Inspection on 17/07/08 for Scarletts

This inspection was carried out on 17th July 2008.

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

Scarletts 25/07/07

Scarletts 17/08/06

Scarletts 06/12/05

Scarletts 09/06/05

Scarletts 12/10/04

Scarletts 18/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Scarletts Recreation Road Colchester Essex CO1 2HJ Lead Inspector Jane Offord Unannounced Inspection 17th July 2008 10:20 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 Scarletts DS0000017928.V368611.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. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scarletts Address Recreation Road Colchester Essex CO1 2HJ 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) 01206 792429 01206 870694 Southend Care Limited Mrs Mandy Faires Care Home 50 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (50) of places Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 50 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 16 persons) The total number of service users accommodated in the home must not exceed 50 persons The registered provider must review staffing levels (care and ancillary) in consultation with the Commission, within six months of dementia registration, to ensure that staffing levels are sufficient to meet the needs and number of service users 25th July 2007 Date of last inspection Brief Description of the Service: Scarletts is a purpose built, ex-local authority home that is now owned by Southend Care Ltd. It is situated in a quiet, residential area of Colchester. The service offers accommodation and support to fifty older people. It is registered to care for up to sixteen people with a diagnosis of dementia. The accommodation is over two floors with several stairways and a passenger lift to access the upper floor. The building is set in it’s own extensive grounds with gardens and woodland around. The woodland is home to a variety of wild life that can be observed from the home. There are five different lounges in the home with a number of other small informal seating areas around the building. The dining room is large and airy and there is a patio area with level access, garden furniture and sunshades. There are forty-four single rooms and three shared rooms, some rooms have en suite. Both floors have a number of bathrooms with hoists. Fees for the home range between £389.83 and £409.29 per week. The fees do not cover toiletries, hairdressing, chiropody, newspapers and personal clothing. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is two star. This means that people who use this service experience good quality outcomes. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 10.20 and 17.30. The registered manager was present throughout the day and assisted with the inspection process by providing documents and information. This report has been compiled using information available prior to the inspection, such as the annual quality assurance assessment (AQAA), which is a self assessment document completed by the service and sent to CSCI, as well as evidence found on the inspection day. During the day a tour of the home was undertaken with the manager and part of a medication administration round was observed. The files and care plans of five residents were looked at as well as four staff files and a variety of other documents, policies and service certificates. The lunch serving was seen and a number of residents, staff and visitors were spoken with. On the day the home was clean and tidy with poor odour control associated with one room only. Residents were using all areas of the home and in between rain showers some people were sitting on the patio. One resident said, ‘I love being out here even when it rains I can sit under the umbrellas’. The meal at lunch looked appetising and residents had a choice of dishes. Residents spoken with said, ‘The lunch was lovely’ and ‘I really enjoyed my salad’. Interactions between residents and staff were cheerful, caring and friendly. The medication is stored securely but some aspects of recording need to be addressed. During the afternoon a knitting club took place in one lounge and a quiz in another. What the service does well: The service meets the health care needs of residents promptly and appropriately. Good working relationships have been established between the local community nurses and the staff team of the home. A wide variety of activities and outings are organised and people are consulted about what they would like to do. The menus offer a balanced diet that is appealing and the food is well prepared. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 6 Staff training and development is encouraged and staff have supervision every six to eight weeks. Investigation into any complaint is thorough and follow up action taken with staff, if required, is positive and appropriate. What has improved since the last inspection? 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. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 7 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 Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6. Quality in this outcome area is good. There is a robust assessment process in place so that people who want to use the service know that their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a comprehensive statement of purpose that was updated in January 2008. It contains the information required under the national minimum standards (NMS) and is available at the entrance of the home for residents and visitors. Prospective residents are encouraged, when able, to visit the home to meet staff and other residents. If people are unable to visit a relative or representative is invited to visit. One visitor spoken with talked about how welcome they had been made on their initial visit. The first month of a new resident’s stay is considered a trial period for both parties to ensure the correct decision has been made to enter the home. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 9 Southend Care Ltd employs a placement co-ordinator who undertakes all the pre-admission assessments for the home. The assessment is written in report form identifying all the physical and mental health issues of the person. Information about any action taken to address any needs, such as, a referral to the falls prevention team, is included as well as any outstanding health care appointments. The medication regime is detailed and any concerns that will need monitoring for example blood sugar levels for diabetics or skin complaints are noted. A written decision that the home can meet the needs of the person assessed is recorded. The files of five residents were seen and each contained a pre-admission assessment report. The home has three rooms for the short-term use of people leaving hospital and requiring a little support before returning to their own home. The home has adequate equipment in the form of hoists, raised toilet seats and assisted baths to meet the needs of intermediate care residents. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. People who use this service will have a plan of care in place to help meet their needs as they would wish, they will be treated with respect and mainly protected by medication practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of five residents were inspected and all contained a care plan generated from the pre-admission assessment and a residents’ profile based on the activities of daily living (ADLs). The care plans in the files all covered physical needs such as personal care, nutrition, continence, mobility and communication. There was a record of the person’ preferred daily routine and their night needs. One resident wished to sleep with their door open at night so a risk assessment was generated and an automatic door closure fitted to that door. An intervention for another resident about pressure relief said, ‘needs a pressure cushion on their chair as they like to sit for long periods’, and it was observed that one had been provided. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 11 Care plans covered other areas of need where a person could require support including their spiritual choices, management of their finances and specific medical conditions such as treatment of MRSA. There were risk assessments for moving and handling, nutrition needs and falls. One resident wandered a lot and there was a risk assessment for managing the risk of them leaving the home unaccompanied. However the guidance did not include any strategies for distracting the resident from their purpose and helping them relax, it detailed the security measures needed. There was also one resident who had diabetes but the care plan did not include any signs for recognition of low blood sugar and interventions required if that should occur. This was discussed with the deputy manager who has recently attended training on care planning and they agreed that the care plans could be more person centred and had plans to instigate that. Records were kept of health professionals’ visits and any treatment prescribed. A discussion was held with a visiting community nurse. They said that the referrals they receive from the staff at the home are timely and appropriate. Staff know the residents and their needs well and are quick to observe if some one is unwell. The community nurses have a dedicated room in the home to store any medical supplies and the nurse said there is a referral book kept there that the staff use to raise any concerns about residents. The nurses visit the home every day and always check the book for new concerns. Other documents in the files included weight records, a medication regime and a body map for showing bruises or skin tears. There was evidence that team leaders continually reviewed care plans during the month to ensure any changing needs were captured. The daily records showed that not only the physical care of the resident was considered but also sometimes their activities and moods were included. Part of a medication administration round was followed at lunchtime. Medication is stored in a dedicated cupboard that is kept locked and the key held by the senior in charge of the shift. The home uses a monitored dosage system (MDS), which means that tablets are dispensed into blister packs by the local pharmacy ready for staff to administer. The medication administration records (MAR sheets) were fully completed with an explanatory note on the reverse if a medication was missed for any reason. Observing the carer doing the medication it was noted that at times they signed for medication as they dispensed it before the resident had taken it. When they gave some eye drops to one resident they did not wash their hands before or after the procedure and gave the drops during the resident’s lunch at the dining table. Residents were offered the choice of ‘as required’ medication and assisted patiently with tablets. The controlled drugs (CDs) storage and register were seen and meet requirements. Stocks checked tallied with the records. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. People who use this service will be able to choose their pastimes and influence the choice on the menus. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the five residents’ files seen there were contact details for the next of kin and any close relatives or friends. Each one had a life history with names of family members and significant life events. The home has an open visiting policy and during the day visitors were seen to come and go. People visited residents in the lounges or sat outside on the patio. They were welcomed and offered refreshment. A number of them were involved with the planning of the summer fete for the home and sought out the manager to discuss arrangements and their contribution to the proceedings. One visitor spoken with commented that they were always made welcome and that staff kept them informed about their relative. The home has received a number of cards and letters from people thanking the staff for all their hard work and care. One said, ‘you have always made us very welcome. Thank you for the endless cups of tea’. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 13 Throughout the home on notice boards there were displays of photographs of outings and activities undertaken by residents and staff. There was a visit to the Moscow State circus, a summer fete at the local school, a trip to the beach hut at Brightlingsea owned by a sister home and birthday celebrations. A photographic record of the wild life that visited the gardens was also on display for residents and visitors interest. The activity records showed that there had recently been a visit from the ‘pat’ dogs and a snake charmer had performed for entertainment. Residents spoken with said they had really enjoyed both visits but the staff were less keen on the snake. In the gardens there were vegetables growing in some areas with tomatoes in the greenhouse that the manager said were being grown by one of the residents. One resident spoken with said, ‘we planted up the hanging baskets at the front. We had such fun doing it and they look nice now’. Another resident said, ‘what a pity the weather is bad today, we were going to spend the day in Clacton but it has been cancelled. I had been looking forward to it but we will go to Brightlingsea next month’. Activity sheets completed by the carers showed that games, films, reminiscence, hand care, seated exercises and chatting were frequently part of the care offered. The records included comments from the residents about the activity. One said, ‘had a good laugh today’, another commented on an old movie that had been shown saying, ‘it took me back, it was lovely’. On the day of inspection a cheerful knitting group took place in one lounge and a quiz was overheard taking place in another. The menus were seen and showed that the main meal of the day is at lunch and there is a choice of main dishes and desserts. On the day of inspection the choice was between lamb hotpot with vegetables and potatoes or a ham salad with chips. There was banana custard, rice pudding or yoghurt for dessert. The meal looked appetising and was clearly enjoyed by the residents. Vegetarians are offered the same dishes but prepared with Quorn products. There is a roast each Sunday and fish on Fridays. The cook said all the cakes and pastries were home made and a selection of freshly baked cakes were seen in the kitchen ready for teatime. Minutes of residents’ meetings were seen and showed that menus and favourite dishes were discussed and the cook said changes were made as a result. The manager or deputy manager always help serve the meal so they are aware of each residents’ appetite. Two residents who had chosen not to have their meal in the dining room were served their choice of dish on small tables by their armchairs. It was noted that neither of them ate much of the meal. This was discussed later with the deputy manager who had been aware that the two residents had had a very small intake but said that they had both had good breakfasts. They would be monitored and if there was concern a referral would be made to the GP and a dietician. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 14 The kitchen was visited and found to be clean and tidy. There were good stocks of dry ingredients and fresh fruit and vegetables. Some left over food stored in refrigerators was not labelled with content or date. The refrigerators and freezers were temperature checked to ensure they were functioning within safe limits for food storage. One of the freezers had a fluctuating temperature range. When it was opened it dropped to –10 degrees and after fifteen minutes had only risen back up to –15 degrees. The safe temperature level is between –18 and –21 degrees. The cook said the freezer had recently been repaired. This was raised with the manager who said they would get it checked again. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. People who use this service can be confident that their concerns will be taken seriously and know that staff practice will protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints policy that is displayed within the home for residents and visitors information. The complaints log was seen and showed one complaint since the last inspection. It related to an injury sustained by a resident during a moving and handling manoeuvre. A full investigation was undertaken and a written response was sent to the complainant. There was evidence that action was taken with the staff involved to ensure that their training was repeated and that the incident was discussed during supervision to make sure that good care practice principles were being followed. Four staff files were seen and they all had certificates of attendance for protection of vulnerable adults (POVA) training. Staff spoken with were clear about their duty of care and could give examples of situations that would be cause for concern. One visitor spoken with said they had never had any concern that their relative was at risk from poor care practice, ‘I have never heard a raised voice in the home’. The manager said they had attended updated training on Safeguarding Adults and had the new referral forms if they should be required. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. People who use this service live in a comfortable environment that is well maintained but may be aware that odours are not always well managed making some parts of the home less pleasant. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is divided into four areas each with some residents’ accommodation, a lounge, bathrooms and toilets. The corridors are named to reflect the wild life outside the home, muntjac, badger, squirrel and forest view. There is a large communal dining room that is light and airy. The corridors all had a selection of pictures and the bathrooms had a seaside theme. There were grab rails throughout the home to aid people with reduced mobility and level access to the gardens and patio. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 17 A tour of the home was undertaken with the manager. Everywhere looked clean and tidy with poor odour control confined to one room but that did affect the corridor where the room was situated. The area was revisited after the carpet in the room had been cleaned and was more pleasant but the odour was not entirely eradicated. This was discussed with the manager who was aware that it was an issue that needed resolving. They said they would look into the possibility of changing the floor covering to something that was easier to clean. Residents’ rooms that were seen were bright and clean with evidence of personal belongings such as pictures, photographs and ornaments around them. Soft furnishings were colour co-ordinated and furniture was comfortable and suitable for the client group. All the rooms had views over the gardens and woodland. A number of the rooms had photographs of the resident on the door to aid identification of their rooms. Some rooms also had a notice reading, ‘Diabetic resident’ on the doors. This was raised with the manager who had introduced the practice to aid carers but agreed that it was a breach of residents’ confidentiality and said they would remove the notices immediately. A number of areas and rooms in the home have been redecorated since the last inspection and there is an ongoing programme for decorating rooms if they fall vacant, in preparation for a new resident. The colour schemes and furniture were different in each of the lounges and the manager said some lounges were more popular with residents than others but they were not sure why as they were all attractive. There were informal seating areas around the home including one upstairs with a desk for the computer that was for resident use. The laundry was visited and was extremely tidy with all the clothing and bedding very neatly folded and stacked. The washing machine was suitable for the workload and had a sluice programme for managing soiled washing. The home has a dedicated laundry worker who was asked about the procedure for managing soiled linen and said that they soak it and sluice it by hand before putting it in the machine. They have protective gloves and aprons to do this. This procedure was discussed with the manager, as it does not follow the guidance ‘essential steps’ issued by the Department of Health (DoH) and is potentially putting staff at risk of cross infection. They agreed they would try to source a supply of alginate bags that go straight in the machine without the need for soaking and sluicing. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. Staff in the home have the skills and training to support the people who use the service and recruitment procedures followed will ensure that suitable people are employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that during the day there was a team leader and senior carer on duty with six or seven carers. At night there were three carers. The manager and deputy manager were supernumerary but were seen frequently working with residents and interacting with staff during the day. An ancillary team of domestics, a laundry worker, a maintenance person and an administrator supported the care team. Staff spoken with said there were generally sufficient people to meet residents’ needs. Residents said they did not have to wait long for staff to answer bells if they needed something. The home employs twenty-five permanent care staff and of that number fourteen have achieved an NVQ award at level 2 or above and two more are working towards it. This more than meets the recommended 50 in standard 28 of the national minimum standards (NMS). Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 19 The files for four new members of staff were seen and each one contained a POVA 1st obtained prior to the person commencing work. There was a criminal records bureau (CRB) check in two files but the other two were for people very recently started in post. The administrator said that they had sent off for them but they had not yet been returned. Copies of the application for a CRB were seen. One file did not contain photocopied evidence that the person’s identity had been verified although documents must have been seen as the CRB application was completed. All the files showed a comprehensive induction had taken place and one carer spoken with said they had had a number of shadow shifts when they first started work. Training covering mandatory subjects such as moving and handling, fire awareness, infection control, POVA and first aid were undertaken regularly and certificates in the files and the training matrix seen showed that training was up to date. Senior staff spoken with said they had received training for the administration of medication and the manager said some staff had recently undertaken a five-week course in dementia care. The pack for the course was seen and showed that the material was comprehensive. There were feedback comments recorded from the students that indicated that they had found the course very informative. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 20 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, 36, 38. Quality in this outcome area is good. People who use this service can be confident that their opinions will be sought and that practice will protect their finances and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post a number of years and has achieved an NVQ award at level 4 in care management. Observation during the day showed that the manager had an open and friendly manner to residents, staff and visitors. Staff spoken with said the manager was approachable and gave clear leadership and guidance. A visitor spoken with said the manager had responded very quickly when they had raised a minor concern to correct the issue. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 21 The annual quality assurance assessment (AQAA), which is a self-assessment document required by CSCI to be completed by a home giving details of the service offered by the home and how they are managing any problems or incidents, was sent prior to this inspection. The information contained in it was basic with little feel for the level of outcomes experienced by the residents. In the sections headed, ‘What we could do better’ or ‘Our plans for improvement in the next twelve months’ there was very little information and in one section the response was, ‘Unable to answer’. Minutes of meetings held with residents were seen and there was clearly wide discussion about all aspects of life in the home. Ideas were put forward by residents for meal changes and outings. Information was shared about staff recruitment and new care planning methods. At one point the maintenance of the lift meant it would be out of action for four days so the plans to manage that were discussed at the meeting. The home keeps the personal monies for a number of residents and the administrator showed the records that were kept. They were clear and offered a financial audit trail. Money is kept in a safe in the office and the manager and administrator have access to it. Staff files seen showed that after the initial induction the new staff have a six week appraisal followed by a three month and six month appraisal. They have supervision contracts and supervision takes place every six to eight weeks with records kept in their files. Staff spoken with confirmed that they had regular supervision with a senior member of staff and the training needs were identified during those meetings. The fire log and a number of service certificates were inspected and found to be up to date. The gas safety certificate was issued in January 2008 and the lift was serviced in April 2008. Records showed that fire alarms, fire doors, fire exits and emergency lighting were tested weekly and fire drills took place monthly. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 1 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 23 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. Standard OP9 Regulation 13 (2) Requirement Timescale for action 17/07/08 2. OP26 13 (3) 3. OP26 16 (2) (k) 3. OP29 19 (1) (b) Sch 2 Medication records must be signed after the medicine has been administered and topical preparations must be given with respect to residents’ dignity to ensure that residents receive their medication appropriately and an audit trail is in place. Provision must be made for the 15/08/08 safe management of soiled linen to protect residents and staff from cross infection. Steps must be taken to manage 17/07/08 the odour problem from one room so that residents live in a pleasant environment. Documentary evidence must be 17/07/08 kept to evidence that all the recruitment checks in Schedule 2 of the Care Homes Regulations have been undertaken on new staff to protect the residents from unsuitable people being recruited to work in the home. Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Scarletts DS0000017928.V368611.R01.S.doc Version 5.2 Page 26 - 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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