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Inspection on 16/01/08 for Sceats Memorial Home

Also see our care home review for Sceats Memorial Home for more information

This inspection was carried out on 16th January 2008.

CSCI found this care home to be providing an Adequate service.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a team of staff that work hard to maintain the quality of the lives for people who use the service. All comments received about the staff were very complimentary. For example "The staff look after my every need". The Registered Manager and Deputy Managers have worked at the home for a number of years resulting in continuity for staff and people who use the service. The dietary needs of people who use the service are well catered for with a balanced and varied selection of food available that meets their tastes and choices.

What has improved since the last inspection?

The home has reviewed their care planning system to ensure that care plans are now updated with any changes to people`s conditions and that care plans are in place for all their needs. The majority of care plans are now individual to each person and not task orientated. Improvements have been made to the medication systems to ensure the safety of the people who use the service. However there are still some areas that need further work and this includes care plans for people who use `as required` medication. Building work has started at the home to improve the communal area for people who use the service. Redecoration of the bathrooms has taken place to make them look less clinical and institutional. Staff are now receiving formal supervision sessions to ensure they are meeting the needs of the people who use the service. An ongoing training and induction programme is now in place to provide staff with the skills and knowledge they need to care for people who use the service. A robust recruitment procedure is now in place to ensure all the required preemployment checks are undertaken prior to new staff starting at the home to prevent people who use the service from being put at risk. All staff have either completed or are booked on the training provided by the local Council about the `Alerters` guide, which tells staff how to report any suspicions of abuse. Pre-admission assessments are now completed in full to determine if the home is able to meet the needs of the proposed person and they are also confirming this in writing to the person who is planning to move in.

What the care home could do better:

The home still needs to continue to devise their quality assurance system to ensure the home is run in the best interests of the people who use the service. Some areas in relation to medication need further improvement to ensure people who use the service are not put at risk. A small number of maintenance issues were identified that need to be addressed for the safety of people who use the service. The home needs to continue with their ongoing training programme to ensure staff have the skills and knowledge to meet the needs of the people who use the service.

CARE HOMES FOR OLDER PEOPLE Sceats Memorial Home 1-3 Kenilworth Avenue Gloucester Gloucestershire GL2 0QJ Lead Inspector Sharon Hayward-Wright Key Unannounced Inspection 11:00 16 & 17th January 2008 th 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 Sceats Memorial Home DS0000016573.V354905.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. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sceats Memorial Home Address 1-3 Kenilworth Avenue Gloucester Gloucestershire GL2 0QJ 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) 01452 303429 01452 303429 Sceats Memorial Housing Association Limited Mrs Iris Anne Burton Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2007 Brief Description of the Service: Sceats is a Care Home, which provides personal care to the older person. It is situated in a residential area on the outskirts of Gloucester City. It offers accommodation over two floors in two, extended Victorian houses. Bedrooms are single and have wash hand basins. Communal toilets and bathrooms are near to all bedrooms and main communal rooms. There are two lounges, one dining room and a sunroom on the front of the property. The building is accessible by wheelchair; the first floors are reached by stair lifts, but some bedrooms are not easily accessed unless the individual is confidently mobile and advice would need to be sought from the Registered Manager as to which bedrooms are affected. The home has a copy of their Statement of Purpose and Service Users Guide on display in the main entrance hall and people who use the service are also provided with a copy of these guides. The fee range for this home is £320 to £402.60 per week and extras include hairdressing, newspapers and chiropody. Sceats Memorial Home DS0000016573.V354905.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 service is 1 star. This means the people who use this service experience adequate quality outcomes. One Inspector carried out this inspection over two days in January 2008. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes in to account the views and experiences of people using the service. The Registered Manager and Deputy Managers were available during the inspection as were other members of the homes team. A total of 26 standards were inspected. Where possible, people living at the home were spoken with to ascertain their views on the care and services provided. Surveys were sent to the home for people who use the service and their relatives/representatives prior to the inspection to obtain their views. Surveys were also sent to the home for staff to complete. We received four surveys from people who use the service, and one-relative/representative survey. The comments received from speaking to people during the inspection and the surveys have been used in the report. The care staff were spoken with throughout the inspection and were helpful and co-operative. Three requirements have not been complied with in full since the last inspection. On this occasion the timescales have been extended as indicated in the requirements made. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale may lead the Commission for Social Care Inspection to consider enforcement action to secure compliance. Since the last inspection the home has worked very hard to address the number of requirements issued and made improvements to the home for the benefit of people who use the service. We (The Commission) now expect the home to maintain this improvement. What the service does well: Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 6 The home has a team of staff that work hard to maintain the quality of the lives for people who use the service. All comments received about the staff were very complimentary. For example “The staff look after my every need”. The Registered Manager and Deputy Managers have worked at the home for a number of years resulting in continuity for staff and people who use the service. The dietary needs of people who use the service are well catered for with a balanced and varied selection of food available that meets their tastes and choices. What has improved since the last inspection? The home has reviewed their care planning system to ensure that care plans are now updated with any changes to people’s conditions and that care plans are in place for all their needs. The majority of care plans are now individual to each person and not task orientated. Improvements have been made to the medication systems to ensure the safety of the people who use the service. However there are still some areas that need further work and this includes care plans for people who use ‘as required’ medication. Building work has started at the home to improve the communal area for people who use the service. Redecoration of the bathrooms has taken place to make them look less clinical and institutional. Staff are now receiving formal supervision sessions to ensure they are meeting the needs of the people who use the service. An ongoing training and induction programme is now in place to provide staff with the skills and knowledge they need to care for people who use the service. A robust recruitment procedure is now in place to ensure all the required preemployment checks are undertaken prior to new staff starting at the home to prevent people who use the service from being put at risk. All staff have either completed or are booked on the training provided by the local Council about the ‘Alerters’ guide, which tells staff how to report any suspicions of abuse. Pre-admission assessments are now completed in full to determine if the home is able to meet the needs of the proposed person and they are also confirming this in writing to the person who is planning to move in. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 7 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. Sceats Memorial Home DS0000016573.V354905.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 Sceats Memorial Home DS0000016573.V354905.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 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home now has in place an admission procedure that ensures prospective people receive an assessment of their needs and assurance these can be met. EVIDENCE: Following the last inspection the home has made amendments to their Service Users Guide to include about how people who use the service access and pay for additional services that are not provided in the fees. The home combines their Statement of Purpose and Service Users Guide into one document and people who use the service all have a copy. At the last inspection the home had accepted a new person without completing a full assessment and obtaining additional information. This resulted in the person eventually being moved to a more suitable placement. Following this the management of the home have reviewed their admission procedures to include devising letters to send to prospective people to confirm if the home is Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 10 able to meet their needs and if the home feels they are unable to. Since the last inspection one person has been admitted to the home and this was on an emergency basis. This person visited the home for an assessment of their needs and immediately following this the home confirmed they could meet their needs and they stayed at the home. The assessment was examined as well as a copy of the letter they sent confirming the home can meet their needs. This assessment contained information about the care needs of this person and information about their hobbies and social activities. This person was spoken to and confirmed that they had stayed at the home following their assessment. A friend chose the home for them, as they were not able to do this at that time. They were able to confirm they had a copy of the homes Statement of Purpose and Service Users Guide. Four people who use the service who returned their surveys were asked if they had received enough information about the home before they moved in to decide if it was the right place for them, and all four said ‘yes’. One person said “we researched various homes before deciding on this home”. Standard 6 does not apply, as the home does not provide intermediate care. Sceats Memorial Home DS0000016573.V354905.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 & 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people who use the service receive is based on their individual needs. However some areas of record keeping in relation to care plans and medication need to improve. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The care of three people was examined in detail and this includes reading care records, speaking to the person where able and speaking to staff. All three people had an assessment of need in place that contained personalised details about the care they require. Evidence was seen that these are reviewed on a monthly basis. Two people had signed their assessments. From these care plans are devised. All three people had care plans in place for each assessed need. However one person’s care plans lacked individual details about their care needs and what assistance is offered. The other two peoples care plans contained this information. Reviews were seen for all care plans and people had signed their care plans. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 12 Risk assessments were in place for moving and handling and falls. Again reviews were seen of these. One person requires a risk assessment as they wish to have a hot water bottle at night. Care staff write in the care records for each person at the change of each shift. Evidence was seen of health professional involvement in people’s care. A Psychiatrist was visiting on one day of the inspection and the GP on another. Community nurses and Community Psychiatric nurses visit people at the home when required. People also have access to a Chiropodist that visits the home and other health professionals as required. These three people were spoken with and were satisfied with the care they receive from the care staff. People who use the service were asked in the surveys if they receive the care and support they need and two said ‘always’ and two said ‘usually’. One person had written “first class care”. People were also asked in the survey if they receive the medical support they need and three people said ‘always’ and one person said ‘usually’. The medication systems used by the home were examined. The home uses trolley’s to transport medication around the home and the Registered Manager said they use a lockable box for areas that are not accessible to the trolleys. Two medication rounds were observed in the dining room. One member of care staff was very patient in their approach to people when assisting them to take it and ensured the medication did not touch their hands, they then went back to sign the Medication Administration Records (MAR). The second member of care staff was observed dispensing the medication into their hands before putting it into the pot. This is poor practice from infection control procedures and can place the member of staff at risk of absorbing the medication. Records were seen for medication received into the home and for medication returned to the local pharmacy. All MAR were checked and several had gaps where no entry had been made so it was difficult to determine from the records whether the medication had been given or not. An audit of one of these ‘gaps’ was undertaken and this included counting the medication in line with how many doses had been given, it was found that it had been given. The home must ensure that accurate recording is maintained. A number of people who use the service had hand written entries on their Medication Administration Records, but it was difficult to ascertain if they had been checked and signed by a second member of staff. The Registered Manager was certain they had but agreed to ensure the second member of staff signs where it is obvious they are checking the entry and not for receipt of medications. Dates of opening were seen on boxes of medication, liquids and eye drops. Controlled medication was checked against the records and found to be in order. Consideration should be given to the home auditing this on at least a monthly basis as part of their medication audit. A member of the management team does audit the MAR daily to pick up on any gaps and a member of care staff is allocated each day to ensure the trolley and cupboards are in order. This is very good practice, however the home should consider auditing all Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 13 areas of their medication on at least a monthly basis and this then can be used as part of their quality assurance procedure. Care staff at this inspection confirmed they have to undertake training prior to being able to administer medication. A medication reference book and reference sheets for individual medications are available for care staff use. The home still needs to devise care plans for people who receive ‘as required’ medication. Since the last inspection the home has implemented assessments for people who wish to self-medicate. The home is looking to review the format they are using at present, as they do not feel it is detailed enough. From discussions with a number of people who use the service, the staff respects their privacy and dignity. Staff were observed knocking on people’s door prior to entering. Sceats Memorial Home DS0000016573.V354905.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 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle and more able people can plan and undertake their own activities. However some people feel that a lack of planned or a structured activities programme means their recreational interests are not being met. EVIDENCE: From talking to a number of people who use the service the feedback in relation to activities is mixed. Some people said they are happy to make their own and do join in the activities provided by staff. Other people said that there are minimal activities and they would like more. The care staff provide activities once they have completed their caring role. No activities were seen taking place during the inspection. The hairdresser was visiting the home on one of the days of the inspection and a large number of people were looking forward to having their hair done. The home has a monthly church service if people wish to attend. One person who uses the service has moved to this country many years ago and to maintain their culture they are visited regularly by other people from Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 15 outside the home who are also part of their culture. At Christmas they came to the home and sang songs, which the Registered Manager said that other people who use the service also took part in. People who use the service who returned surveys to us (The Commission) were asked if the home provides activities they could take part in; two people said ‘always’ and two people said ‘sometimes’. Four people attend day centres outside the home and two people said how much they enjoy them. Visiting to the home is not restricted and visitors were seen during the inspection and people who use the service confirmed this. A number of rooms used by people were seen and these were all personalised and people confirmed that they are able to bring in items of furniture with them. People said they are able to make daily choices with in the confines of living in a care home. People said they can choose what they have to eat, where they eat it and what they do with their time each day. The home still operates on a four-week menu rotation as at the last inspection and the home can cater for people who require a therapeutic diet. A breakfast time, lunchtime and evening meal were all observed. People who use the service were offered a number of choices for their breakfast and evening meal. At lunchtime people are offered choices if they do not like what is on offer. People are offered as much food as they wish to eat. The home has a dining room assistant who serves people and they were seen to be very attentive. All mealtimes were seen to be a sociable event and the Manager on duty eats their meals in the dining room with people who use the service. A lunchtime meal was sampled and found to be very tasty. People who use the service who were spoken to had mixed comments about the food. Some people said it was “very good” and one person said “this cook makes the best cakes and puddings” and other people said it varied from day to day. Some people felt the type of meals on offer were of the same variety where as other people were very happy. People who use the service were asked in their survey if they enjoy the meals provided and one person said they ‘always’ like the meals and three people said ‘usually’. An inspection of the kitchen took place to review the health and safety checks and food records. All were in place and up to date. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns and they have access to a complaints procedure. There are now systems in place to ensure people who use the service are protected from possible risk of harm and abuse. EVIDENCE: The home has not received any complaints since the last inspection in August 2007. A copy of the homes complaints procedure is displayed on the notice board. People who use the service each have a copy of the homes Statement of Purpose and Service Users Guide where a copy of this procedure is included. In their surveys people all said they knew how to make a complaint and from speaking to people during the inspection they would talk to the Registered Manager if they were unhappy or had any concerns or complaints. At the last inspection the vast majority of staff had completed a distancelearning course in relation to abuse, however there was no information or training for staff about the local reporting procedures. Following the inspection the Registered Manager and Deputy Managers have completed the one day ‘enhanced’ adult protection training provided by the local council. Six care staff have undertaken the half day training in the ‘Alerters’ guide and places have been booked for all staff to attend this training throughout the year. A Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 17 copy of the local guidance and procedures for reporting any suspicion of abuse is now available to staff. This is great improvement and the home has also updated their policies and procedures in relation to protection and abuse. Care staff spoken with confirmed that some of them have undertaken this halfday training. At the last inspection the home was not undertaking Criminal Records Bureau Disclosures (CRB) and POVA checks on all new staff. The home has now rectified this situation and were able to provided evidence that all new staff appointed since the last inspection have had these checks carried out. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service live in a home that is well maintained, clean and comfortable. EVIDENCE: A tour of parts of the environment took place with a numbers of room seen that belong to people who use the service. The home has started their building work to the front of the property, which has resulted in the old ‘sun lounge’ being demolished to make way for a new larger communal room. People who use the service said the building works are noisy as both communal rooms face the ongoing work. The home should consider displaying information about the ongoing works for people in the home and visitors so they are kept up to date and know what to expect. The Registered Manager said that they have told everyone what is happening and it is particularly noisy at the moment due to the foundations being put in but this should be over Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 19 very soon. People’s rooms were individualised to them and their personal possessions were on display. Aids were seen around the home to assist people and these included toilet frames, bathing aids and stair lifts. A number of people who use the service were asked if they were happy with their rooms and on the whole they said yes. The home has redecorated their bathrooms since the last inspection as their appearance made them look cold and uninviting and very clinical. A number of maintenance issues were identified at this inspection and need to be addressed, 1. Toilets number 102 and 204 have cardboard over the windowpane where damaged to this has taken place. They must be replaced. 2. The outside door of the kitchen has a cracked windowpane, which has been taped up, and paint is chipping off. This must be addressed, as it could be a security issue for the home. The Registered Manager said that they have plans to replace this door as part of the building works. 3. A number of toilet frames were rusty in places and need to be repaired or replaced. 4. The ceiling in the corridor by toilet 102 has cracks in it and the paintwork is tired. At the last inspection we raised concerns about the infection control procedures that were undertaken by staff as they placed people who use the service and staff at risk. The Registered Manager said they have plans to provide staff with training in infection control once a number of other courses have been completed. No concerns were raised at this inspection. Staff were seen wearing protective clothing but need to be reminded of this when serving meals. The domestics were doing their best to keep on top of the extra cleaning due to the building work. People who use the service were asked if they were happy with the cleanliness of the home and they said ‘yes’. In the surveys returned by people to us three people said the home is ‘always’ clean and fresh and one person said ‘usually’. No concerns were raised by people about the laundry service and people said they were happy with their clothes and how they are laundered. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is confident that the number and competencies of the staff on duty meets the needs of the people who use the service. And now with the implementation of an ongoing training programme for staff this will assist them with the skills and knowledge to do this. EVIDENCE: The Registered Manager said there have been no changes to the care staffing levels at the home since the last inspection. Additional hours have been provided for a part-time laundry assistant/activities and they will also help out at meal times to reduce the burden on the care staff. Also extra administration hours have been provided to help the management team. The home has been using agency staff to cover vacancies but the Registered Manager said they use the same agency and they usually have the same member of care staff for consistency. Ancillary staff are available to support the care staff. People who use the service who were spoken to all praised the staff and one person said, “The staff look after my every need”. The Registered Manager said that three care staff have got NVQ 2 and one has got NVQ 3 qualification in health and social care. Four staff are doing the NVQ 2 and two are doing NVQ 3. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 21 The personnel files of three new staff appointed since the last inspection were examined. All had the required recruitment checks in place. At the last inspection the home was not doing this. This is a vast improvement and helps to reduce the risks to people who use the service. At the last inspection the home could not demonstrate that new staff were undertaking induction training. The records relating to the three recently appointed staff were examined and the home was able to provide evidence that they all undertook induction training with an external training centre and in house. This again is a vast improvement. The home is looking to review the in-house form they are using as they feel it is not right for the home at the present time. All new staff are given mentors or supervisors and the home was able to demonstrate this. The home was able to demonstrate that they have an ongoing training programme in place. This includes food hygiene, dementia and abuse. One member of care staff requires an up date in moving and handling as they last did this course in July 2006. Certificates were seen of staff training and staff spoken to confirmed that training is provided. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. Once the home has implemented its quality assurance system; this will help to ensure that the service is run in the best interests of the people who use the service and any shortfalls will be identified and addressed. EVIDENCE: There have been no changes to the management of the home since the last inspection. The Registered Manager has the NVQ 4 training and the Registered Managers Award. The home has two Deputy Managers who run the home in the absence of the Registered Manager. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 23 People who use the service who were spoken to during the inspection said they could go to the Registered Manager if they had any concerns and complaints. The Management of the home are kept updated about the needs of the people who use the service by shift handovers and staff are able to access the managers at anytime during their shift. The home also has an on call system as the Registered Manager was contacted in the early hours of the morning during one of the inspection days for advice about the condition of one person. The Registered Manager said they would attend the home if necessary. Since the last inspection the home has worked very hard to meet the requirements issued and we now expect to see the improvement continuing to ensure the home is run in the best interests of the people who use the service. The Registered Manager said they still have work to do on their quality assurance procedure but have sent out questionnaires to relatives and some have been returned and the are going to collate the results. From some of these views changes have been made but the home has not documented it, as this would form part of their quality assurance. Regulation 26 visits are being carried out and copies of these reports were seen. The home is undertaking many checks that can be used as part of their quality assurance but they need to find ways of incorporating them all together. The home has secure systems in place for managing people’s monies, with the appropriate records and receipts kept. At the last inspection the home was not able to demonstrate that all staff were receiving formal supervision especially night staff. At this inspection the home has put a plan in place to meet the recommended six sessions per year and records were examined of some staff supervision session. All staff have appraisal and these take place six monthly. Records were seen of some recent appraisals and the Registered Manager said they write to the member of staff to inform them when it is due to take place. This is a vast improvement on the last inspection and the home was able to demonstrate that night staff are also receiving formal supervision on a frequent basis. The servicing of equipment and ongoing maintenance was not examined in detail at this inspection as it was all in place at the last inspection. However the home was not able to provide evidence that their boilers had been serviced or that they have an up to date fire risk assessment and evacuation procedure. The Registered Manager said that all boilers are going to be replaced as part of the building works. The home has obtained the services of an external expert to complete their fire risk assessment and a letter was seen confirming this and that the report was due to be sent shortly. The Registered Manager has also written to us (The Commission) to inform us that the requirements issued by the local Fire Service have been addressed. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 24 Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 3 X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? yes 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 The registered person must ensure that people who use the service have care plans in place for medication that is ‘prn’ or ‘as and when required’. This will ensure all staff follows the same procedure. This requirement remains outstanding since the last inspection. Staff that administer medication must not dispense the medication into their hands as this is an infection control risk and places people who use the service at possible risk of cross infection. Detailed records of all medication administered to people who use the service must be kept. This will help to ensure that people receive the correct levels of medication. The home must address the maintenance issues identified in the Environment Standards to ensure people who use the DS0000016573.V354905.R01.S.doc Timescale for action 30/03/08 2. OP9 13(2) 17/01/08 3. OP9 Sch 3 (3i) 17/01/08 4. OP19 23(2b) 30/03/08 Sceats Memorial Home Version 5.2 Page 27 5. OP30 18 6. OP33 24(1) service live in safe and pleasant environment. The registered person must ensure that staff receives training pertinent to the needs of the people who use the service. This is to ensure the needs of the people are met. (This relates to dementia training, moving and handling, infection control and food hygiene). This requirement has been partly met since the last inspection. The registered person must devise a quality assurance system to ensure the home is run in the best interests of the people who use the service. This requirement has been partly met since the last inspection. 30/06/08 01/04/08 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. Refer to Standard OP9 OP19 Good Practice Recommendations The home should audit all their Medication systems used on a monthly basis as part of their quality assurance procedure and maintain records of this. The home should display information about the ongoing building works and keep this updated to ensure people who use the service and visitors are aware of what is taking place. Sceats Memorial Home DS0000016573.V354905.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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