Inspection on 17/04/07 for Spratslade House

This inspection was carried out on 17th April 2007.

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

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

Other inspections for this house

Spratslade House 05/01/10

Spratslade House 11/11/09

Spratslade House 14/07/09

Spratslade House 27/05/09

Spratslade House 18/02/09

Spratslade House 30/10/08

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Spratslade House Belgrave Avenue Dresden Stoke-on-trent Staffordshire ST3 4EA Lead Inspector Mrs Irene Wilkes Key Unannounced Inspection 9:15 17th April 2007 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 Spratslade House DS0000068917.V329717.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. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spratslade House Address Belgrave Avenue Dresden Stoke-on-trent Staffordshire ST3 4EA 01782 311 531 01782 311 532 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) Pearlcare (Spratslade) Ltd Mrs Janet Ann Bentley Care Home 30 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (30), Physical disability over 65 years of age (3) Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection New service Brief Description of the Service: Spratslade House is located in Stoke On Trent, Staffordshire and is accessible via public transport, and also has all local amenities close by. The large mature detached property provides residential accommodation for 30 older people. The home’s registration category also enables the home to provide a service for individuals with dementia needs and also people who have a physical disability. Corridors and doorframes are of a suitable width to accommodate people who use wheelchairs. Ramp access is also provided. The two-storey property offers 30 single occupancy bedrooms, 28 of which are equipped with an en suite facility. Bedrooms are located on both the ground and first floor. The installation of two passenger lifts allows residents access to all facilities within the home. Bathrooms and toilets are situated on both the ground and first floor and are found close to bedrooms and communal areas. All bathrooms are equipped with an assisted bath to promote the independence of residents who have restricted mobility. The home is divided into units, having a small kitchen adjacent to each, allowing residents access to drinks and light snacks. Three lounges are provided on the ground floor that are pleasantly decorated and equipped with essential furnishings and items to allow relaxation, and to enable residents to socialise with other people living in the home. There are sufficient dining areas within the home. Residents are also able to have their meals in their bedrooms if they so wish. All meals are prepared and cooked within the home. Residents have access to a pleasant and safe garden area. Sufficient parking is available at the front of the property. Staffing is provided on a 24-hour basis by an experienced staff team who ensure the continued support of all residents. The home has achieved the Investor In People award (IIP). The homes fees are between £354 and £415 per person per week. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken over 4 days in April 2007 by 1 inspector. This consisted in time spent in looking at the information provided by the home in a pre inspection questionnaire, looking at relatives and relatives survey forms that were returned, a full day spent on an inspection visit, with the remainder of time spent in gathering all of the information together and in writing the report. 4 residents returned a questionnaire, completed with the assistance of their relatives. 7 relatives comment cards were returned. The majority of residents were spoken to during the inspection visit, with 3 people talking more extensively about their life in the home. 2 relatives kindly agreed to speak to the inspector about their views about the care provided. 2 staff were interviewed and their training and knowledge about the residents and the promotion of good practice were discussed. The way that staff assisted and responded to the residents was discreetly observed throughout the visit. Records relating to residents, staff rosters, recruitment and training, and health and safety records such as those relating to fire safety were all looked at during the day. The manager provided assistance throughout the visit, supported by a senior member of staff. A discussion and feedback was provided to the manager and the Area Manager who was visiting on the day. What the service does well: All of the feedback received from residents and their relatives was very positive about all of the staff in the home and the way that they are treated. ‘‘Care exemplary.’ ‘Mum is well cared for by staff who are helpful and understanding of her needs.’ ‘I feel the home provides very good care for my mother.’ ‘Staff are continually asking if I’m all right, and they say that I must tell them if I’m not well. They make sure care is private. The staff are all very nice. I’m contented here.’ Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 6 Prospective residents have their needs fully assessed so that they and the home can be sure that their needs can be met. Once they move in, this information and more discussions take place with the individual so that a care plan can be drawn up recording exactly what support is required. This means that people can have confidence that the staff will support them in the way that they choose. Good attention is paid to all healthcare needs. Any illness or issues are quickly responded to. The manager invites entertainers, choirs and local clergy into the home. There are occasional craft sessions including flower-arranging demonstrations, and there is a fortnightly keep fit session. Residents go out on trips to places of interest, and shopping and to concerts. Everyone said that the food in the home is good. ‘Mum has never made any complaints about food. She seems to enjoy meals and the tables are nicely kept and laid.’ ‘The meals have fresh meat and vegetables.’ 28 of the 30 bedrooms have an en suite. There are also bathrooms and toilets on both the ground and first floor, close to bedrooms and communal areas. All bathrooms are equipped with an assisted bath. The home is divided into units, having a small kitchen adjacent to each, allowing residents access to drinks and light snacks. One of these units is for people with dementia needs that has patio doors that open onto a safe enclosed seating area. All parts of the home are comfortably furnished. Staff are fully vetted before they commence working in the home. Once they start they receive very good initial training to equip them to meet the needs of the residents. Following this on-going training s provided in all of the required areas. 90 of the staff have a National Vocational Qualification in care. This shows the emphasis that has been placed in the past on providing well trained staff. The manager said that the aim of the new owner is to have all staff trained to this level. The manager was one of three registered managers under the previous ownership. She is now the only registered manager for the home as is usually the case, and she is well respected by residents, their relatives and staff alike. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Spratslade House DS0000068917.V329717.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 Spratslade House DS0000068917.V329717.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): Standard 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who consider using the home, and their representatives, have the information needed to make that choice in the knowledge that the home will meet their needs. EVIDENCE: Discussion with people at the home found that they and their families were advised to visit the home and stay for a while before making a decision to move in. Several had done this to reassure themselves that they would be happy living there. Examination of files of residents showed that people had their needs assessed before they moved into the home. There was also information available from the Social Services Department, where relevant, about the person’s needs. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 10 This information, together with all of that gathered through discussion with the prospective resident and their families about their needs gave the home good information about what support the person would require. This assessment information was then used to develop an individual care plan. There were copies of letters sent to the prospective resident confirming that after these discussions the home considered that they could meet the individual’s needs. Spratslade House does not provide intermediate care, and so Standard 6 does not apply. Spratslade House DS0000068917.V329717.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): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The inspection of 3 care plans showed that they had been drawn up from the initial needs assessment. Each person’s needs were then reviewed monthly together with the care plan to ensure that the support being provided by staff was at the right level for the individual. Where needs had changed this was recorded and the care plan updated to reflect the required support. There were also individual risk assessments in place linked to the needs of each person, such as assistance with mobility, any individual health needs, and any needs arising from a person’s dementia. Evidence from the manager, residents and relatives confirmed that users of the service were involved in the review of their care plan where possible. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 12 Inspection of care plans showed that residents’ health is maintained and access to health care services is ensured. Care plans were detailed about support needs, including the maintenance of independence. Information provided by the home before the inspection showed that there was one resident with a pressure sore. The person’s records were looked at during the visit and these showed early involvement of the District Nurse. The sore had now healed. A relative comment card said ‘Mum had a sore and this was dealt with.’ Inspection also showed that advice is sought about promotion of continence and evidence was seen that the aids and equipment needed are provided. Relatives and users confirmed that the home responds quickly to any aspects of healthcare needs. All aspects of medication including the receipt, recording, storage, handling, administration and disposal of medication were discussed and inspected, including observation of the lunchtime medication round. All aspects were satisfactory. The policy and procedure for medication provision in the home was discussed with the staff member who was administering the lunchtime medication, and she had a good understanding of the home’s procedures and the importance of compliance. There was a full record of all staff who are able to administer medication, with signature and initials. There was a homely remedies list and it was also recorded in each individual’s care plan if any homely remedies had been brought in by the family. Evidence was seen that all staff that administer medication receive both internal and external medication training with annual refresher training. Everyone spoken with said that the staff treat them with respect and ensure that their privacy and dignity is respected. A typical comment was: ‘Staff are continually asking if I’m all right, and they say that I must tell them if I’m not well. They make sure care is private. The staff are all very nice. I’m contented here.’ Visitors were also confident that their relative was treated with respect, this confidence coming from what they had observed and what their relatives said about life in the home. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 13 The approach of staff to residents and visitors and staff interaction was discreetly observed throughout the visit. The staff showed respect to everyone at all times. They responded promptly to the call system and were seen knocking on bedroom doors. They were discreet when escorting people to the toilet, and arrangements in place for assisting people at mealtimes preserved their dignity. A discussion was held with the manager and the Area Manager about their views on how equality and diversity is approached within the home. Examples given were that they had assisted with the purchase of some special equipment for a person with sight impairment to assist in watching the TV, and talking books are borrowed from the local library. The home has developed some picture cards to assist people with dementia to recognise various foods, equipment etc. A monthly Holy Communion service is facilitated by the home. Another resident has a weekly visitor from her church. At present she chooses to see the visitor in her own bedroom, but the manager said that the use of the quiet lounge would be facilitated if she chose otherwise. They gave examples of responding to requests for food to be presented differently. For example a resident’s family said that their relative did not like sandwiches and would prefer the filling and the bread to be put separately on a plate. This had been facilitated. The Commission will expect the home to continue to focus on respecting all people equally and valuing and supporting their differences and the different choices that they may wish. Spratslade House DS0000068917.V329717.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): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about their lifestyle and the standard of meals is appreciated. For some people an increased availability of daily activities would be welcomed. EVIDENCE: Several residents spoken with said that they made their own choices about rising and retiring, and this was also evidenced in records in the care plans. Information provided by the home showed an extended breakfast time of 8am to 10am, but other mealtimes showed a set time. People said however that they were happy with the timing of meals. Residents and relatives confirmed that the home has visiting entertainers, a keep fit session is provided fortnightly, and flower arranging sessions and trips out to shops and garden centres are arranged. Several board games and dominoes are available, and sometimes a member of staff will undertake reminiscence therapy. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 15 The manager and a member of staff said that staff are encouraged to promote activities every afternoon, but they find it difficult to motivate residents. While this may be the case, several residents and visitors made comment about the lack of stimulation in the home. ‘We are sometimes bored – we could do with more to occupy us.’ Some relatives spoken with said that there were never many activities going on when they visited. One said that a number of residents had told her that they are bored and would appreciate something to stimulate them. This particular relative said that she kept highlighting in the quality questionnaire that she completed for the home that more activities are required, but that it is never addressed. Residents spoken with could not recall being asked about the type of activities that they would enjoy. The home is recommended to consult with the residents to seek their views about how social activities could be improved, for both males and females. Some discussion with relatives may also provide some fresh ideas about stimulating activities, and would also demonstrate the home’s commitment to positive development of the service. On a positive note one resident was seen throughout the day assisting with drinks and washing up in the kitchenette attached to the dining room. This was a good example of the home responding to an individual’s choices. Discussions with residents and relatives and examination of returned questionnaires showed that visitors are made welcome at any reasonable time. Residents said that their relatives and friends were encouraged to visit. There were several relatives visiting throughout the inspection and the home had a very relaxed atmosphere. Residents confirmed that they had been able to bring personal possessions into the home. Two residents’ rooms were seen and they were well personalised. One had a birthday the previous week and still had the helium balloons and cards on display in her room. The staff confirmed that they would stay there as long as she wished. Two residents confirmed that they knew that the home had records about their care needs and said that they were aware that it was their right to look at the records should they wish. Menu plans were seen that showed that the residents receive a varied and nutritious diet, with choices offered, and with meals available at regular Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 16 intervals. The cook confirmed the arrangements in place to respond to a residents need for a gluten free diet, and for meals for people who have diabetes. The lunchtime meal was discreetly observed. It was clear that residents were given ample time and that the meal was seen as a social occasion. Staff were discreet in supporting those who required some assistance regarding food. There was ample evidence that the meals at the home are enjoyed. ‘The meals are good and there is always fresh fruit available.’ ‘Mum has never made any complaints about food. She seems to enjoy meals and the tables are nicely kept and laid.’ Discussion with the cook evidenced that she had commenced work in November 2006 but she still had not had Food Hygiene training. It is a requirement of this report that the cook receives this training. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services can express their concerns, they have access to a robust, effective complaints procedure and they are protected from abuse. EVIDENCE: The home has a clear complaints procedure in place that is part of the Service User Guide and is also displayed in the entrance hall. The procedure includes the stages and timescales of the process and an assurance that any complaints would be addressed within 28 days. It also provides information about making a complaint to the Commission. Some residents and visitors were asked about the complaints procedure. They all said that they knew who to complain to and that they would feel comfortable in raising any issue with staff and the manager, and were confident that it would be addressed. To further promote this confidence the home may wish to consider displaying the complaints procedure at other strategic points in the home in addition to the hallway, and to developing the complaints procedure in other formats. These are recommendations of this report. The Commission has received no complaints about the home. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 18 The home has a Complaints log and there was one complaint recorded since the last inspection. This had been appropriately addressed. The home does not currently keep a record of informal complaints made, and the manager is recommended to keep a brief record of informal complaints and how they have been addressed, for quality assurance purposes. The home has policies and procedures in place, including a Whistleblowing Policy for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of users of the service. They also had a copy of Staffordshire Inter Agency Vulnerable Adult Policy as guidance in the referral of any incident. The examination of records relating to the recruitment process identified that two written references, a timely Protection of Vulnerable Adults (POVA) clearance where used, and a Criminal Records Bureau (CRB) was undertaken prior to the appointment of staff. Staff have received training in behaviours that challenge and this included an understanding of abusive practice. Two staff who were interviewed separately were each set a different scenario about a fictitious abuse and asked about how they would respond. Both of the staff had a good understanding and responded appropriately to the questions. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 19 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): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home is well situated in maintained, safe and pleasant grounds. There is an enclosed area with seating to ensure the safety of people with dementia needs. Doorways within the home are of sufficient width for free access by people with physical disabilities who may use a wheelchair. Internally the home is comfortable and homely. Information provided showed that there is continuous planned decoration of the premises. There is a Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 20 handyman employed to ensure that small works/repairs are speedily addressed. The 2 units in the home have their own kitchenette area as well as the main kitchen to enable drinks and snacks to be provided from there. This also enables those residents who wish to assist in the kitchenette within a risk assessment framework. The Fire Officer visited in August 2006 to assess the home for compliance with new fire regulations. All requirements have been met. The new owner has agreed in writing to the Commission that the outstanding wash hand basins in the original part of the building that do not have temperature regulators will have them fitted, and also that electric hand drying facilities in the new wing toilet will be installed in place of paper towels. The manager has confirmed that this work will be completed within the next few weeks. It was also found at the inspection that all of the communal toilets still had reusable cotton towels that are changed daily. The manager is required to liaise with the local infection control nurse for guidance to ensure that suitable arrangements are put in place for hand drying in the communal toilets to prevent the spread of infection at the care home. The laundry facilities, situated in the basement are adequate. There is a dirty laundry area, with a large industrial washing machine, and a clean area for drying and ironing. There are suitable sluicing facilities. Storage facilities for residents clothing is provided. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff who are well trained and skilled to support the people who use the services. EVIDENCE: Staffing rotas had remained as those under the previous ownership. These showed that 4 to 5 staff were provided per shift during the day, with 2 waking staff at nights. Staff rotas were flexible to provide additional staffing at peak times of the day and there is a half hour hand over period at shift changes. The rota was checked out for the numbers of staff on duty on the visit and these corresponded. People asked about the staffing levels all said that they considered that there were always sufficient staff on duty. They did not have to wait unduly for a response if they called for assistance. Staff and visitors also considered that the staffing levels are sufficient, including domestic and kitchen staff. The home has 90 of its staff trained to National Vocational Qualifications (NVQ) 2 or above. The remainder are relatively new staff who will be enrolled once their full induction to Skills For Care standard is completed. This high level is seen as good practice. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 22 Staff files showed full recruitment information including 2 written references, a full employment history, a timely POVA First check where staff had commenced before the full CRB had been received, and a full timely CRB in every instance. There were records available to show that the recruitment process is thorough and consistent. All staff have a terms and conditions of employment contract and have been given copies of the General Social Care Code of Conduct. There was clear evidence in the staff files that they receive induction training to the required standard. A new member of staff talked through the workbook that she is completing and about how she is supported and assessed by the manager. Staff spoken with confirmed their training record and the regular updates that they receive in moving and handling, fire safety and refresher training. Evidence of training was also seen via certificates in staff files and copies were also displayed all around the office wall. The current manager was one of three managers registered to run the home under the previous ownership, with the previous owners being the other two. Training was not previously an area of responsibility of the current manager who is in the process of acquainting herself with the current position overall. It is recommended that an overarching training matrix is kept to show the training completed by all staff, when any training is due etc. and to record any additional training identified via the supervision and annual appraisal process. This would assist the manager to keep abreast of training requirements and provide a clearer audit trail of staff training overall. The evidence was that staff receive all mandatory training and the majority are trained in dementia awareness. Some have been trained in conflict management. The manager agreed that the needs of people with dementia are increasing and that the course that staff have received is at a basic level. It is recommended that consideration be given to more extensive training for some staff in the understanding of dementia. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is good. 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, and the health, safety and welfare of the users of the service is maintained by the maintenance of effective systems. EVIDENCE: The registered manager previously worked in this capacity alongside the two owners who were also registered managers for the service. She has been working as the sole manager since the new ownership from February of this year. As such she is taking on duties that were previously not part of her responsibility, and she talked about how she is prioritising her workload to ensure that the home retains the high standards that it has always held. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 24 The manager feels well supported by the new owner and her line manager (Area Manager) who visits twice a week to ensure that the home is operating, as the new provider requires. Staff spoken with said that the manager has an open, approachable style. They felt relieved and confident that the home is continuing as before and to the high standards that have always been expected. Residents spoken with said that the manager is very caring and considerate and that she is always available if they wish to discuss anything. They felt ‘comfortable’ with her. This feeling was also expressed by relatives who said that they were naturally concerned about the change of ownership initially, but that they had not noticed any falling in standards and the continuity of the manager was reassuring. All asked confirmed that the change of ownership had been handled positively with the new provider being available in the home to speak to residents and their relatives about any concerns. The Area Manager has since visited approximately two times a week since then. The home undertakes a resident meeting periodically and an annual survey of residents and relatives is also conducted. Questions asked are comprehensive and cover all aspects of life in the home. The manager said that all responses are considered on an individual basis, and the individual is responded to in writing and advised about what action will be taken about any issues raised, or the reasons why if something cannot be altered. Relatives confirmed that they completed a questionnaire but one person said that they never noticed any changes subsequently around the issues that are raised. It was emphasised that these were not complaints but suggestions for improvement, particularly around activities in the home as has been raised earlier in the report. The owner and manager are asked to particularly note these comments. An Annual Quality Assurance Assessment has recently been sent to the home for completion. Information from the provider’s own assessment of the service via the completion of this document will give a clearer insight into the plans that the new owner has for the development of the service. Information provided by the home showed that the majority of residents rely on family to assist them with their finances, although one person handles their own financial affairs. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 25 The manager is the appointee for two people for Social Security benefits, and keeps money for several other residents for payment of the hairdresser, for toiletries etc. The records and monies of the two people where the manager acts as appointee and one other were examined. These showed appropriate recording and availability of receipts. The money available tallied with the records. All were securely kept. Staff records showed that staff received regular supervision. This was discussed with two members of staff, one of whom is still completing her induction. The staff confirmed that they receive formal supervision from the manager. Information provided by the home showed that all maintenance was up to date including all equipment servicing. Sampling of other records showed: All staff had been trained in moving and handling. Fire records showed that staff fire training is up to date and fire drills are held quarterly. All fire equipment; including emergency lighting is tested at the required intervals as shown in the records. People all had an individual fire risk assessment. There was a fire risk assessment for the whole building. There was a contingency plan should there need to be an emergency evacuation of the home. 15 staff hold a current first aid certificate. There is a qualified first aider on duty at all times. The home had been inspected by the Central Registration Team of the Commission in November 2006 in readiness for the registration of the new owner. The only issues found were as highlighted previously in this record under environment, and the Commission is confident that these will be addressed. A tour of the home was made and there was no evidence seen at the visit of any unsafe practices. The last inspection found that some of the risk assessments for the building had not been reviewed since 2004. This has still not been addressed. Such assessments would benefit from review on a more frequent basis, to ensure that information contained is still relevant to the environment and the current resident group. The manager was aware of this and said that this review is on her list of tasks to complete. Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 26 It is recommended again that this be addressed. It was noted at the visit made towards registering the service that Control of Substances Hazardous to Health (COSHH) items are stored adjacent to the laundry in the basement. While this area is not accessible by residents, it was made a recommendation that a separate locked cupboard is used for the storage of COSHH items. This is also a recommendation of this report. Spratslade House DS0000068917.V329717.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP30 Regulation 18 ( c) (i) Requirement The manager must ensure that any staff undertaking cooking in the home have Food Hygiene training to make sure that people who use your service receive food that has been safely prepared. Appropriate professional advice must be taken and followed about the most appropriate way to minimise the spread of infection in the home. This particularly relates to the communal toilet areas, because the home currently provides material reusable towels in the communal toilets, which could aid the spread of infection. Timescale for action 16/06/07 OP26 2 13(3) 16/05/07 Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 29 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 OP12 OP16 Good Practice Recommendations Consult with residents about the social activities that they would enjoy on a day- to- day basis with a view to widening the range of pastimes on offer. Consider displaying the Complaints Procedure in prominent areas around the home to ensure that residents and relatives are aware of the home’s positive approach to complaints. Keep a record of more informal complaints made and their outcome to assist in quality assurance monitoring. Develop a training matrix to show the full training details of all staff, to assist in keeping abreast of training requirements and to provide a clear audit trail. Consider providing more extensive training for some staff about the needs of people with dementia, to ensure that the increasing needs of residents are understood to enable good outcomes for them. Provided a locked cupboard for the storage of Control of Substances Hazardous to Health (COSHH) items. OP16 3 OP30 4 OP30 5 OP38 6 Spratslade House DS0000068917.V329717.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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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