Inspection on 27/06/08 for Silverpoint Court Care Home

This inspection was carried out on 27th June 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.

Other inspections for this house

Silverpoint Court Care Home 03/05/07

Silverpoint Court Care Home 17/05/06

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 Silverpoint Court Care Home Silverpoint Marine Canvey Island Essex SS8 7TN Lead Inspector Pauline Marshall Unannounced Inspection 27th June 2008 09:10 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 Silverpoint Court Care Home DS0000066764.V367218.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. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Silverpoint Court Care Home Address Silverpoint Marine Canvey Island Essex SS8 7TN 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) 01268 515564 01268 510404 silverpoint.court@nellsar.com Nellsar Ltd Mr Ajam Bye Karim Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2007 Brief Description of the Service: Silverpoint Court provides residential accommodation for thirty-six older people. The home is a purpose built property with accommodation on three floors with a passenger lift allowing access to each floor. The home’s facilities include two large lounge areas on the first and second floors and the main dining room on the ground floor. There are thirty single and three double bedrooms and several toilets and bathrooms. The home is situated in a residential area of Canvey Island and close to the seafront. A large conservatory that is surrounded by a secure garden with a raised flowerbed and patio area with a pagoda is nearing completion. A copy of the homes Statement and Purpose and Service User Guide is available on request and is provided to all people with an interest in living at Silverpoint Court. Current fees range from £450 to £500 per week and there are additional variable charges for hairdressing, chiropodist and newspapers Silverpoint Court Care Home DS0000066764.V367218.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. This was an unannounced key inspection that lasted eight and a half hours. The process included discussions with people living in the home, their relatives, the manager and the staff; an examination of a random sample of the files (including those of staff and people living in the home) and some of the records that the home is required to keep. The inspection covered all of the key standards and included a tour of the property. The manager completed his annual quality assurance assessment (AQAA) and information from this has been used throughout this report. The AQAA is a form used by the manager to carry out a self-assessment of how well the outcomes of people using their services are being met. An expert by experience assisted us with the inspection and she focused on how it feels to live at Silverpoint Court, the activities that are offered and the quality of the meals; her valuable input has been included in this report. Surveys were sent to the manager to distribute to twenty people who live at the home, twenty of their relatives, six health and social care professionals and twelve care staff. At the time of writing this report surveys had been returned from eleven people living in the home and five of their relatives; they contained mainly positive comments about the home and are reflected throughout the report. To date no other surveys have been returned. What the service does well: The manager provides people with good up to date information on the service provided at Silverpoint Court. A thorough assessment of needs is carried out before a person is admitted to make sure that the home can meet their needs. People have the opportunity to visit the home to make sure that they like it and they are able to stay at the home on a short trial basis just in case they change their mind. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 6 The manager deals with any concerns that are raised with him and ensures that all major complaints are recorded in his complaints records. Staff has recently received updated adult safeguarding (POVA) training. The manager offers people a good standard of well-maintained accommodation that is clean and tidy. People are offered a choice each day from a variety of healthy meals. The manager has made many improvements to the home since taking up his post and these include the security of the gardens, the new conservatory, the raised flowerbeds and the new patio area and pathways around the building. Many of the staff either have or are working towards NVQ qualifications. What has improved since the last inspection? What they could do better: The care plans must be fully completed and give detailed information on how staff is to meet peoples needs; they must include the persons view and wishes and be regularly reviewed. All of the care files must have an up to date photograph of the person and any health charts in place must be fully completed to ensure consistency for Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 7 people’s health care. Risk assessments must include plans on how to manage any identified risks and they must be regularly reviewed. Medication practice must be improved and staff must ensure that medication is taken before they sign for it. The medication records must be correctly completed to minimise the risk of any mistakes. The manager should make sure that minor complaints are fully recorded. The manager should make sure that the worn stair carpet is replaced as soon as possible. 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. Silverpoint Court Care Home DS0000066764.V367218.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 Silverpoint Court Care Home DS0000066764.V367218.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to receive a thorough pre-admission assessment and up to date information on the home prior to their admission providing them with positive outcomes. EVIDENCE: The Statement of Purpose, Service User Guide (welcome pack) and the homes brochure are detailed and contain sufficient information to enable people interested in living at Silverpoint Court to make an informed choice on whether or not it will meet their requirements. The welcome pack can be translated into other languages if required. Since the manager came into his post in February 2007 a full pre-admission assessment for each person wishing to live at Silverpoint Court is carried out; Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 10 this is in addition to any assessments that have been carried out by other professionals. The care file of the most recent admission contained a thorough pre-admission assessment, which was informative and very detailed and covered social, physical and psychological areas of need. The pre-admission assessments carried out by the previous manager were stored in the archive files and were not available for inspection. People living at the home said that they had the opportunity to spend time there before they made the decision to move in and that their family also had the opportunity to look round the home and help them to make that decision. The manager said in his annual quality assurance assessment (AQAA) that “all admissions are accepted on a trial basis for two – four weeks to allow residents ample time to decide whether to become a permanent resident or not”. Silverpoint Court does not provide intermediate care. Silverpoint Court Care Home DS0000066764.V367218.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inconsistent approach used in the care planning system could potentially affect any positive outcomes for people living in the home. Medication is generally well managed but some areas of practice do not fully protect people. EVIDENCE: The care plan format has been reviewed in the past year and the manager said that staff was in the process of updating the care plans using the new format. The new care plan format allows for a more detailed description of how staff is to meet people’s needs. Four care files were examined and the care plans varied on the level of information contained within them. One of the care files included a personal fact file which provided a detailed account of what the persons life had been like, what they enjoyed and a history of events that had taken place; other files examined did not contain this information. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 12 There were different shortfalls on the care files that were examined and these included a list of prescribed medicines only in the medical history section, a declaration of involvement in the care plan unsigned and undated, an uncompleted weight chart where the care plan had identified a need for weight to be taken weekly and parts of one care plan were missing altogether. One of the care files examined contained a moving and handling risk assessment for a person who uses a hoist; the risk assessment did not provide details on how the identified risks were to be managed. There was no photograph of the person on the care file of the most recent admission to the home; the manager said that he had run out of film. The manager said in his annual quality assurance assessment (AQAA) “we put together a detailed care plan from a comprehensive pre-admission assessment and our care plan has seen great improvement, we shall continue to develop this area further”. People spoken with and surveyed said they were happy with the care they received at Silverpoint Court and one survey said, “I am satisfied with the support that I get here”. One relative said in their survey “the home meets all my relatives needs and if I am needed by my relative the home always phones me and I visit twice a week”. People living in the home said that they felt that their healthcare needs were met and on looking in the care files this was evident in most cases, however the new care planning system provides a document for all health care visits to be recorded and these were not completed on all of the care files that were examined. Silverpoint Court has a visiting chiropodist who was at the home on the day of the inspection; people spoken with said they were happy with the treatment and that it was carried out privately. The home has a medication policy dated February 2008 and an update in staff training had taken place the day before the inspection. Senior staff is responsible for ordering and administering the homes medication. The manager said that he has recently changed to a different pharmacy that provides the medication on a weekly basis in a monitored dosage system with printed MARS (medication administration sheets). The manager said that the previous pharmacy had provided a photocopy of the medication administration sheets and that this had led to minor errors in recording. The senior staff enters any medication due for return in their returns book and the pharmacist signs to confirm receipt; returns are stored in a locked metal cupboard in the office. The medication keys are now kept separate from the main bunch and senior staffs is responsible for them throughout their shift. An Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 13 observation of the medication round took place together with a check of the medication administration records. The member of staff administering medication to one of the people living in the home did not stay with them to witness they had taken it; the medication administration sheet was signed to confirm that the medication had been taken. There was a staff signature on the wrong date and a blank space where staff should have signed the medication administration sheet the previous night. People who were prescribed as and when prescribed (PRN) medication were being given the maximum dose on a daily basis. There was no photograph of the person on the medication administration records. People living in the home and their relatives spoken with said that “staff were very kind and it’s as nice a place as anyone could ever wish for” and one person surveyed said “I find this place very acceptable as do the other folks”. People spoken with said that staff respects their privacy and that the staff and manager always treat them with dignity and respect. Staff were observed treating residents respectfully throughout the day. Silverpoint Court Care Home DS0000066764.V367218.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect good outcomes as they are offered a range of activities both in the home and out in the local community and they can expect to be provided with a healthy and nutritious diet. EVIDENCE: Silverpoint Court employs a part time activities co-ordinator that works each weekday afternoon from 1pm until 4.30pm exclusively to arrange activities for people living in the home. The manager said in his annual quality assurance assessment (AQAA) “we have an excellent programme of activities and each resident has a meeting with the activity organiser and plans their social activities to suit him or her”. The staff said that the activities offered at Silverpoint Court includes, bingo, quizzes, film shows and occasionally trips out. People spoken with said that there had been a recent visit by Prince Edward to the yacht club opposite the home and staff had taken a few people over to meet him; there was Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 15 photographs of people with Prince Edward displayed on the dining room wall. The manager said that the yacht club had arranged a Christmas meal for people to attend and people spoken with confirmed that the meal was a most enjoyable experience. The expert by experience spent some of her time speaking with people living in the home and they told her that there are no church services coming into the home, nor do they go out of the home to any church service. The manager said in his annual quality assurance assessment (AQAA) “residents are assisted to attend the church on special occasions and take part in religious functions at the home”. The manager said that the Vicar used to visit Silverpoint Court every 4th Wednesday until she left in March 2008 and that her replacement has visited three times since then, the last time being on 23rd April 2008 and as he was now on annual leave the next service is planned for 6th August 2008. There are two lounges on separate floors of the building and a majority of people use the first floor lounge; there was a film show taking place on the afternoon of the inspection. People spoken with after the show said “I love watching old movies and it is much better now we have such a big television”. People who live at the home said in their surveys “I enjoy the entertainment, I enjoy bingo and watching TV and I am satisfied with the activities”. Other people said that they had the opportunity to participate but preferred not to, though have done so when they felt like it. The activities co-ordinator said that she provides a different activity each day and that a record of what has occurred and who has attended is kept in her diary. The diary listed the people that attended each activity and it was noted that it was generally the same group of people that participated regularly. The activities co-ordinator said that in the time she had available to her she was not able to offer people more than one activity daily and that these included film shows, bingo, quizzes, sing-songs, music, hair sessions and that sometimes she was able to go out for a walk with individuals. The activities co-ordinator said “when I start work I set up the activity and gather people up and we have a little break with a cup of tea mid way and the time the activity has finished and I have assisted people back to their rooms there is no time for any further activities to take place”. A discussion took place around the possibility of holding smaller more focused sessions to enable more people to participate. The expert by experience said in her report “all comments both from staff and residents was that this activities person has a very positive outlook, is well Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 16 liked and the sessions are looked forward to”. The expert by experience also said in her report that there was no list of planned activities either at the information point or anywhere else that she could see. People spoken with told the expert by experience that bingo; quizzes and the other entertainment such as singers are popular. The manager said that a large conservatory is under construction at the rear of the dining room and is due to be completed within weeks. The conservatory leads onto a secure garden, patio and seating area and there will be a raised flowerbed for people living in the home to plant flowers if they wish. The manager said that he would be purchasing new garden tables, chairs and parasols when the conservatory is complete. People living in the home said they are looking forward to using both the conservatory and the garden. The manager said that there is a range of cane conservatory chairs that have recently been recovered and they will be available in the conservatory on its completion. People living at the home said that they were able to see their visitors when they wanted and that they could always see them in private if required. Relatives of people living in the home confirmed this and one said in her survey “I never have a set day or time to visit and go and stay as long as I choose”. People said they were able to bring small personal items with them when they moved in and this was evident in people’s individual bedrooms. One person using the service said in their survey “I am 90 years old and I still have my memory and I find everyone here always ready to listen from the laundry staff to the top”. Relatives said in their surveys “my first impression of the home was excellent and it has lived up to my expectations. Silverpoint Court displays its menus in the reception area and they are changed on a four weekly cycle to suit the requirements of people living in the home. People spoken with said that the food was always nice and plenty of it and they could always have an alternative if they did not fancy what was on offer. Relatives of people living in the home said in their surveys “there is always a choice to either dine alone or in the dining room and excellent fresh food is provided that is cut up for my relative as they cant see to do it properly”. People living in the home said in their surveys “I like the meals and am always offered an alternative; kitchen staff are very kind and helpful”. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 17 The expert by experience focused on the meals provided at Silverpoint and the following is an extract from her report: The Kitchen The cook I spoke with was very pleasant and helpful and willing to answer any queries. One cook and one assistant cook work in the kitchen 7 days each week between the hours of 07.30 and 14.00. The kitchen was clean, tidy and organised. At 11.15, the lunch was in the process of being cooked. The choice today was fried or baked fish, with either chips or mashed potatoes and peas. There were also sausages being cooked as an alternative. The food for lunchtime meals are generally cooked freshly each day and, as the cook finishes work at 14.00, the evening meal is organised by the remaining staff. The evening meals, therefore, required less preparation than the lunchtime meal, some of which would have been prepared earlier by the morning cook. There was a good selection of food for the evening meal. Bread and butter pudding, bread pudding and cakes were always a winner and would be prepared by the cook. When asked whether there were any residents who needed to have special diets or food, I was informed that one of the residents was diabetic but no other resident had any sensitivity or allergies to any ingredients. One resident required the meals liquidised and that appeared to be no problem. The menu for the month is varied and is constantly monitored. Changes are made when a particular choice proves to be unpopular. The residents I spoke with all seemed more than satisfied with the food generally. The meal midday is a three-course meal and today the choice was soup, fruit juice or fresh fruit as a starter. Fish and chips generally are the main offer each Friday. I was shown the freezer where the majority of the weekly supply of meat is kept. The meat is delivered fresh each week and is then frozen on the day of delivery and used throughout the week. Fruit and vegetables are delivered twice each week. The fridge was used for each day and items within the fridge were clearly date labelled. Fresh melon was being cut up for lunch and apples were ready to be cut up. Dining Room Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 18 The dining room is a large and spacious room. Large double doors into the room enabled easy access for wheelchairs and walking frames. It is a very pleasant room, nicely decorated. Several windows were open as it was a warm sunny day. Background music was being played and this was pleasant and not intrusive. The tables, set for four residents, were covered with linen tablecloths and napkins. Paper napkins were also available for any resident. At the table I sat, three variations of the meals available were served. The residents appeared to enjoy the food. Everything was eaten. My meal was well presented, neither too cold nor too hot and enjoyable. Staff was visible and available throughout the meal and assisted whenever required. The majority of the residents dined in the dining room but some residents, who require more assistance with their eating, remained on the second floor or in their rooms. The manager undertook a food survey in April 2007 and as a result of this amended the menus to reflect people’s wishes. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. People can be confident that their complaints will be dealt with effectively and that they will be protected from abuse. EVIDENCE: The manager has a good complaints procedure that can be produced in a variety of formats including other languages, Braille, audio and pictures and a written copy is displayed on the homes wall behind the visitors signing in book. The last complaint was received on 31/1/08 and was dealt with appropriately, the manager kept all of the relevant people informed. There was no record kept of minor concerns. The manager said that he would record these in the future. People said that they felt that they could share their concerns either with staff or with the manager. Relatives of people living in the home said in their surveys “ I made a complaint and it was dealt with, I received a letter of apology given to me at a meeting with the manager” and “my concerns are always listened to and addressed”. The manager said in his annual quality assurance assessment (AQAA) “our survey reveals that residents feel free to complain when they have concerns knowing that their complaints will be taken seriously and dealt with”. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 20 An anonymous complaint was received at the CSCI office; a copy was given to the manager so that he could carry out an investigation into the allegations; the manager said that the outcome of the investigation will be notified to the CSCI. The adult safeguarding (POVA) policy was reviewed in January 2008 and works within the Essex County Council’s procedures. The manager said in his annual quality assurance assessment (AQAA) “staff are made aware of our whistle blowing policy and all staff receive training in Safeguarding Vulnerable Adults”. All of the staff files examined contained evidence that staff had recently attended adult safeguarding (POVA) training. Staff spoken with showed a good awareness of adult abuse and was familiar with the homes whistle blowing policy. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 21 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. This judgement has been made using available evidence including a visit to this service. People can expect to live in a safe, homely, clean and comfortable environment. EVIDENCE: The home was purpose built in 1995 and is situated just off Canvey seafront; both lounge areas and some of the bedrooms have uninterrupted sea views. The home is nicely decorated and individual rooms are personalised. People spoken with said “the home is marvellous, there is plenty of choice and enough to do and it is always so clean and tidy and we enjoy living in such a nice place”. The manager said in his annual quality assurance assessment (AQAA) “we have purchased a new flat screen TV, a hi-fi, a DVD and projector and we have Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 22 renewed some of the bedroom carpet; there is also a programme for redecoration”. The manager said that new carpet had been laid in the downstairs hallway and new chairs had been purchased for the lounge areas. People spoken with said that the new larger TV was much better for them and that the new furniture was comfortable. The home employs a handyman for 24 hours a week and routine jobs are carried out by him. The stair carpet on the stairs near to the kitchen has began to fray on the treads; one relative made a comment about this in their survey. The manager said that a replacement of the stair carpet has been planned and he is waiting for a date for the work to be carried out and expects this to be soon. A new conservatory is in the final stages of being built; it leads off the dining room and has access into the garden area. The garden has a block-paved path all around the building and there is a raised flowerbed for people to plant flowers and plants if they wish to. There is also a patio area with a pagoda and the manager said he would be purchasing new tables, chairs and parasols for this area. People spoken with and their relatives said they were looking forward to the completion of the new conservatory and that the garden was looking “lovely”. One relative said in their survey “there is absolutely nothing I can think of that could be done to improve the care home as I find it to be perfect”. The manager employs four part time domestic staff that works sixty hours per week between them; the home was clean and tidy and no odorous smells were noticed. Two of the domestic team said that they had worked at the home for many years and that despite reaching retirement age they wanted to continue working at the home because of the lovely atmosphere. The relatives of people living in the home said in their surveys “the place is always spotlessly clean, I have never found it to be anything other than clean and tidy”. People spoken with said how nice the domestic staff were and we observed both domestic staff that were on duty interacting with people living in the home throughout the morning in a courteous, cheerful and pleasant manner. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 23 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. This judgement has been made using available evidence including a visit to this service. People can be confident that a qualified well-trained staff team will care for them. The manager has robust recruitment policies and practices. EVIDENCE: The manager employs a deputy manager (who had been in her post for one week at the time of the inspection), four senior carers, twelve care assistants and six bank carers. In addition to care staff the manager employs an activity organiser, two day time cooks, two evening cooks, four domestics, two laundry workers and a handyman. The rota showed that there is generally four care staff working throughout the day and three care staff throughout the night. There were occasions where the rota showed that three care staff was on duty in the day and there were other occasions where the rota showed that there were five care staff on duty in the day. The manager, the cooks, the domestics, the laundry workers and the handyman hours were all in addition to care hours. There was sufficient staff on duty to meet the needs of the people currently living at Silverpoint Court. Staff spoken with said they had completed their NVQ at level 2 and intended to undertake level 3 during the next year. The manager said in his annual quality Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 24 assurance assessment (AQAA) “we have accessed a training grant and many staff have completed NVQ2, moving on to NVQ3”. The AQAA showed that four staff has attained NVQ level 2 or above and that ten staff are working towards it and that 41 of the homes staff either have or are working towards the qualification. The manager carries out a thorough induction programme for all new staff. There was evidence of induction on all of the four staff files examined. All of the four staff files examined contained the documentation that is required in the regulations. The relatives of people living in the home said in their surveys “the staff are very caring people who work very hard making sure that people living in the home are well looked after and happy and I am aware of them having training courses and NVQ’s”. The manager said that since taking up his post £12,000 has been spent on staff training. The manager has prepared a training matrix and this identifies the training needs of his staff team. Each of the four staff files examined contained a range of certificates confirming that training had taken place. There was evidence that staff have recently undertaken training in care planning, medication, challenging behaviour, dementia, first aid, moving and handling, infection control, communication, fire and adult safeguarding (POVA). Staff spoken with confirmed that they have been attending lots of training in the past year and that they felt it was beneficial to their role. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to live in a safe well managed home that is run in their best interests. EVIDENCE: The manager has been in his post since February 2007 and has been the registered manager since 21/11/07; he is a trained registered mental health nurse and has owned and managed a care home in the past so has the appropriate knowledge and skills to run a home. The manager is nearing completion of the registered managers award. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 26 Since taking up his post the manager has installed a suggestion box in the reception area to allow for people living in the home, their relatives and staff to offer their opinions on how the home is run. The manager has also undertaken a food survey in addition to his annual review and has compiled a short report on his findings and amended the menus as a result of this survey. People spoken with confirmed that they were regularly consulted on the quality of the food and services at Silverpoint Court and relatives spoken with said that they felt included in any consultations. Regular regulation 26 provider’s visits to the home take place and were fully recorded. The home does not hold any monies for the people currently living there but has policies in place for if they do so in the future. There was evidence on all of four staff files examined that supervision takes place, however it has not been as often as required in the National Minimum Standards. The manager had identified this as an issue that needed addressing and has devised a new system where senior staff will undertake the supervision of care staff and the manager will provide supervision for ancillary and senior staff. Staff spoken with was aware of the changes and made a point of saying that they were able to talk face to face with both senior staff and the manager on a daily basis. With the exception of the homes gas safety certificate all health and safety checks had been carried out and certificates were in place. The annual gas safety check had expired on 2/6/08 and the manager said that this had unfortunately been overlooked and he arranged for this to be carried out immediately; the work was completed on 7/7/08 and a copy of the satisfactory certificate sent to CSCI. Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 27 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 15(1) Requirement To ensure that people get the correct level of assistance the manager must make sure that each person has a detailed care plan; all care plans must be regularly reviewed and amended to reflect a persons changing needs. This refers to the care plans needing details of the level of support people need, evidence that they have participated in its creation and the health charts that were not completed. Risk assessments must have a plan on how to manage any risks identified. This is a repeat requirement; the previous timescale of 15/8/07 was not met. To protect people from the potential risk of incorrect medication administration, the manager must make sure that staff carry out the administration process correctly and record their actions. DS0000066764.V367218.R01.S.doc Timescale for action 01/09/08 2. OP9 13(2) 08/08/08 Silverpoint Court Care Home Version 5.2 Page 29 This refers to medication signed for on the wrong day and staff leaving a person with medication without ensuring that they had swallowed it. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations It is good practice to keep a record of all complaints therefore it is recommended that the manager keep written records of any minor concerns/complaints in his complaints records. To minimise any potential risk to people living and working in the home it is recommended that the worn stair carpet be replaced. 2. OP19 Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 30 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 Silverpoint Court Care Home DS0000066764.V367218.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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