Inspection on 12/06/07 for Scarbrough Court

This inspection was carried out on 12th June 2007.

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

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

Other inspections for this house

Scarbrough Court 20/01/09

Scarbrough Court 13/02/06

Scarbrough Court 04/10/05

Scarbrough Court 01/02/05

Scarbrough Court 25/10/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Scarbrough Court Alexandra Way Cramlington Northumberland NE23 6ED Lead Inspector Elaine Charlton Key Unannounced Inspection 12th June 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 Scarbrough Court DS0000000603.V338047.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. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scarbrough Court Address Alexandra Way Cramlington Northumberland NE23 6ED 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) 01670 712215 cedden@rmbi.org.uk www.rmbi.org.uk Royal Masonic Benevolent Institution Mrs Caroline Edden Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49) of places Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 Brief Description of the Service: Scarborough Court is registered to provide accommodation for 49 older people who need residential or nursing care. It is built on a local housing development close to the centre of Cramlington. The home is near public transport links and local shops. The home is run by the Royal Masonic Benevolent Institution (RMBI) and mainly provides accommodation for retired Freemasons and their families. Residents who have no connections with the (RMBI) also live at Scarborough Court. The home is purpose built and bedrooms are at ground and first floor levels. There are two passenger lifts to help residents move around the home. Some bedrooms are suitable for a married couple. The registered manager, deputy manager and a strong staff team support residents to be as independent as possible. A new home is being built in the grounds of Scarborough Court and will replace the existing building. Fees are between £455 and £687 per week. The RMBI has an information pack that is given to people who may wish to move into one of their homes. It contains information about RMBI homes and where they are, eligibility qualifications for admission, an application form (parts 1 and 2), a copy of the complaints policy and information on funding arrangements. Copies of CSCI inspection reports are available in the home. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was made on date the 12 June 2007, with a further follow up visit on the 26 June 2007. The manager was present on both days. Before the visit we looked at: • • • • • Information we have received since the last visit on 28 February 2006; How the service dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The provider’s view of how well they care for people; The views of people who use the service, their relatives, staff and other professionals who visit the service. During the visit we: • • • • • • • Talked with 12 people who use the service, 10 staff, the manager and visitors; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building/parts of the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit; Left “Have your say” questionnaires for service users to complete. We told the manager what we found. What the service does well: People are provided with the information they need to make a decision about moving into the home. Their views are sought about first impressions of the home. Full assessments are obtained and carried out to make sure that the home can meet a persons needs. Residents receive care and support in the way they want and when they need it. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 6 Staff promote residents’ privacy, dignity, choice and independence. Care and support is given to residents in a professional and sensitive way. Residents are consulted about how the home runs and what they like to eat. An excellent choice is provided for residents at meal times and alternatives are always available. Staff are qualified, capable and receive a high level of training to help them support people who live in the home. Hygiene and infection control systems are good and promote the safety of residents and staff. Residents know who to speak to if they are unhappy and how to make a complaint. Strong, clear, recruitment and selection procedures protect the health, safety and welfare of residents. Residents said: “I have a copy of the terms and conditions in my bedroom.” “I was recommended to come to Scarborough Court by a friend.” “I receive excellent care at Scarborough Court.” “I expressed the need for some additional help with care needs and this was discussed with a senior member of staff immediately.” “The staff at Scarborough Court are wonderful.” “The staff are very good, I like the home.” “I never have to wait an unreasonable amount of time to have my needs met.” “I am very pleased the nurses can visit through the night.” “I need help to take part in some activities, this is provided for me.” “Although there are many activities available, I only take part in certain ones.” “The staff are like my friends.” What has improved since the last inspection? Requirements made at the last inspection were fully met. Staff and residents are preparing a time capsule to be buried under the new home. Care plan recordings are more out-come based and show how care and support has affected the daily life of a resident. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 7 Ionisers have been bought to help with the control of odours throughout the home. New equipment, including hoists, slings and beds have been purchased as and when residents needs have dictated. Extra equipment has been bought for the laundry to promote infection control. Building of the new home is well underway and residents are being kept up to date with progress and can see the builders at work. 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. Scarbrough Court DS0000000603.V338047.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 Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are given good information to help them decide about moving into the home. Their needs and wishes are assessed before they are given the chance to move in. EVIDENCE: Fourteen “Have your say about” questionnaires were left at the home for residents to complete. Twelve have been returned. All twelve residents said they received enough information to help them decide whether the home could meet their needs. Residents said: “I have a copy of the terms and conditions in my bedroom.” “I was recommended to come to Scarborough Court by a friend.” The Royal Masonic Benevolent Institution (RMBI) has an information pack that is given to people who may wish to move into one of their homes. It contains Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 10 information about RMBI homes and where they are, eligibility qualifications for admission, an application form (parts 1 and 2), a copy of the complaints policy and information on funding arrangements. Added to the information pack is a statement of general information about what the accommodation provides, an information summary about Scarborough Court and the combined Statement of Purpose and Service User Guide. People who may wish to move into the home are given the chance to visit, look around the home and have a meal if they wish. Staff support visits and are there to answer any questions visitors and/or their families may have. Extra visits and temporary stays at the home can be arranged. The home has a Business Co-ordinator who can help families understand the terms and conditions for anyone wishing to live in the home. The manager is looking at ways to improve the methods used to get information to people who may wish to live in Scarborough Court. Families and residents are asked to give information about their first impressions of the home. This is good practice. The latest assessment for a new resident was seen. The quality of information was good. A full National Health Service Care Assessment had been obtained. There was a personal plan, copy of the home’s pre-assessment and details of nursing needs. An application form and statement of terms and conditions were also available. Once the assessment process has been completed a “welcome letter” is sent to the new resident. The home does not provide intermediate care. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are asked how they wish their personal care to be provided, and by whom. They are supported and helped to be independent with medication and can see health care professionals as their health needs dictate. EVIDENCE: All twelve residents who sent back questionnaires said they always received the care and support they needed and that staff listened to and acted upon what they said. Seven said staff were always available when they needed them, five said they usually were. One person said “I never have to wait an unreasonable amount of time to have my needs met.” Another said “I am very pleased the nurses can visit through the night.” Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 12 Eleven residents said they always received the medical support they needed. One person did not comment. Residents said: “I receive excellent care at Scarborough Court.” “I expressed the need for some additional help with care needs and this was discussed with a senior member of staff immediately.” “The staff at Scarborough Court are wonderful.” “The staff are very good, I like the home.” “I am so happy in Scarborough Court I don’t want to move into the newly built home.” Service user and care plans for four residents were seen. Records are kept in a standard way, were legible and up to date. Some documents are colour coded to make it easier to access them. Evidence was seen of assessments covering areas of risk, nutrition and skin care. Daily records show the type of care a resident has received. Recordings were generally good. Some included nice out-come based notes which is good practice. Residents can see a GP, District Nurse, Dentist, Optician, Chiropodist or any other healthcare professional as and when they need. Good records of appointments were seen. Throughout the inspection residents were treated with respect and their privacy and dignity was promoted. Staff knocked on doors before entering bedrooms, introduced themselves and dealt with personal needs sensitively. A member of the nursing team negotiated the attendance of a GP and admission of a resident to hospital in a very professional way. All files contained a copy of Homely Medicines guidance that had been signed by the residents GP to show what they could be given. A random check was carried out on medication kept for both the residential and nursing units. All medication is securely kept with separate facilities and recording arrangements for controlled drugs. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 13 One member of staff on both the residential and nursing units is responsible for the ordering, disposing and checking in of medication. Appropriate systems are in place on the nursing unit for the disposing of medication. Staff receive training and updates on the safe handling of medication. No issues were identified during the check of medication on the nursing unit. Two recording errors were identified on the residential unit. One was resolved on the day of the inspection and one the following morning. All medication was accounted for but staff had not clearly followed the home’s procedures. The deputy manager carries out and records monthly medication audits. Staff are being reminded through staff meetings of the need to follow the home’s policies and procedures for the safe handling and dispensing of medication. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality n this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are encouraged to be as independent as they wish. They access social opportunities within the home and the wider community. Choice and rights are promoted as well as healthy living. EVIDENCE: Five residents who sent back questionnaires said there were always activities that they could take part in. Five said there usually were and two said sometimes. Six residents said they always like their meals. Five said they usually did and one said they sometimes did. Residents also said: “I need help to take part in some activities, this is provided for me.” “Although there are many activities available, I only take part in certain ones.” Residents are able to go out when they wish. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 15 It is easy for them to move around in the home. They can choose which leisure and social activities they wish to take part in. The home employs two activities co-ordinators. One person takes the lead on the residential unit and one on the nursing unit. A time capsule is being put together to bury under the new home. When the existing building is demolished it is intended to hold an event to open the capsule that was buried 40 years ago. A group of residents were seen taking part in armchair games. Staff were encouraging and sensitive to people’s abilities. Both residents and staff were laughing and cheering. Books and videos are kept all around the home so that people can easily get to them if they want. Residents are encouraged and helped to stay in contact with their families and friends. The contact with families policy also includes reference to staff recording the details of people a resident might not want to see or keep in touch with. One resident’s family had been able to hold their wedding reception in the home to make sure that their relative could join in. One gentleman visitor was having lunch with his relative. The RMBI is generous when providing gifts for residents on their birthdays and at Christmas. All residents receive presents to the same value whether they have links with the RMBI or not. The Friends hold a coffee morning in the home each month. Several residents were spoken to as they left the large dining room. They were in good humour and said they had enjoyed their lunch. Tables are set with linen cloths and napkins, flowers and nice crockery. Where necessary people are given help to enjoy their meal in a sensitive and unhurried way. The manager makes unannounced visits to the dining rooms and samples the food. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 16 The kitchen is of a commercial standard and was found to be exceptionally clean and well organised. A member of the kitchen staff speaks to residents after each meal to see if everything has been all right for them. Records of feedback are kept in the kitchen. Staff are able to meet residents needs for soft, pureed and diabetic diets. One person needs a gluten free diet. All products needed to provide a gluten free diet are kept separately to avoid any mistakes. There was a good supply of bread, scone, cake and gravy mixes for this purpose. All meals are served from the hot trollys to promote choice for the residents. The dry store was well stocked. Deliveries of dry products arrive fortnightly. Fresh items are brought into the home three times a week. The home has a walk-in refrigerator that extends to a walk-in freezer. All products were covered and labelled. An outside catering company employs the catering manager and his staff team. The manager meets regularly with the catering manager to make sure that residents choices are being met. The Catering Manager has a schedule for staff training and updating of risk assessments. Evidence was seen of staff induction. Each member of kitchen staff has an individual training log and they receive a good level of training. All kitchen staff were appropriately dressed in a standard uniform and hat. The inspector was also given a coat and hat before she could enter the kitchen. This is very good practice. Residents have a choice of two hot meals and one cold at lunch-time. Soup, one hot meal and one cold meal at teatime. Records showed that residents were able to have an alternative if the days menu did not meet their needs. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 17 Nursing staff identify which of the choices need to be provided in soft or pureed form by writing in red on the menu choice record. Kitchen staff have a separate office, changing area and shower facility. The home has it’s own hairdressing salon and hairdresser. He has visited the home for many years and knows the ladies and gentlemen well. Notice boards give residents information about activities, “things they need to know”, and keep them up to date with the building of the new home. There is a monthly church service in the home and the “Friends” hold a monthly coffee morning. It is also possible for residents to take a holiday in another RNBI home (if there is a suitable vacancy). One gentleman who had previously lived in the home had just been back for a holiday. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of people who live in the home are listened to. They are protected from harm through policies, procedures and staff training. They can also join staff training to help them understand procedures. EVIDENCE: Ten residents who sent back questionnaires said they always knew who to speak to if they were not happy. One said they usually did and one said they sometimes did. All twelve knew how to make a complaint. One person said: “there has been no need to complaint but I understand how to make a complaint if necessary”. Others said: “I would voice concerns to care staff and management if necessary.” “I would talk to the nurse.” “I would voice my complaint to a senior member of staff and would also relate to terms and conditions for information of how to make a complaint.” Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 19 The RNBI have clear policies and procedures for handling complaints, dealing with residents’ money and adult protection. Residents have the right to vote and freedom to make choices. The management team operates an “open door” policy for both staff and residents. They will see anyone at anytime if they are free. The home’s incidents and occurrences book and complaint register were seen. The first logs the date, time, event and who has been informed. The complaints form (part C) is signed and dated by the Responsible Individual or their representative as part of the audit process. This is very good practice. The recording system for complaints starts with a carbonised form that has a personal identification number, gives evidence of the investigation and, where appropriate, contact with the Adult Protection Team. Outcome letters are sent to complainants at the end of an investigation. Letters and cards of compliment are sent straight to RNBI headquarters so the inspector was not able to see these. All staff are trained in the Protection of Vulnerable Adults. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in a homely environment that promotes their independence and the chance to spend time privately. Everywhere is clean and tidy and hygiene routines are good. EVIDENCE: Although a new home is being built, Scarborough Court is being maintained to a good standard. Corridors and communal areas give residents lots of room to move around freely and promote the use of wheelchairs and/or motorised chairs where necessary. Bedrooms are of a good size and residents are encouraged to bring personal items with them when they move in. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 21 Several residents were spoken to in their bedrooms. Each room was very different and nicely personalised. Where bedrooms are not en-suite, residents have easy access to bathrooms and toilets. Toilets are equipped with high/low seats and grab rails. All those seen were provided with soap and towel dispensers to promote infection control. Hand gel is provided at the entrance to the home. Residents, staff and visitors are encouraged to use this when they enter and leave the home. This is very good practice. There are separate areas in the laundry for soiled, infected and clean items and clear guidance on the disposal of clinical waste. An unannounced visit was made to the laundry. It was found to be extremely clean, tidy and well organised. Staff also benefit from having a drying/airing room. The laundry assistant on duty, although relatively new, was able to describe the process for dealing with each type of laundry. No staff are allowed to leave the home wearing their uniform. Sluices were well equipped, clean tidy and odour free. The home has an excellent range of equipment and is aiming for everyone to have their own sling. The manager has a generous equipment budget and the Friends of the home also buy “one off” pieces of equipment. On bedroom landings there are small kitchens were visitors can make themselves a drink. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are protected by recruitment and selection procedures that are properly followed. Staff are supported through training and supervision to provide care to people in a way that meets their individual needs. EVIDENCE: Residents are confident that staff can and will meet their individual needs. No one is able to start work for RNBI without first having completed the interview process and received a clear Criminal Records Bureau (CRB) check at an enhanced level. People will also not be employed if they cannot or will not give their current or last employer as a referee. This is very good practice. Proper checks are carried out on nursing staff to make sure that their registration is current and they have not been disqualified from working. Staff are inducted into the home’s practices and then do the Skills for Care Foundation course. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 23 They are encouraged to complete National Vocational Qualifications (NVQ) at levels 2 and 3. Nursing staff are given the opportunity and time to keep their practice and skills up to date. All staff are given paid time off to attend training. The homes induction procedure refers to all the RMBI’s policies and procedures. Staff are given a copy of the RNBI handbook. They are given clear advice about the acceptance of gifts and gratuities, the RMBI’s vision and goals, use of alcohol, drugs and smoking. The handbook gives staff easy access to the grievance and disciplinary procedure, guidance of safety, accidents, harassment and violence at work. During the inspection one lady told the inspector that the staff “are like my friends”. At all times relationships between residents and staff (of all levels) were seen to be warm and friendly. Residents and staff know each other well. All mandatory training is up to date. Training was taking place in the home on both days of the inspection. Line managers and the human resources manager check that mandatory training is up to date. The training officer also does this at a national level. Three senior staff have applied for Equality and Diversity training. The course will be evaluated and if it meets the needs of all staff will be made widely available. A new monitor system for training, Snowdrop, was due to “go live” in the next month. Some staff have already been trained to use this system. Training records are not updated until certificates are received. All staff have a training passport that records training they have completed and when. A local training organisation is currently putting together a bespoke Infection Control course for the home. This is to make sure that staff get the training they need that is relevant to their job , and specific to the home. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 24 The manager and deputy manager have recently completed the Northumberland Care Alliance (NCA) management development course. This was reported to be excellent. Out of 35 care staff, 25 have already achieved a qualification at NVQ level 2 or 3. Two other staff have recently completed their course and another has just started. Recent training in the home has included moving and handling, deaf awareness and Boots Monitored Dosage Administration (MDA). The home has staff who are trained to deliver MIDAS, moving and handling and fire safety training. There is one NVQ assessor on night duties and two on day duties. Five people have completed Training the Trainers courses. Four staff files were seen. All were up to date and in order. Records showed that staff received regular supervision and an annual performance development review. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well run which benefits the people who live there. They are consulted about what goes on in the home through surveys and meetings. Both people living in the home and staff are protected through good health and safety procedures, systems and training. EVIDENCE: The manager is experienced and well qualified to carry out her job. The management and administrative team were seen working well together. They are clear about each other’s roles and responsibilities. There is a high team commitment to providing quality care for the people who live in the home. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 26 The manager and deputy manager completed an excellent Annual Quality Assurance Assessment (AQAA) that CSCI has just introduced. They intend to use this as a “living document” and keep it updated for future use. Residents said that staff listened to them and would act on what they said. Staff were seen taking time to talk to people, or answer questions, even if they were busy doing something else when they were approached. The RMBI has a comprehensive set of policies and procedures that staff have easy access to. Policies and procedures are promoted through staff meetings. One is brought to each meeting as “policy of the month”. Residents are given information about advocacy services that include access to people outside the RMBI. Staff meetings are held with all groups of staff on a quarterly basis. Extra meetings are held if there is a specific issue that needs to be discussed or dealt with. The regional human resources manager attends staff meetings. They also audit new staff files on a monthly basis. Residents meetings are also held quarterly. Health and safety procedures and process are promoted at a high level. Residents are encouraged to join staff training in the control of substances hazardous to health (COSHH), fire safety and health and safety. Scarborough Court is to be included in the first wave of a new quality assurance process. An outside agency is to carry out customer satisfaction surveys. The views of residents, and those of their relatives, will be sought about the home and it’s surroundings, life in the home, food and drinks, administration of the home and staffing. Their overall view of the home is asked for and any recommendations or suggestions they might like to make. They are also asked if they would recommend the home to someone else. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 27 Information is available all over the home to help residents. As well as information the RMBI produces, leaflets from other agencies are available for them to pick up. The leaflets cover things like keeping mobile, better hearing, managing medicines, safety, and many other subjects. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 4 Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 29 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. Standard Regulation Requirement Timescale for action 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 OP16 Good Practice Recommendations Copies of cards and letters of compliments should be kept in the home. Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Scarbrough Court DS0000000603.V338047.R01.S.doc Version 5.2 Page 31 - 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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