen to evidence care and input provided. As a result, it was Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 17 advised that the owner/manager contact the relative and speak directly with them to reassure them over the actions taken (and to be taken) to address the concerns raised. At the last inspection, concern was raised by residents over missing items sent to the laundry in the home. This was discussed with the owner/manager who confirmed (at this inspection visit) that the system was reviewed and action taken to make sure laundry was returned to the residents correctly. A concern was raised over the use of powdered milk and the cleanliness of the home. The latter concern was passed to the provider to investigate. A response was received from the owner/manager which addressed the issues appropriately. No further issues have been raised since. Discussions with staff confirmed that training in safeguarding adults has been provided to them and if they had any concerns over any of the residents they knew the appropriate steps to take. No safeguarding adults issues have been raised by the home since the last inspection, although the home has taken a proactive stance in relation to two residents who have needed additional support/protection. The owner/managers have demonstrated their understanding of the safeguarding protocols in place and have used these to ensure the safety of residents. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People live in a reasonably well-maintained and safe environment which provides a pleasant and homely place for them to live in. EVIDENCE: A tour of the home took place and it was noticeably cleaner with no unpleasant odour present. There is a new carpet in the small reception lounge. Some new bedroom furniture has been purchased along with some redecoration of some bedrooms. Repairs, improvements and issues of cleanliness raised in the previous inspection report have been addressed. Information supplied by the home confirmed that in the last 12 months there has been installation of safety flooring in bathrooms and toilets, new bathroom Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 19 suite, refurbished a lounge, partly refurbished dining room, provided a safe garden area, redesigned dining room and quiet lounge areas. There are plans to continue with the redecoration and plans to put a door into the garden area so that residents can access freely. There are plans to continue with the refurbishment work to enhance the facilities within the home. Although not all areas of the home were viewed, communal areas and some rooms were seen and these were found to be clean, tidy, warm and reasonably comfortable for residents to use. The layout of the home is homely, with one small lounge, a small reception lounge and a larger main lounge, which is generally used by residents. The dining room provides a reasonable environment, although some of the furniture is now looking tired and some dining chairs needing cleaning. The lighting and furnishings are all domestic in character and add to the homely environment. The home continues to maintain a reasonable standard of facilities, with individual rooms being clean, and reasonably maintained. Most provide a comfortable private space for the people who use the service. Feedback regarding the environment confirms that generally no major concerns are raised, although comment was made that “the could be better accommodation – individual rooms are small and lack character”. In line with caring for people with dementia, some residents have made their rooms homely and familiar, with treasured possessions being brought in. As part of the admissions procedure, relatives could be encouraged to bring in items to make individual rooms more homely and familiar and thereby enhancing the environment for people with dementia. Generally people who use the service do not have a choice of room but discussion will take place as needed. People who were spoken with and who provided feedback all confirmed that they are happy with their rooms, the communal areas and the home is clean, warm and comfortable for them to feel at home. There are a range of aids and adaptations in the home which meet the needs of those currently in residence. The registered manager is aware and would make the appropriate contacts should additional needs be identified. It has previously been confirmed that all rooms are individually and naturally ventilated with most windows overlooking the gardens. All rooms are centrally heated with pipe work and radiator guards in place. All baths and sinks have Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 20 pre-sent valves to prevent any resident being scalded. Emergency lighting is also in place. There are no CCTV cameras in use in the home. There is a separate laundry and the washing machine conforms to the requirements for washing foul laundry. The home has policies and procedures in place for infection control, safe handling of clinical waste. Information supplied by the home confirmed that infection control training has been undertaken by 8 members of staff and staff have had training in MRSA and cross contamination control. The home has not accessed the Department of Health’s guide ‘Essential Steps’ to assess current infection control management, nor does it have an action plan for work on infection control management. This may be something for the home to address as the service develops. Toilets and bathrooms are provided with paper towels and soap dispensers to aid hygiene, although soap dispensers should be wall mounted to avoid risk of ingestion and or removal. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The level and calibre of staff is generally good. Residents are safeguarded as their care is provided by a staff team who are vetted, qualified and competent. EVIDENCE: The owner/manager confirmed that, as well as herself and Mr Owen (who both work full-time at the home), there is always a senior on duty along with 2 carers. The owner/managers are also looking to develop the management team in the next 12 months. The same staffing levels are maintained for the afternoon period. In the evening there are 3 carers on duty, including 1 senior carer and, at night, there are 2 carers who are both on waking watch. The owner/manager is also now working different times of the day so that she can oversee and monitor staff and speak with residents and is aware of the need to ensure adequate staffing levels are maintained to meet the needs of the residents. Information provided by the home confirms that they have a happy, confident staff team, with a very low staff turnover. Feedback forms from residents and relatives confirmed that staff are available when needed and no issues were raised over staffing in the home. Individual comments included : “nice staff”; “staff always make you feel welcome Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 22 whenever you ring up or go to the home” and “we are always made welcome at Scaleford. My relative is very kindly cared for”. One healthcare professional commented that the staff should “never loose the focus to treat people as individuals”. Information provided by the home states that of the 14 staff employed, 11 have National Vocational Qualification (NVQ) Level II or above, with 1 member of staff working towards this award, and 2 enrolled to start. Two senior carers are enrolled to do NVQ Level III. This means that the home has achieved 79 of staff trained to NVQ Level II and above. Examination of the new member of staff’s file evidenced that all the required checks have been carried out. One member of staff, whose Criminal Record Bureau disclosure check is awaited, is currently working under full supervision. Information from the home confirmed that all staff have had satisfactory CRB checks carried out prior to employment, which means they are safe to work with vulnerable people. The home has a training matrix in place from which training is identified and organised. Information provided by the home confirmed that training and team building is ongoing and this will be continued in the next 12 months. Staff spoken with confirmed that a range of training has been provided and is planned. Feedback from residents and relatives confirmed that car staff “usually” have the right skills and experience to care for people in the home. One GP comment cards commented that “some staff may need more training about patients with complex physical and mental health needs”. Training, especially the care of people with dementia, is something the home needs to continue to develop, along with understanding and competency assessment. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 23 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): Standard 31, 33, 35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is generally well managed and provides a safe environment for the residents and staff. EVIDENCE: The owner/manager confirmed that as well as holding the National Vocational Qualification Level IV/Registered Managers Award she has completed training in - Dementia Awareness, Key mover for Moving and Handling training, NHS prevention of falls in older people course and risk assessment training. In addition, she has managed the home for over 20 years. The associate owner/manager has attended dementia awareness training and first aid. Both owner/managers are auditors for the ISO quality award system. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 24 Information supplied by the owner/manager confirms they operate an open door policy for staff to feel at ease to talk. Staff spoken with confirmed that they feel the home is well managed and the owner/managers are “fair people” and can be approached at any time if they need advice or guidance. Comments from external healthcare professionals included – “Scaleford always seems to provide a friendly, professional and caring service to the residents” and the care home “treats patients as individuals, genuinely cares about users”. A relative commented “we are always made welcome at Scaleford”. The home continues to hold residents meetings, asking relatives for feedback via questionnaires sent out. Feedback questionnaires from relatives were seen along with a number of Thank You cards which included positive comments - “excellent and loving care you gave to our relative”, “you and your staff are special people who have a great deal of patience”. The home has recently had its ISO 9001 award renewed for a further 3 years, and also holds the Investors in People award. Staff spoken with confirmed that staff meetings are held regularly (every 2-3 months) and daily handovers take place. As well as this the owner/managers are on site and can be spoken with at any time. Financial records for the resident’s case tracked were examined and found to be accurately maintained. The home generally ensures that the commission are notified of events or incidents affecting residents but two events have not been notified. This was discussed with the registered owner/manager who is to ensure this does not reoccur. Information from the home confirms that all necessary equipment and facilities has been tested or serviced as recommended. Also, risk assessments are in place. Record keeping and document control is also carried out by the owner/managers. Staff confirmed that any issues or concerns regarding safety or maintenance are dealt with promptly. Information from the home indicates that policies and procedures are in place and these have either been reviewed or are being reviewed. Staff confirmed that policies and procedures are kept in the small reception lounge and are available for them to consult with. The accident book was seen to be accurately maintained, with appropriate actions being taken. Information from the home confirmed that there is a fire risk assessment in place, along with fire detection and fire fighting equipment. A recent visit from Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 25 the fire officer also provided guidance to the owner/managers. A few fire doors were seen to be wedged open. The registered owner/manager confirmed that automatic fire door release mechanisms are to be purchased to avoid this. Staff also confirmed that they have taken part in fire drills recently (about 6 weeks ago). Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 26 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 3 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 27 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 OP19 Regulation 23(2)(b) 23(2)(d) Requirement The ongoing redecoration and refurbishment of the home must continue and be completed by the date agreed (previous timescale of 30/09/06 not met) Medication must be safely administered to residents as detailed by the Medication Administration Record and as required under administration guidelines The home must ensure that fire doors are not wedged open (previous timescale of 02/08/06 not met) Timescale for action 31/03/08 2. OP9 13(2) 14/08/07 3. OP38 23(4)(a) 14/08/07 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 OP7 Good Practice Recommendations Better recording should take place for personal care and bathing of residents. The home may consider having an individual personal care/bathing record in residents’ rooms DS0000064565.V342699.R01.S.doc Version 5.2 Page 28 Scaleford Retirement Home 2. OP1 3. OP7 4. 5. 6. 7. 8. 9. 10. OP12 OP9 OP15 OP15 OP26 OP26 OP26 to assist staff. The home should develop the idea of providing visual information for prospective residents (about the home and in the service user guide, and including the complaints procedure) in a visual format for those people with dementia who are no longer able to comprehend written information The admissions procedure should include involvement in the care plan and also include encouraging relatives to bring in/make their relative’s room homely and familiar with personal items (dependent on any risk assessment). The activities offered to residents should continue to be developed alongside current ideas for people with dementia. Appropriate outings should also be developed. The owner/manager should consider purchasing a trolley so that medications can be safely stored and administered with due regard to safety and privacy Where cultural or specialist diets are provided these should be evidence and recorded as part of the care plan and meals served records Staff should be made aware to ensure residents are offered choices for sweets, providing a visual prompt if needed. Some dining room chairs need to be cleaned Soap dispensers should be secure to avoid possibility of ingestion and removal The home may wish to consider accessing the Department of Health’s guide ‘Essential steps’ to assess current infection control management. Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Scaleford Retirement Home DS0000064565.V342699.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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