Inspection on 15/05/08 for St Leonards

This inspection was carried out on 15th May 2008.

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

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 Leonards 15/05/07

St Leonards 19/06/06

St Leonards 12/01/06

St Leonards 05/07/05

St Leonards 04/01/05

St Leonards 30/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE St Leonards 86 Wendover Road Aylesbury Buckinghamshire HP21 9NJ Lead Inspector Joan Browne Unannounced Inspection 15th May 2008 09:30 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 St Leonards DS0000023023.V363735.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. St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Leonards Address 86 Wendover Road Aylesbury Buckinghamshire HP21 9NJ 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) 01296 337765 01296 339529 www.bmcare.co.uk Colley Care Limited (Trading as B & M Care) Manager post vacant Care Home 45 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories only: Old age not falling within any other category (OP) 2. Dementia (DE) The maximum number of service users to be accommodated is 45. Date of last inspection 15th May 2007 Brief Description of the Service: St. Leonards is a purpose built care home providing personal care and accommodation for 45 older people. It is divided into two units. One unit caters for older people requiring general support, the other for older people with dementia. It is owned by B & M Care, which is a private care organisation. The home is located on the outskirts of Aylesbury, close to shops, pubs, a post office and other amenities. Public transport is easily accessible. The home was registered on the 19th April 2000 and consists of two floors. All bedrooms are single with en suite (WC and hand basin) facilities. Three rooms have an en-suite shower. There is a passenger lift. The home has a secure garden to the rear that is accessible to service users. Fees range from £550.00-£700.00 per week. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. St Leonards DS0000023023.V363735.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 1star. This means the people who use this service experience adequate quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was undertaken by Ms Christine Sidwell and Joan Browne on the 15 May 2008 and lasted for six hours The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document was received by CSCI and is referred to throughout the report. The new manager of the home assisted CSCI (us) on this site visit. The majority of the service users spoken to were able to express their thoughts and feelings about the care they receive. The information contained in this report was gathered mainly from observation by the inspectors, speaking with a number of service users, relatives, care staff, and from user surveys and information contained within the AQAA. Further information was gathered from records kept at the home. As part of this inspection we used our thematic probe based on “Safeguarding Adults”, as part of the methodology of IBL. The manager, three members of staff and three service users were asked and they agreed to participate. Their responses are included under Complaints and Protection and Staffing outcomes for service users. The first part of the inspection was spent discussing and agreeing the inspection process with the manager followed by a tour of the home, which included time spent in discussion with service users and care workers. All service users in this home are Caucasian and this was reflected in the staff mix. One requirement and five recommendations of good practice were issued on this visit. Please see Staffing outcomes, health and personal care outcomes, complaints and protection outcomes for full disclosure. The final part of the inspection was spent giving feedback to the manager and deputy manager about the findings of the visit. St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 6 The inspectors would like to thank all the service users and care staff that made the visit so productive and pleasant on the day What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that all staff have a PoVA first check before they start work and an enhanced criminal record bureau clearance (CRB) must be obtained. The home must ensure that the home’s generic complaints policy and procedures are supplemented with details of the specific local contacts. The home must ensure that generic safeguarding procedures within the new management system are supplemented with details of the specific local contacts, which should ensure that people using the service, staff and relatives are aware of who to contact if they wish to report a safeguarding matter. St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 7 The organisation’s quality monitoring must include monitoring the recruitment procedures to ensure that they are being implemented correctly and not putting people at risk of unsuitable carers. 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. St Leonards DS0000023023.V363735.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 St Leonards DS0000023023.V363735.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): 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that there is an assessment of people using the service needs, which is person centred, and they and people close to them have been involved in. EVIDENCE: The care of four service users was case tracked. All had been visited by the manager before they moved to the home and their needs had been assessed. There were copies of the care management assessments and hospital discharge letters in the care files. Two service users were spoken to and both said that they or their family had visited the home before they moved in. One said that she stayed for a few weeks before deciding to take up residency. Two family members were spoken to and both said that they had visited the home and that their relatives’ needs had been assessed. One said that the staff had been very supportive, as their family member had been disorientated when they first moved. St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that people’s health, personal and social care needs are met sensitively to their race, age, gender and disability. There is a plan of care that the person or someone close to them has been involved in making. EVIDENCE: The care of four service users was case tracked. Their files contained comprehensive care plans and there was evidence in some files that family members were involved in supporting and planning some individuals’ care. The staff spoken to were knowledgeable about service users’ care needs and preferences. The care plans had been reviewed regularly and updated when appropriate. The care planning documentation did not have a space for the date and signature of the person developing the care plan. This should be addressed and all entries should be dated and signed. Service users’ risk of acquiring pressure damage due to immobility had been assessed and appropriate equipment was available. Nutritional risk assessments had been undertaken. The carers said that the cook would provide special diets to meet individuals’ health and cultural needs if St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 11 necessary. The carers were aware of the need to provide some people who suffer from dementia with a high calorie diet. Records seen indicated that service users were being weighed regularly. Those individuals whose care was followed through had maintained their weight on moving to the home. There was evidence that falls assessments are undertaken and the advice of the local Primary Care Trust specialist falls prevention team is taken where necessary. All service users were registered with local general practitioners, who visit the home regularly. The medication administration record (MAR) sheets were examined and there were no unexplained gaps. All medicines are administered from a lockable drugs trolley. The home keeps a controlled drug register and medication in stock corresponded with the register. A record of the temperature for the medication fridge was maintained and recorded daily. There were no service users on the day of the visit that were self-administering. Care staff identified as capable to administer medication are requested to leave a sample of their signature, which is kept in the medication record folder. A record is maintained for all medication disposed of to ensure that there is no mishandling. There was evidence that regular management checks are carried out to monitor compliance Staff assist service users with their personal care in their bedrooms ensuring privacy. We also observed service users being treated in a friendly but respectful manner by care workers. Individuals’ attire was in a good state of repair with attention to detail. Most had had their hair dressed recently. Service users and relatives spoken to on the day of the site visit said that ‘staff were kind, caring, and always asked them what they would like to do and gave them a choice.’ One service user told us “I am very happy here. Everything is so nice. I have my own room. I can have as much privacy as I want”. Another service user said “We have good staff here; they treat me well. I choose my own clothing every day”. We observed that care workers wore name badges to enable visitors and service users with memory impairment to be sure of whom they were speaking with. St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensure that people who use service are involved in meaningful daytime activities of their own choice and according to their individual interests and diverse needs. Nutritional and wholesome meals are provided in pleasing surroundings. EVIDENCE: Service users have the opportunity to exercise their choice in relation to leisure, social activities and cultural interests. The home employs two activity organisers and there is a variety of activities provided such as, trips to places of interests, poetry group, reminiscence, bingo, coffee mornings, card games such as bridge, garden parties and entertainment by outside entertainers. A ‘pets as therapy (PAT) dog’ visits the home once a month and a church service is held once a month to ensure that those service users who wish to promote their spiritual needs are able to do so. Information in the annual quality assurance assessment (AQAA) reflected that every service user birthday is celebrated with a party and friends and family are invited to join in the celebration. This was demonstrated by photographs of social events displayed on the notice boards around the home. Evidence of activities provided was St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 13 included in the home’s newsletter. Up to date information on the weekly activities provided was circulated on the notice boards around the home. The AQAA reflected that within the last twelve months further improvement had been made by ensuring that regular service users’ meetings take place and individuals are given the opportunity to discuss the activity programme. We were told that plans were being made to develop the gardening activity further by providing a log cabin for plants to be displayed. Service users spoken to confirmed that the home provides meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capability. However, not all service users participate in the activities provided. Some choose to go for daily walks and be part of their local community. Some service users were observed in the lounge reading the newspapers and listening to music in the background. It was observed during the site visit that service users in the front lounge tended to sleep when there were no staff in the lounge and when staff were involved in providing individual care and support to other service users. It was evident that service users could benefit from more attention when the activity organiser was not around to ensure that individuals’ social needs are met throughout the day. Service users told us that their friends and relatives were able to visit at any time that was convenient for them to visit. Service users spoken to said they had choice in their clothing and sometimes they receive help from their key worker. On the day of inspection all service users were dressed appropriately for the weather with attention to detail. Arrangements were in place to ensure that service users and their relatives are informed of how to contact external agents for example, advocates, who will act in their interests. We were told that plans were being made for service users’ meetings to be chaired by a representative from the local advocacy organisation. On the day of the visit we observed the lunchtime meal, which consisted of boiled gammon, champ potatoes, carrots and parsley sauce. Dessert was fruit jelly and ice cream. A variety of fruit juices and water was served with lunch and service users had a choice on which beverage they wanted. We were told if service users did not like the choice on offer an alternative would be provided. There were no service users requiring special diets on the grounds of religious or cultural needs. The surrounding in the dining room looked homely and welcoming. The tables were covered with tablecloths with the appropriate cutlery and condiments provided. The inspector did not sample the lunch, but service users said that the food was very good, tasty and the right amount. We observed care workers interacting in a friendly but dignified manner with service users during the lunchtime. Staff offered assistance to service users who required assistance with eating. However, more sensitivity is needed to St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 14 ensure that staff are not multi-tasking when assisting with feeding. Consideration should be given to review the administration of medication during mealtimes to ensure protective mealtimes and to promote individuals’ nutritional needs. St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures if people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. Inconsistency in the home’s recruitment procedure could put people using the service at risk of harm from unscrupulous persons working with them. EVIDENCE: The organisation has recently implemented a new management system, which includes generic policies and procedures for all the homes in the group. There is a complaints policy and procedure, which clearly describes the way in which complaints should be handled and the deadlines that are set for response. The generic policy and procedures should be supplemented with details of the specific, local contacts should service users or their families wish to make a complaint. The annual quality assurance assessment (AQAA) reflected that the home had received 3 complaints since the last inspection. The complaints log was seen and all recorded complaints had been dealt with in a constructive way and within the timescales described in the procedure. The Commission for Social Care Inspection (CSCI) has not received any concerns or complaints about the service. Those service users who responded St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 16 to the Commission’s survey said that knew how to make a complaint. Of the three relatives spoken to, two said that they had not had occasion to raise a concern and one said that they had raised an issue verbally which was dealt with immediately. All the service users spoken to said that they did not have any concerns and that they would speak to a team leader if they had. The home has recently undertaken a quality assurance survey and 89 of respondents said that any concerns they had raised was dealt with ‘as expected’ or ‘better’. There are also generic safeguarding procedures entitled ‘elder abuse procedure’ within the new management system. These too should be supplemented with details of the specific local contacts. The manager said that she had an old copy of the local multi-agency safeguarding procedures and that she had contacted the lead person in the local authority for the updated guidance. The training records showed that thirty of the thirty- six staff had undertaken safeguarding training although not all had had recent updates. The staff spoken to were knowledgeable as to what constitutes a safeguarding issue and said that they would report any concerns to the manager. One added that if the concerns were about the manager they would report the concern to the Commission for Social Care Inspection or social services. The Commission for Social Care Inspection has not been notified of any safeguarding allegations since the last inspection. The home’s recruitment practice is not consistently thorough, which could place service users at risk of harm from unscrupulous persons working with them. This is covered under standard 29 St Leonards DS0000023023.V363735.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 & 26 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is well maintained, clean, pleasant and hygienic which should ensure that it is safe and comfortable for people using the service to live in. EVIDENCE: The home is a pleasant purpose built building located just off the main road between Aylesbury and Wendover, about one mile from Aylesbury town centre. The layout of the home is on two floors and is divided into two units – a 22 place elderly frail unit and a 23-place unit for people with dementia. All areas of the home are accessible by wheelchair. All bedrooms are single occupancy with en suite facilities such as, toilet and wash hand basin. The fixtures and fittings are of a high quality, well maintained and adapted to meet the diverse needs of individuals. Service St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 18 users are able to personalise their rooms and can use their own furniture if they wish. The bathrooms looked homely and were fitted with aids and adaptations to meet the needs of the people using the service. There were enough toilets to enable immediate access. The annual quality assurance assessment (AQAA) stated the following: “We have pleasant gardens that are maintained by staff and an outside gardener. Residents are able to access the gardens which have very good garden furniture.” We observed that the gardens were very well maintained and there was a secure garden at the back that service users could access. The home has a selection of communal areas so service users can sit quietly and meet with family and friends or be actively engaged with other people who use the service. Service users spoken to during the inspection said that they felt safe and secure living in the home. The most recent fire service report was made available for the inspection purpose and reflected that all safety matters were considered satisfactory. The home was well lit clean, tidy and free from offensive odours on the day of the inspection. The laundry area is situated away from where food is stored and prepared. It is equipped with a drier and two washing machines with the specified programming ability to meet disinfection standards. The floor and walls in the laundry room were satisfactorily maintained. The home provides red alginate bags for soiled linen to prevent and control the risk of infection. The home has policies and procedures in place for the control of infection, which staff adhere to. We were told that several service users are assisted with transfer from bed to chair with the use of the hoist. The manager was advised that to comply with best practice slings should not be shared between service users and should be laundered in hottest wash cycle allowable. St Leonards DS0000023023.V363735.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 People use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Consistency in the home’s recruitment practice is needed to ensure that people using the service are cared for by staff who have had the appropriate checks to make sure that they are suitable to work with vulnerable adults. EVIDENCE: The staffing arrangements in the home provides for four care staff in the unit for people with dementia throughout the day and the number is reduced to two care staff at night. It provides for three care staff in the elderly frail unit during the day and two at night. Domestic staff are available on the two units daily and there is also a full time cook and kitchen assistant. A part-time administrator supports the home. The rota seen demonstrated that the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was adequate to meet their diverse care needs. Service users who responded to the Commission’s survey said that staff were ‘always’ available when needed. Relatives spoken to during the inspection were complimentary about the staff and the provision of care provided. The following additional comments were noted: “Staff are very kind always.” “Staff are excellent.” St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 20 47 of care workers have attained the National Vocational Qualification (NVQ) Level 2 and above qualification. Review of care workers’ files demonstrated that care workers had regular and up to date training to enable them to fulfil their roles. The recruitment files of four staff members who had been appointed to the home since the last inspection were reviewed. All had application forms, which described their work history and references had been sought from the last employer. Three had evidence of the person’s identity and an up to date photograph. Three had evidence that Criminal Records Bureau (CRB) disclosures had been obtained before starting work. One staff member did not have a Criminal Records Bureau disclosure or a ‘POVA’ first check. The manager spoke to the staff member who confirmed that she could remember completing the application although not receiving the disclosure. The manager undertook that the person would not work with service users until a repeat CRB application was sent and the POVA first check received. She also undertook to audit all staff records for those who had been recruited in the last year to ensure that all other staff had the appropriate disclosures. The audit was received within two days and confirmed that all other staff had CRB disclosures. A copy of the POVA first notification had not been retained for all staff and it was not possible to tell from the records whether individuals had started work before this was received. Recruitment policies and procedures must be reviewed to ensure that the required checks on a person’s suitability to work with frail older people are undertaken before they commence work. Ensuring that the recruitment procedures are being implemented correctly should also form part of the organisation’s quality assurance monitoring. Guidance on good practice in recruitment can be found on the Commission for Social Care Inspection web site www.csci.org.uk. St Leonards DS0000023023.V363735.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has quality assurance systems in place, which should ensure that the environment is safe for people and staff and health and safety practices are carried out. EVIDENCE: The acting manager had recently taken up her post in the home having previously managed the service and has worked as the training and development manager for the organisation. She was able to demonstrate that she had undertaken training to update her knowledge, skills and competence and recently acquired BSC honours in dementia. St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 22 Lines of accountability, both in the home and within the larger organisation were clear. The manager reports to a senior manager. The deputy manager, team leader and senior care workers report to the manager. The organisation’s new management system includes a quality assurance module, which the manager has begun to implement. She has undertaken a satisfaction survey, the results have been analysed and she said that an action plan would be drawn up to address any improvements needed. Regular service users and family meetings are held. There are confirmed plans for these to be independently chaired by Age Concern. Care planning and medication audits have been undertaken and have shown improvement. Senior managers from the organisation also undertake regular monitoring visits. Reports of these visits are kept at the home and are open to scrutiny. The annual quality assurance assessment (AQAA) was not returned to us by the date it was requested. The evidence to support the comments made was satisfactory, although there were areas where more supporting evidence would have been useful to illustrate what the service has done in the last year, or how it was planning to improve. The home does not manage any money on behalf of residents. Review of documented records demonstrated that health and safety checks were routinely carried out at the home. All equipment examined on the day of the inspection was properly maintained. Records indicated that regular fire drills were being facilitated. Evidence was seen indicating that weekly checks on the fire panel are carried out. St Leonards DS0000023023.V363735.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A 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 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Leonards DS0000023023.V363735.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. 1. Standard OP29 Regulation 19 Schedule 2 Requirement All staff must have a PoVA first check before they start work and an enhanced criminal record bureau clearance (CRB) must be obtained. Timescale for action 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP7 OP15 Good Practice Recommendations The care planning documentation should be reviewed to ensure that there is sufficient space for the date and signature of the person developing the care plan. Consideration should be given to review the administration of medication during mealtimes to ensure protective mealtimes and to promote individuals’ nutritional needs. The home’s generic complaints policy and procedures should be supplemented with details of the specific local contacts to ensure that people using the service and their families are aware of this information. DS0000023023.V363735.R01.S.doc Version 5.2 Page 25 3. OP16 St Leonards 4. OP18 5. OP18 6 OP26 Generic safeguarding procedures within the new management system should be supplemented with details of the specific local contacts to ensure that people using the service, staff and relatives are aware of who to contact if they wish to report a safeguarding matter. The organisation’s quality monitoring should include monitoring the recruitment procedures to ensure that they are being implemented correctly and not putting people at risk of unsuitable carers. To comply with best practice guidelines slings should not be shared between people using the service and should be laundered in hottest wash cycle allowable. St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 St Leonards DS0000023023.V363735.R01.S.doc Version 5.2 Page 27 - 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. 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