Inspection on 29/11/06 for St Anne`s

This inspection was carried out on 29th November 2006.

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

St Anne`s 04/07/06

St Anne`s 12/01/06

St Anne`s 07/07/05

St Anne`s 03/02/05

St Anne`s 27/07/04

St Anne`s 25/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE St Anne`s 21 Wayside Road Southbourne Bournemouth Dorset BH6 3ES Lead Inspector Carole Payne Key Unannounced Inspection 13:50 29 November & 4th December 2006 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 DS0000020496.V321750.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. DS0000020496.V321750.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s Address 21 Wayside Road Southbourne Bournemouth Dorset BH6 3ES 01202 425642 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) Mr M J Lingam-Willgoss Mrs N Lingam-Willgoss Mrs N Lingam-Willgoss Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places DS0000020496.V321750.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: St Annes is a care home providing nursing and personal care for up to eighteen older people. Situated in a quiet residential road in Southbourne close to local amenities. There are sixteen single rooms, eight of which have en-suite facilities and one double room. There is a communal lounge area on the first floor although this is not used very much by service users, a desk at one end provides staff with office space. A passenger lift and two staircases provide access between the floors. A kitchen is centrally sited on the ground floor from which all meals are prepared and other utility areas (laundry and food stores are in an adjacent building. Outside the home there are small gardens to the front and rear with a small parking area to the front. Mr and Mrs LinghamWilgoss are the registered providers (owners) of St Annes, and Mrs LinghamWilgoss also takes the role of manager with the support of a deputy manager. The home’s current fee range is £550 to £650. Fees are based on an individual assessment of the needs of prospective residents. See the following website for further guidance on fees and contracts: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choos.aspx DS0000020496.V321750.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on the 29th November and 4th December 2006 and took a total of 9 hours, including time spent in planning the visit. The inspector, Carole Payne, was made to feel welcome in the home during the visit. The registered manager, Mrs Lingam-Willgross, was in the home during the visit and was present to give support with the inspection when required. This was a statutory inspection and was carried out to ensure that the residents who are living at St Anne’s are safe and properly cared for. Requirements and recommendations made as a result of the last inspection visit and key standards met at the last inspection on 4th July 2006 were also reviewed. The premises were inspected, records examined and the daily routine observed. Time was spent in discussion with all residents living in the home, who were able to participate in the inspection process, two staff members on duty and staff members in an informal group. Details of written feedback from residents and relatives / visitors and health and social care professionals involved with the home are referred to in the inspection report of the visit to the home on 4th July 2006. Throughout the visit the hard work and commitment of the provider, the management team and staff working in the home were reflected in the progress made by the service in addressing previous issues raised. What the service does well: Positive feedback was received from all residents and staff members spoken with during the inspection. One resident said ‘they all treat me wonderfully’. St Anne’s is the ‘right place for me’. One resident spoken with said ‘I do what I feel like doing during the day. This is my home’. A staff member said ‘It is not like coming to work’. Another said ‘I would have no hesitation in recommending the home to my own family’. A contract is issued to people moving into the service ensuring that residents and their representatives are aware of the terms and conditions of residency. Detailed assessments and plans of care support staff to meet the health, personal and social care needs of residents. DS0000020496.V321750.R01.S.doc Version 5.2 Page 6 St Anne’s provides a homely environment, supporting the meeting of residents’ healthcare needs, promoting general well-being, and treating people with the utmost care and respect for their privacy and dignity. Residents enjoy a lifestyle, which is respectful of their expectations for both privacy and companionship. Relatives and friends are made welcome at the home and residents are supported to continue to enjoy relationships that are meaningful to them. Residents are supported to make choices, exercising autonomy and control over their lives. A varied and nutritious diet is provided, which supports nutritional health. Residents enjoy food in the surroundings of their choice. Two residents said that the standard of food is ‘very good.’ Residents who live at St Anne’s benefit from a clean, pleasant and hygienic environment, which is well-maintained. The registered manager is an experienced Registered nurse and manager; she is competent and caring, ensuring that the well-being of people living in the home is promoted. Residents’ financial interests are satisfactorily safeguarded. What has improved since the last inspection? The home has made progress in meeting the requirements and recommendations issued in the last report. Prospective residents now receive suitable information to enable them to make an informed choice about where they would like to live. Thorough assessments now reassure prospective residents that their needs can be satisfactorily met by the home. Residents and or their representatives are now included in the assessment process and the person providing information is detailed in records. Satisfactory care plans are produced to meet the needs of residents with catheters. Where residents are identified as being at risk when a nutritional risk assessment is completed, satisfactory action is taken to ensure that residents’ dietary and healthcare needs are met. Detailed daily records are completed, ensuring that satisfactory support is provided to meet both the needs and wishes of people living in the home. Residents are satisfactorily protected by the home’s procedures and commitment to continuously improve the safe administration of medicines. DS0000020496.V321750.R01.S.doc Version 5.2 Page 7 The home has a detailed complaint’s procedure, which supports residents to feel confident that any concerns that they raise will be appropriately listened and responded to. The home’s policies, procedures and training promote the protection of residents from abuse. The home benefits from recent new carpeting in all communal areas and some individual rooms. All bathrooms are now fitted with locks. The redundant curtain rail and curtain in the ground floor room, noted during the last visit, has been removed. The garden to the rear of the home has also been landscaped and made more accessible for residents who use a wheel chair. The numbers, skill mix and competency of staff working in the home satisfactorily meet residents’ needs, ensuring that people are safely cared for. Generally thorough recruitment processes ensure that residents are protected by the home’s employment procedures. Recruitment records were available for inspection during this visit. The home is making progress in introducing quality assurance systems, to ensure that the service is run in the best interests of residents. Training is being introduced to ensure that residents’ health and safety is promoted and protected. 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. DS0000020496.V321750.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 DS0000020496.V321750.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, 2, 3 & 4, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents receive suitable information to enable them to make an informed choice about where they would like to live. A contract is issued to people moving into the service ensuring that residents and their representatives are aware of the terms and conditions of residency. Thorough assessments reassure prospective residents that their needs can be satisfactorily met by the home. The home is taking steps to ensure that the home is registered to accommodate the resident group, ensuring that people’s needs can be met. DS0000020496.V321750.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has amended the service user’s guide since the last inspection visit to the service to include all items required by regulation. The guide provides clear information about what the service is able to offer prospective residents, including guidelines regarding the aims and ethos of the service. The guide provides reference to the role of the Commission for Social Care Inspection. It is recommended that the last inspection report is made available to prospective residents and that the guide includes information as to how recent reports can be accessed. Reports can be accessed on the Internet website at http:/www.csci.gov.uk. Signed terms and conditions of residency were seen for two residents living in the home. The document includes information regarding fees, including the amount exclusive of the nursing contribution and details of items included and excluded from the fee. A set of terms and conditions is also included in the service user’s guide providing contractual information to prospective residents. The manager also writes to residents, or their representatives, confirming details regarding fees payable. Pre-admission assessments were viewed for two residents who had recently moved into the service. Detailed records had been completed, enabling the home to assess if the service was suitable to meet people’s needs. Information seen included the place where the assessment took place and the person providing the information. A letter is sent to residents confirming that the home is able to meet prospective residents’ needs. The manager confirmed that a minor amendment would be made to the letter confirming the offer of a place, making clear that the suitability of the home is based upon the outcome of the assessment process. One resident said that they had recently moved into the service. Their relative had visited the home, and this, and the information provided by the service, reassured them that the home was able to meet their needs. The resident said that St Anne’s was the ‘right place for me.’ They said the manager and staff had welcomed them when they had moved in. Two residents who have recently moved into the service have needs, which fall outside the home’s current categories of registration. The manager appreciated the importance of ensuring that the home can satisfactorily meet the needs of residents moving into the home according to the service’s registration with the Commission for Social Care Inspection prior to new residents moving in. The home is currently applying to accommodate up to four residents between the age of 50 and 65 and one named resident with dementia. DS0000020496.V321750.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 good. This judgement has been made using available evidence including a visit to this service. Detailed assessments and plans of care support staff to meet the health, personal and social care needs of residents. St Anne’s supports the meeting of residents’ general healthcare needs, promoting well-being. Residents are satisfactorily protected by the home’s procedures and commitment to continuously improve the safe administration of medicines. People who live at St Anne’s are treated with the utmost care and respect for their privacy and dignity. DS0000020496.V321750.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care plans were viewed for three people living in the home. The records included detailed assessments of the residents’ needs, including risk assessments. This informed the development of plans setting out care needed and people’s choices about the care that they receive. Thorough daily records support care, which is considerate of the personal, social and health care needs of residents. One resident said that they had been consulted about their plan and its review. Detailed monthly reviews were included on care plans for each care need identified. One resident has become less well and reviews of each care need identified set out current care required. However, this had not been updated on the individual care plan. On the second day of the visit, all the care plans for the resident had been satisfactorily updated. The manager confirmed that Registered nurses would be reminded of the importance of ensuring that care plans address current and changing needs. During the inspection the nurse in charge on the morning shift provided a comprehensive handover to the afternoon staff, enabling them to be aware of residents’ continuing social and healthcare needs. Detailed manual handling, pressure sore and manual handling risk assessments enable specific healthcare needs to be identified and met. Regular monitoring of nutritional needs, including fluid balance, dietary intake and weights is carried out and care plans set out clearly the support required. Recommended amounts of fluid intake are now included in records. All residents visited had cold drinks in their rooms and were offered regular warm drinks during the visit. The manager confirmed that residents are able to choose from several local General Practitioners. A catheter care plan set out action to be taken in relation to care, including dates for catheter changes, size of catheter required and monitoring of output and drainage. The Registered nurse in charge on the morning shift detailed prompt action taken, when a catheter had blocked and had ceased to drain satisfactorily. The home, has, therefore, adequately addressed a requirement issued in the last inspection report regarding the provision of thorough catheter care plans. Residents’ well-being is promoted. A physiotherapist was visiting a resident on the first day of the inspection and the resident spoke about the exercise programme she follows. Care plans set out support to promote mobility and the nurse in charge talked about encouraging mobile residents to take a stroll around the home and take tea with other residents. ‘Flexicise’ (exercise) sessions are also held each week. DS0000020496.V321750.R01.S.doc Version 5.2 Page 13 The home maintains efficient records for the receipt and disposal of medicines. All medicines not in the Nomad system, cassette boxes, which are made up by the pharmacy, are dated when started, supporting a clear audit trail. Medication Administration Records, (MAR) charts, seen were signed confirming medicines administered. A Registered nurse had signed some of the handwritten entries on the MAR charts and a trained person had countersigned the entry. However, a Registered nurse had not signed five handwritten entries. She returned to the home during the visit to sign and verify the entries with a counter signatory. A maximum, minimum thermometer is used to record the temperature of the drugs fridge, which holds medicines requiring refrigeration. Daily recording of the temperature ensure that it is appropriately monitored. A controlled drugs register is used to record controlled medicines administered. Amounts of one medicine checked corresponded with the amount detailed in the register. It was advised that a regular audit is introduced to support the home’s processes to ensure that medicines are safely handled. A draft audit form was available for inspection on the second day of the inspection. The deputy manager, who has responsibility for the monitoring and ordering of medicines, intends to liaise with the pharmacist inspector to ensure that the audit process supports safe practice in the home. Throughout the visit staff members were observed providing gentle and sensitive care to residents. Staff members knocked on residents’ doors as appropriate. Care records reflected the wishes of people living in the home and respect was shown for the manner in which residents choose to receive help with personal care. One resident said ‘they all treat me wonderfully.’ DS0000020496.V321750.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. St Anne’s provides a lifestyle, which is respectful of residents’ expectations for both privacy and companionship. Relatives and friends are made welcome at the home and residents are supported to continue to enjoy relationships that are meaningful to them. Residents are supported to make choices, exercising autonomy and control over their lives. A varied and nutritious diet is provided, which supports nutritional health and enables residents to enjoy food in the surroundings of their choice. EVIDENCE: All residents, who were able, said that they were satisfied with the lifestyle offered by the home. Two residents commented that they had particularly chosen the home as it offered privacy, whilst being able to enjoy the company of both staff and perhaps the occasional visit from another resident for a chat DS0000020496.V321750.R01.S.doc Version 5.2 Page 15 over a cup of tea. A book club visits the home and there is a regular library service. Flexicise (exercise) sessions are held each week. One resident said that their relative regularly visits the home and is always made welcome; another resident commented that visitors are always offered tea. The service user’s guide states that residents are welcome at any time, and encourages the involvement of both residents, and their representatives, in care planning. During the visit friends and relatives came and spoke openly with the manager and her deputy. One resident was taking a phone call from relatives from abroad. Daily records included reference to visits from friends and family members. Residents’ choices were reflected in care plans, which set out residents’ wishes about the daily routines they prefer; for example preferences regarding nighttime routines and times for getting up and going to bed. One resident spoken with said ‘I do what I feel like doing during the day. This is my home.’ Records detail advocates, including personal representatives. There is a four weekly menu plan, which includes fresh vegetables and fruit. Two residents said that the standard of food is ‘very good.’ Records are maintained of food provided. One resident explained that there is a set menu at lunchtime, but alternatives are always made available. The resident said that there is always a choice for supper. Residents dine in their own rooms and people commented that they would prefer to eat in their own surroundings. DS0000020496.V321750.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a detailed complaint’s procedure, which supports residents to feel confident that any concerns they raise will be appropriately listened and responded to. The home’s policies, procedures and training promote the protection of residents from abuse. EVIDENCE: The home has a detailed complaints procedure, which is displayed in the home and is included in the information provided to prospective residents prior to moving in. A pre-admission assessment that had been completed included reference to discussion regarding how to complain. No complaints had been received since the last inspection. During the visit a resident raised a concern regarding the conduct of a member of staff. The manager was sensitively and appropriately responding to the concern. Since the last inspection adult protection training has taken place in the home and the service’s adult protection policy has been suitably updated to include reference to the local Dorset protocol. A user-friendly folder is maintained of information regarding adult protection for staff members. This includes Department of Health guidelines for the protection of vulnerable adults. A staff member spoke confidently regarding the action that she would take should an allegation of abuse be brought to her attention. DS0000020496.V321750.R01.S.doc Version 5.2 Page 17 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, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents who live at St Anne’s benefit from a clean, pleasant and hygienic environment, which is safe and well-maintained. Risks identified are satisfactorily monitored and assessed. EVIDENCE: All areas of the service visited were clean and well maintained. The home benefits from recent new carpeting in all communal areas and some individual rooms. There is a lounge on the first floor, an area of which is also used as office space for staff meetings. The lounge is little used by residents and there is no separate dining room. However, from discussion with people living in the home, it is clear that they make a positive choice when they move in regarding the suitability of the environment provided. The home offers a variety of delightful and homely personal rooms, which are personalised by residents. DS0000020496.V321750.R01.S.doc Version 5.2 Page 18 From discussions with residents they like to have the privacy of their own space, with the reassurance that help is close at hand should they require assistance in any way. The redundant curtain rail and curtain in the ground floor room, noted during the last visit, has been removed. Three residents said that if they press the call alarm, staff members always respond promptly. The home benefits from two assisted shower rooms and an assisted bathroom. All bathrooms are now fitted with locks. The gardens to the rear of the home have been pleasantly landscaped and include ramped access and a patio area. On the first day of the inspection it was noted that stand-alone heaters were being used in two rooms. These heaters presented a risk of scalding. On the second day of the inspection, the manager had carried out risk assessments, consulted the Health and Safety Executive and spoken with a relative. One of the residents is mobile and likes to be able to touch a surface to feel that it is warm. The manager has taken into account the strong wishes of residents to keep the radiators, the distress that it would cause to remove them, whilst ensuring that risks are minimised and people are made aware of the danger of scalding. She confirmed that the risk assessments would be reviewed and monitored to ensure residents’ safety. The home’s laundry is accessed to the rear of the service. The Registered nurse in charge confirmed that the laundry is used during the day and is not accessed at night. There are two commercial washing machines, a sluice programme and a tumble dryer. Laundry seen was carefully looked after and from minutes of a staff meeting special care is taken to ensure that residents’ clothing is carefully handled and returned to the residents to which they belong. Staff members were observed using good hand hygiene techniques and infection control in carrying out their day-to-day work. Infection control training was taking place on the second day of the inspection. DS0000020496.V321750.R01.S.doc Version 5.2 Page 19 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. The numbers, skill mix and competency of staff working in the home satisfactorily meet residents’ needs, ensuring that people are safely cared for. Generally thorough recruitment processes ensure that residents are protected by the home’s employment procedures. EVIDENCE: Rosters are maintained of staff members working in the home and now include details of the qualifications of each staff member. Residents spoke very highly of the staff team working at the service. The Registered nurse in charge showed the inspector around the home and spoke gently and caringly to residents, who were all pleased to see her. Sixteen residents were living in the home at the time of the visits. On the first day of the inspection there was one Registered nurse on duty with three care staff members. In addition to this the manager and, or her deputy are often on duty and two members of domestic staff in the morning and a cook. One Registered nurse and a care staff member work in the home at night. Three members of staff currently have a National Qualification in Care (NVQ) at level 3 and two are in the process of studying for the award. The deputy DS0000020496.V321750.R01.S.doc Version 5.2 Page 20 manager is an NVQ Assessor and has recently completed the Registered Manager’s Award. Recruitment files were viewed for three staff members working in the home. All contained two written references, proof of identity and a Criminal Records Bureau check, which had been obtained prior to the stated start date. Each applicant had completed an application form; there was a thorough interview record sheet and copy of employment contract on each file. One applicant had not stated places of work, although recent work history was evident from references obtained, ensuring a detailed work history is completed was discussed as part of the selection process. Confirmation of a verbal check of a Registered nurse’s entry on the professional register of the Nursing and Midwifery Council (NMC) was included on one of the files seen. The manager confirmed that she was awaiting the return of written confirmation from the NMC. One member of care staff said that they had completed their induction programme at the service. The home has started to keep copies of certificates on individual files and signed records of attendance are completed for each course attended. It was advised that a summary record be completed for all mandatory training so that training needs can be easily identified, monitored and reviewed. The home is utilising an external training provider to delivery mandatory training and there was evidence within records that Registered nurses attend suitable professional updates in current good practice. The training provider was holding infection control training on the second day of the inspection. She confirmed that courses work to Skills for Care standards and incorporate a review of learning, where the attendee completes a questionnaire to ensure that learning outcomes have been achieved. Now that formal training has been established copies of these, including induction records will be kept on individual training files, evidencing competency. DS0000020496.V321750.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is an experienced Registered nurse and manager; she is competent and caring, ensuring that the well-being of people living in the home is promoted. The home is making progress in introducing quality assurance systems, to ensure that the service is run in the best interests of residents. Residents’ financial interests are satisfactorily safeguarded. Training is being introduced to ensure that residents’ health and safety is promoted and protected. DS0000020496.V321750.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager and the deputy were present in the home during the inspection. The manager holds the Registered Manager’s Award and the deputy has just completed the programme. Both the manager and the deputy have separate and clear responsibilities promoting the efficient management of the day-today running of the service. The manager has recently acquired a quality assurance system from an external provider. Regular staff meetings are held and minutes kept. These include reference to issues of concern and plans for improvements in standards in the home. Informal procedures also exist, within an environment in which residents feel confident that they can raise worries and know that they will be responded to. Staff members also expressed commitment to the service. One member of staff said it is like ‘a family’, an environment in which people feel at ‘home’. On the second day of the inspection infection control training was taking place in the home. Records of attendance showed that manual handling training had recently taken place and a staff member confirmed that health and safety training was booked to take place the following day. Fire records seen reflected regular checks of fire fighting equipment and services. Four staff members confirmed that they attend regular fire training and drill practice. DS0000020496.V321750.R01.S.doc Version 5.2 Page 23 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 3 3 2 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000020496.V321750.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP30 Good Practice Recommendations The registered person should introduce a summary record of training, to ensure that training needs are identified, monitored and met, ensuring that all staff members have the appropriate skills to care for people living in the home. 1. DS0000020496.V321750.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000020496.V321750.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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