Inspection on 09/06/05 for Scarletts

This inspection was carried out on 9th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Scarletts 17/07/08

Scarletts 25/07/07

Scarletts 17/08/06

Scarletts 06/12/05

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Scarletts Recreation Road Colchester Essex CO1 2HJ Lead Inspector Kathryn Moss Unannounced 9th June 2005 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 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 I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Scarletts Address Recreation Road, Colchester, CO1 2HJ Telephone number Fax number Email 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 Mrs Mandy Faires Care Home 63 Category(ies) of Dementia - over 65 years of age 1 Female registration, with number Old age, not falling within any other category 63 of places Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 63 persons) 2. One named person, aged 65 years and over, who requires care by reason of dementia, whose name was made known to the Commission in January 2003 3. The total number of service users accommodated in the home must not exceed 63 persons Date of last inspection 12th October 2004 Brief Description of the Service: Scarletts Residential Care Home is a purpose built care home for older people, located close to Colchester town. It accommodates up to 63 people, in 31 single rooms and 16 double rooms. Accommodation is on two floors, with a passenger lift providing access to the first floor, a variety of communal lounge areas, a large dining room, and pleasant grounds. Scarletts is registered to provide care to 63 older people (over the age of 65). The home provides 24 hour personal care and support, and has appropriate aids and equipment (e.g. mobile hoist, assisted bathing facilities, hand rails, etc.) to assist residents with limited mobility. The homes conditions of registration reflect the fact that prior to April 2002 the home was caring for an individual who had dementia and is still living in home. However, the home is not registered to admit people with dementia, and does not provide nursing care. The home is owned by Southend Care Ltd, and the manager (Mandy Faires) was present on the inspection. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 9/6/05, lasting eight and a half hours. The inspectors were Kathryn Moss and Christine Bennett. The inspection process included: discussion with the manager and with seven staff; discussion with thirteen residents, two relatives and a district nurse; a tour of the premises; and inspection of a sample of records. Comments and judgements in this report are based on information and observations gathered on the day of the inspection, and on any complaints received since the last inspection. On the day of the inspection there were 54 residents living in the home. 19 standards were covered, and 5 requirements and 13 recommendations have been made. During the inspection, staff showed a very good awareness of service users’ needs and individual likes and dislikes, and were caring and patient with service users. Service users spoken to appeared content with their lives at Scarletts, and were positive about the care and assistance they received from staff. The focus of this inspection was mainly on staffing and healthcare related standards. What the service does well: Staff at Scarletts demonstrate an open, caring and professional approach. Two relatives spoken to felt staff were welcoming and friendly: one commented on the staff’s ‘extreme kindness’, and the other said that staff were supportive to them and that they had never seen any unkindness. Several residents similarly commented on how kind the staff were, with comments such as ‘carers are very good – never any unkindness of rough treatment’ and that staff were ‘very good with residents, and give them a kiss and a cuddle’! Staff have shown particular care, patience and dedication in managing one individual’s challenging behaviour, and in developing strategies for minimising the impact of their behaviour on other residents. Residents were all positive about the quality and quantity of the food provided to them at Scarletts. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 6 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. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 4 The home has the skills and facilities to meet the needs of the people who it aims to accommodate. EVIDENCE: The premises, equipment and staff skills are suited to the aims of the home and to the needs of the residents that the home aims to accommodate. Residents and their relatives spoken to during the inspection were happy with the care provided by staff. Staff spoken to showed appropriate awareness of the issues affecting residents. The home has for some time accommodated one person whose needs (resulting from their challenging behaviour) fell beyond those that the home aims to meet, and whose behaviour was affecting the quality of life of other residents. The manager and owner had taken appropriate action to request that social services find a more appropriate placement for this person, but had not received a satisfactory outcome to this. However, it was noted on the inspection that the manager and staff have shown considerable patience and skill in managing the care needs of this resident, working with great care and perseverance in addressing their personal and healthcare needs. The staff should be commended on this. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11 Health care needs were well met within the home, but care plans did not adequately set out residents’ health, personal and social care needs. Medication procedures protected residents, although some aspects of recording were not satisfactory. Staff treated residents with dignity and respected their privacy. Practices within the home promoted a respectful handling of death, and a caring approach to those who were ill or dying. EVIDENCE: Residents spoken to and observed during the inspection looked well cared for. Staff were seen to be gentle and caring in their dealings with residents, and a visitor was pleased that a carer had taken time to put sun cream on their relative’s arms when they were sitting in the garden. Staff spoken to showed a good understanding of residents’ needs, and both residents and relatives spoken to were positive about the care provided at Scarletts. Care documentation did not fully reflect the care being provided. Two care files were reviewed in detail: these belonged to residents who had a variety of needs, whose needs had changed over the last year, and (in one case) who were unable to tell care staff what they needed. The home had a wide range of set care plan formats addressing various needs, and files viewed contained a Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 10 range of these care plans. Information recorded predominantly consisted of a tick list of action statements, but in one file some care plans contained some useful and relevant additional information relating to the individual’s needs. However, both files lacked care plans to address some key needs (e.g. care of pressure areas, assistance with feeding, etc.), several care plans did not detail the action required to meet a particular need (e.g. re personal cleansing, selftoileting, etc.), and on both files one or more care plan forms had been signed by the resident and/or carer but had not been completed. Many care plans were not signed and dated by the carer completing them, there was little evidence of regular reviews, and most care plans had not been updated to reflect the changed needs of the individuals. This was discussed with the manager who said that immediate action would be taken to review them. Both individuals whose files were inspected had pressure areas at the time of the inspection, but neither file contained a care plan detailing the care or preventative action required by staff. However, both had pressure relief mattresses on their beds and daily notes reflected that the district nurse was attending to their pressure area. Continence care was included in care plans and the home maintains good links with a continence advisor who offers assessment and advice, and also provides training for staff. Staff were appropriately referring residents for medical support and advice when required. A senior carer stated that male carers only attend to female residents if the resident is happy for this; if the resident did not want a male carer this would be recorded on their file (seen on one of the files viewed). Files also recorded people’s preferred term of address. Double rooms contained privacy curtains, and staff were observed to respect privacy and dignity when caring for people (e.g. closing a bedroom door when feeding someone who was in bed). The home has appropriate storage facilities for medicines held on behalf of residents. Medication administration records (MAR) are pre-printed by the pharmacy, or handwritten by staff when a new resident is admitted. MAR were generally well completed, although there were a few gaps where medication administration was not recorded. The quantity of each medication received by the home was generally recorded on the MAR, although, for someone recently admitted to the home, the quantities of medication had not been recorded on admission. It was noted that one resident self-administered their medication: risk assessments for this were not viewed on this occasion. On previous inspections it had been noted that the home has policies and procedures relating to death and dying, and that their assessment form contains space to record residents’ wishes regarding arrangements after death. On this occasion it was noted that 11 staff had recently attended training in loss and bereavement. Staff were giving appropriate care to someone who was bed-fast, and had responded well to their changed needs (e.g. adapting their clothing to minimise discomfort when dressing them). Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The home’s routines were flexible, and the lifestyle met most residents’ expectations; not all residents felt their recreational needs were being fully satisfied. The home promoted good contact with friends and relatives, and with the local community. Food served to residents was varied, appetising and appropriately served. EVIDENCE: Routines in the home were relaxed and flexible: at 10am, residents were just leaving the dining room after their breakfast, showing that breakfast was unhurried. One resident commented that they liked it at Scarletts as ‘it’s pleasant, and there are no hard and fast rules’! Residents were seen sitting outside in the garden under parasols, enjoying the sunshine, and two particularly commented on the fact that they enjoyed the garden. Evidence on the day of the inspection showed that activities take place within the home. A carer was seen playing bingo with residents in a lounge, and had taken two residents out to a local park the day before; it was reported that staff take individuals out locally, and that the previous weekend the home had taken 13 residents to a tea at a local church. There were monthly planned activities available to the whole home, with information on these displayed in the home in advance. Evidence of previous activities included: bingo, painting and table tennis in the dining room; 1944 videos and Trip Down Memory Lane; an outside singer and sherry; movement to music; and ‘nails and wine’! Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 12 The home had implemented a useful file containing quiz sheets: these were a good resource for staff to use with residents. The manager stated that these quizzes had become very popular, and several residents spoken to reported enjoying the bingo and quizzes. However, five felt that during the day they ‘didn’t have much to do’, one felt that there was not enough entertainment and four said that they would like more trips out. Two residents said that staff were always very busy, and didn’t have time to sit and talk with them. However, three of the staff spoken to were positive about the fact that they were able to get involved in activities and felt that they had time to talk to residents and relatives. In the two files viewed, information on residents’ ‘Social and Family History’ (and previous interests) was fairly brief. In one instance, this stated that they were a practicing Methodist, but there was no care plan to show how their spiritual needs were being met within the home. Care plans for ‘Leisure/Lack of Recreational Activities’ contained some more information on the individual’s interests, but did not describe what action was needed by staff to occupy or stimulate the person. Recent activities records on the two files viewed mainly showed ‘bed-rest’, ‘watching TV’, etc. Whilst it was noted that both people were on partial or permanent bed rest, it would have been good to see evidence of what specific input they received from staff to occupy their day or provide stimulation (e.g. ensuring their radio or TV was on, spending time with them chatting or doing nail care, etc.). It was noted on the inspection that visitors were able to come into the home at any time, and were made welcome by staff. Residents were able to chose who they saw. There was also contact with the local community: as noted above, residents had attended a recent church tea, and the home was organising a garden fete to which relatives and local people would be invited. Menus and food records were not inspected on this occasion, but both residents and staff were very positive about the meals served at Scarletts; a relative spoken to observed that ‘the food is very good and plenty of it’. On the day of the inspection there were seen to be choices available at both lunchtime and teatime, the menus was displayed, food looked appetising and mealtimes were unhurried. Two residents felt that there were too many ‘casseroles’ on the menu, and that they would like a greater choice of sandwich fillings at teatime. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents and relatives were confidant that their complaints would be acted on. Procedures were in place to protect residents from abuse, but some staff showed insufficient awareness of abuse issues and reporting procedures. EVIDENCE: The home’s complaints policy had been inspected on previous visits and seen to contain an appropriate procedure. This is displayed in the home and included in the service user guide/resident handbook. Residents and relatives spoken to all stated that they felt able to go to the manager if they had any concerns, and felt confidant that any problems would be sorted. The home maintains a log of all complaints received: this was viewed and contained an appropriate record of the most recent complaint. This was a complaint that had been received by the CSCI: the home had cooperated fully in investigating this, and although the concerns had not been substantiated a requirement was made regarding the need for staff to consistently and accurately record assessment information. This issue was not specifically reviewed on this occasion. The home was also maintaining a file of compliments received from residents, their relatives and other visiting professionals, and it was good to see a large range of compliments that had been received over the last year. Not all aspects of Standard 18 were inspected on this occasion. Residents said that they had not experienced any unkindness or rough treatment from staff. The home has a Whistle Blowing policy and ‘Abuse Prevention Guidelines’, and Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 14 operates other policies and practices that act to protect residents (e.g. health and safety, staff recruitment, etc.). The manager confirmed that the home’s ‘Abuse Prevention Guidelines’ is currently being reviewed as requested at the last inspection (to include fuller details of the procedure for responding to abuse, and to reflect Essex multi-agency procedures), but that the updated version was not yet available in the home to staff. Records did not show any recent training in adult abuse; however, this is covered as part of new staff induction, and one new carer confirmed that they had watched a video on abuse awareness. It was noted that all current staff had been booked to attend an external Adult Abuse workshop later in the year. During the inspection, a senior carer spoken to showed understanding of whistle blowing, abuse and of the need to report any concerns about abusive practices. However, three care staff spoken to did not show an awareness of the term ‘whistle blowing’, and two of them showed a limited understanding of the different kinds of abuse and of the action they would take if they observed abuse taking place. The manager was advised of this, and subsequently informed the inspector that action was to be immediately taken to ensure that all staff fully understood these issues. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The home provides a safe and accessible environment. However, some of the decoration and furnishings were not in a satisfactory condition. EVIDENCE: Most premises standards were not specifically inspected on this occasion. Previous requirements and recommendations relating to Standards 21, 22 and 24 were discussed with the manager. On the day of the inspection, the general environment of the home appeared safe; grounds were well maintained, and it was good to see these being well used by residents, and that outside seating and sun shades were being provided. Records of maintenance and redecoration were not viewed on this occasion. The home’s 2004-2005 Business Plan had included a range of premises issues, but there was not yet a new plan for 2005-2006. It was noted that some furniture and furnishings in the home were in need of replacing, particularly a number of carpets that were marked, and some furniture that was old and worn. A visitor commented that they felt the home Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 16 ‘needs a bit of an overhaul’, and that some of the décor was ‘not very welcoming’. The manager reported that the registered provider is planning to carry out some major work on the home, including redecoration of the first floor and replacing furniture. There was not currently any timescale for this. Action taken to address previous requirements were discussed with the manager: she stated that previous requirements relating to electrical sockets in bedrooms will be addressed as part of these future refurbishment plans, but that arrangements were already in progress to replace the call system in the home. She also advised that plans were in process to fit alternative flooring to the smoker’s lounge, to address an ongoing problem of cigarette damage to the carpet; this is to be commended. On the day of the inspection, the home was satisfactorily clean and free from unpleasant odours, despite the home being short of domestic staff (see Staffing section). One relative spoken to said that they had previously had occasion to complain about some cleanliness issues, but felt satisfied that things improved after that. It was good to note that two automatic sluice machines had been installed since the last inspection. On the day of the inspection, two yellow bags had come loose from the frames of clinical waste bins, and were lying open on the floor; this resulted in some odour in each location, as well as presenting an infection control hazard. The manager was advised of this. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Residents’ needs were being met by the numbers and skills of staff. The home operated a safe recruitment practice, with appropriate checks being carried out to protect residents. Staff training provided staff with the core skills to do their jobs and to promote safe practice. EVIDENCE: The rota for the week of the inspection was viewed, and showed that the home had been maintaining the agreed care staffing levels; morning staffing levels remained one lower whilst home remained under-occupied, and the home was therefore operating on 9 staff in the mornings, 9 staff in the afternoons and evenings, and 4 staff at night. It was noted that staff were now working fewer double shifts (generally a maximum of one or two a week), and the manager stated that breaks taken by those working long shifts are now staggered to ensure that this does not impact on the number of staff on the floor. The home currently employs 10 senior carers and 20 care staff. At the time of the inspection the home was short of domestic staff: the manager stated that they had been short of domestic staff for a few weeks, but that they were actively recruiting and hoped to fill the empty posts soon. The impact on the home was that on some days there was only one domestic staff member on duty, which is insufficient for a home of this size. Only one domestic was working on the day of the inspection, and they explained that they were prioritising health and hygiene tasks (e.g. toilets and bathrooms). Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 18 The home had appointed some new staff since the last inspection, and the files for two of these were viewed. Both contained application forms detailing the person’s employment history and names of two referees, as well as evidence of appropriate identification (although no photos). There was evidence that two references, a criminal record declaration and health declaration, and a POVAfirst check had been obtained before both candidates had started work. In one case there was evidence of the CRB being received a few days later, in the other there was no evidence of the CRB on file 3 weeks after they had started work. However, the manager believed this had been received. At the time of this inspection, out of thirty care staff, three had completed NVQ level 2 in care, and five were doing this training at present. Several more staff had been in the process of doing this training at the last inspection, but had since left the employment of the home. A few more places were due to soon be available to staff, and senior staff reported that they were waiting to start NVQ level 3. However, it was noted that the home had been on target to achieve the Standard for NVQ training prior to some staff leaving the home, and also that staff had been let down by their NVQ training provider who had failed to fulfil their assessment responsibilities to the home. A good range of training opportunities had been made available to staff since the last inspection. Evidence of training courses attended indicated that staff had attended training in: loss and bereavement (11 staff), ‘six broad values in care and care plans’ (6), diabetes (5), food hygiene (18), emergency aid (10), medicines administration (2), and manual handling (8). Three senior staff were qualified moving and handling trainers, and delivered this training inhouse; other training was provided by the training manager or by outside trainers. The deputy manager stated that the continence advisor is very supportive and will give talks to staff. Induction training was not discussed on this occasion. Individual staff training records were not up-to-date, so evidence of training was taken from a list of attendance at various courses, and from a core training matrix for the home. This indicated that most staff had received current training in moving and handling and almost two thirds had recent food hygiene training. Records showed that only about 25 of staff had attended fire safety training (mostly over 2 years previously), although the deputy manager advised that fire drills also incorporate training on the fire procedure within the home and evidence showed that the majority of staff had attended a fire drill within the last year. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 and 33 The home is well run by a suitably experienced manager. There was clear leadership within the home, with the manager being available and responsive to concerns. Quality assurance processes were in place and service users were consulted on issues relating to their day-to-day lives. EVIDENCE: The registered manager has many years of experience running a care home, and is currently completing her NVQ level 4 in management and in care. There was also evidence that the manager attends other training to update her knowledge and skills. Three staff members said that they felt the staff worked well as a team, and most of the staff spoken to said that they liked working at Scarletts. A senior carer felt that there was plenty of support from management and that any problems got sorted out. There were regular staff meetings (minutes not Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 20 viewed), and there was evidence that the manager gave clear direction regarding practices expected of staff. The manager was not part of the care team, but it was noted that she was around in the home, and assisted in the dining room at lunchtime. She stated that she enjoyed participating in the daily life, as it gave her chance to spend time with residents and to hear their comments and views. Residents spoken to felt that they could approach the manager with any concerns, and also reported that they have monthly residents’ meetings, when they were encouraged to pass opinion on anything. Two residents did not feel that their opinions always got acted on: this was partly in relation to wanting more trips out, and the manager explained that this was difficult to arrange because of the cost of transport involved in taking a group of residents out. The home uses an outside consultant to carry out an annual survey of service users’ views in the home, and a report from the last survey had been seen at the last inspection. The manager confirmed that there had been a 2004-2005 ‘business plan’ for the home (which had included aims and objectives in relation to premises, training and care plans), but that a new plan had not yet been produced for 2005-2006. The organisation’s Operations Manager carries out monthly audits (Regulation 26 visit reports) on the home, looking at a variety of records and environment issues, and speaking with staff and service users. Reports on these visits are regularly sent to the CSCI, and are clear and comprehensive. Internal monitoring of practices and procedures takes place, but are generally not recorded (e.g. checking of premises, auditing of medication and accident records, etc.). Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x x x x x Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 22 Yes 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 7 Regulation 15 Requirement Care plans must be developed further, to cover all of an individuals needs (physical, mental, and social), and to include detailed action to meet each need. Care plans must be reviewed regularly. This is a repeat requirement (previous timescale 21/12/04) It is required that care plans record the intervention required by staff for individuals who have pressure areas or are at risk of developing pressure sores. The registered person must ensure that staff always sign to confirm when they have adminstered medication to a service user. This is a repeat requirement (previous timescale 8/11/04). The registered person must also ensure that all quanitities of medication received by the home are recorded on the MAR. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 23 Timescale for action 31/7/05 2. 8 12 and 15 31/7/05 3. 9 13 30/6/05 4. 18 13 5. 30 23(4)(d), 13 and 18 It is required that the registered person ensures that all staff understand issues relating to the protection of vulnerable adults, and the homes procedures for reporting concerns about abuse. The registered person must ensure that all staff have received current fire safety training. 30/7/05 30/9/05 6. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Refer to Standard 7 12 12 15 18 19, 20 and 24 24 26 27 and 26 28 Good Practice Recommendations It is recommended that care plans are reviewed at least monthly. It is recommended that fuller information is recorded about residents life histories and interests. It is recommended that registered person ensure that care plans detail the action required of staff to assist a resident to engage in activities. It is recommended that registered person consult with residents regarding food choices. It is recommended that the homes revised Protection of Vulnerable Adults Policy is finalised and issued to staff as soon as possible. It is recommended that the registered person replace any worn furnishings and fittings in communal areas and individual bedrooms. The provider should ensure that all bedrooms have sufficient electical sockets to meet residents needs. It is recommended that the registered person review the type of clinical waste bins available in the home, to ensure that these provide secure containment for clinical waste. It is recommended that the registered person ensure that the organisation has contingency plans for covering shortages of domestic staff. It is recommended that the registered person review the homes NVQ training programme, to ensure that the home reaches the target of 50 of staff trained to NVQ level 2. I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 24 Scarletts 11. 12. 13. 29 30 33 The registered person should ensure that all staff files contain a photo of the staff member. The registered person should ensure that individual staff training profiles are accurate and up-to-date. It is recommended that the home develop an annual development plan for 2005-2006, and that care staff are involved in setting resident-focused objectives for the year. Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Fairfax House Causton Road Colchester CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Scarletts I56-I05 s17928 Scarletts v232592 090605 stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!