Inspection on 10/07/07 for Stonehill House

This inspection was carried out on 10th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Stonehill House 28/12/06

Stonehill House 22/02/06

Stonehill House 21/11/05

Stonehill House 10/02/05

Stonehill House 26/10/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stonehill House 106 Churchway Haddenham Bucks HP17 8DT Lead Inspector Barbara Mulligan Unannounced Inspection 10th July 2007 10.15 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 DS0000023025.V339276.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. DS0000023025.V339276.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stonehill House Address 106 Churchway Haddenham Bucks HP17 8DT 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) 01844 290028 01844 299319 abbeyfield.haddenhamsocietyltd@btinternet.com The Abbeyfield (Haddenham) Society Limited Mrs Lindsey McGibbon Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places DS0000023025.V339276.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th December 2006 Brief Description of the Service: Stonehill House is a residential care home, which is owned and managed by the Haddenham Abbeyfield Society, a charitable organisation that is part of the National Abbeyfield Society. The home is registered to provide residential care for up to 11 elderly people over 60 years of age. The home is situated in a residential area in the village of Haddenham and is close to local amenities, which include shops, a library, pharmacy dental practice and health centre. Transport links are available to the towns of Aylesbury and Thame, as well as Oxford City. Stonehill House offers accommodation within a converted and extended home similar in style to nearby properties. The fees for the home range from £ 1781.86 to £2035.94. Service users are charged additionally for hairdressing, chiropody, newspapers should they wish to have. DS0000023025.V339276.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on Friday July 10th 2007 at 10.15am. The visit consisted of discussions with the staff team and service users, a tour of the premises and an examination of the homes records, policies and procedures. The registered manager was on sick leave at the time of the inspection. However, she lives on site and made herself available throughout the day. The inspection officer was Barbara Mulligan. The registered manager is Lindsey McGibbon. Twenty-seven of the National Minimum Standards for Older People were assessed during this visit to the home. Twenty-two of these have been fully met, four of these almost met and one has been assessed as not applicable. As a result of this inspection the home has received four requirements. The inspector would like to thank the registered manager, the deputy manager, the staff team and all service users for their cooperation and assistance during this visit. Service users and relatives/representatives, both those interviewed and those who responded to the survey expressed a high level of satisfaction with the care received from support staff. Positive comments made about the service include, “ exceptionally caring staff” and “additional care has been required for my relative and this has been offered willingly” and “overall we are very pleased with the excellent care received and the friendly manner in which staff interact with our relative. We appreciate their kindness and consideration” and “I regard the home conditions to be excellent. The staff and management are courteous and efficient at all times”. The evidence seen and comments received from discussions with service users during the inspection indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. What the service does well: Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. Healthcare support for service users is good. DS0000023025.V339276.R01.S.doc Version 5.2 Page 6 Service users feel that they are treated with respect and dignity. The home provides a very pleasant and comfortable environment in which service users can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. Meals are of a good standard and presented in an appealing way. Comments made from people who use the service include, “ the food is always very nice ” and “there is always plenty of food and snacks in between meals”. There is a motivated and established staff team that consists of care/support staff who respond to service users in a respectful and appropriate manner. Service users spoken to said that the staff were “very helpful and kind” and “ nothing was too much trouble “. Communication between service users and visitors was observed to be positive and open . Training for care staff is good and service users benefit from a staff team who are appropriately trained to do the job. The care staff are undertaking relevant training and working towards their National Vocational Qualifications. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. There is a good range of policies and procedures, providing care staff with relevant information about all aspects of care and the home/organisation. There are effective Quality Assurance systems in place, including an annual service satisfaction survey and a monthly news letter which is to be commended. Health and safety policies and procedures are clear and informative. What has improved since the last inspection? The home have managed to maintain a good standard of care ensuring the personal, emotional and health care needs for service users continue to be met. Service users spoken to were very positive about the care they receive at the home. Improvements to the premises continue to be made to ensure a safe and homely living environment is maintained. The care plans contain a detailed action plan that records how the care needs of the service user are to be met. DS0000023025.V339276.R01.S.doc Version 5.2 Page 7 The home now ensures that the employees full work history is recorded and any gaps explored before employment The home keeps a record of the content and induction process completed by staff when they start at the home. 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. DS0000023025.V339276.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 DS0000023025.V339276.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 and 6. Quality in this outcome area is good. Service users needs are thoroughly assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. The home does not admit service users for intermediate care so this standard was not assessed during the inspection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is the responsibility of the registered manager to carry out the initial assessment of need. Staff will visit a potential service user either in the hospital or in their own home to undertake the initial assessment of needs and information is also obtained from any referring social services or health care professionals. The inspector observed the assessment documentation for four service users, including those most recently admitted to the home. DS0000023025.V339276.R01.S.doc Version 5.2 Page 10 The assessment includes information of the service users mobility, risk of falls, skin condition and the service user preferences for diet. Service users GP’s are requested to complete a medical questionnaire including information of their medication taken. Service users are asked to complete a financial assessment prior to acceptance of a place in the home. The service users are offered the opportunity to visit the home before they make the final decision to live there. The admission documentation seen is fully completed, detailed and demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. The home does not admit service users for intermediate care so this standard was not assessed during the inspection. DS0000023025.V339276.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 and 10. Quality in this outcome area is good. The care planning system does not presently provide staff with information they need to satisfactorily meet all service users needs. Healthcare support for service users is good, which means that their health and well-being is promoted and protected. Medication procedures within the home are clear and there is consistent implementation resulting in safe working practices. The manner in which personal care is delivered ensures service users are treated with respect and dignity and that their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service uses and relatives confirmed in the survey questionnaire and during the visit that they were very satisfied that their care needs are met. One service user said, “ I am very grateful for the care I receive in this home” and “the manager and staff are always willing to help and they will do any thing to make life easier”. DS0000023025.V339276.R01.S.doc Version 5.2 Page 12 Following the previous inspection a requirement was issued for the care plan to record how the care needs of the service user are to be met. It is pleasing to see that the care plans in place comply with this. The care of four service users was case tracked and their care plans were examined. Following the initial assessment a plan of care is developed. Identified needs of the service users are recorded in the care plans, but these do not tend to include the social care needs the individual. A requirement has been issued under standard 12 of the national Minimum Standards for Older People for improvement in this area. Plans of care seen are informative and include a detailed action plan to guide staff. They have also taken the step to seek and record service users choices for how they wish to be treated by the emergency services should they required. There are approprate risk assessments in place for tissue viability, moving and falls. The home ensures that each service user plan is reviewed regularly and involves the individual and where agreed their family or representative. Service users are registered with a local GP Practice. However they can register with their own GP if this is practical and agreeable to both parties. All have access to local NHS Services. Tissue viability assessments are in place for each service user. At the time of the inspection there was one individual that required pressure area care and the information contained within the care plan was up to date and in line with her present and changing needs. The District Nurse is treating this and pressure-relieving equipment is obtained via the district nurse also. A domiciliary optical service visits the home on an annual basis and service users can visit an optician of their choice if they prefer. Referrals for a hearing test go through the service users G.P. Dental services will visit the home annually or service users can visit their own dentist if they choose to. Weight monitoring was observed in the care plans and this is undertaken monthly. Chiropody services visit the home and some service users visit the local health centre as they need to. The home supports service users to receive the medication that they need by either assisting with medication or providing facilities for service users to self medicate. There is a risk assessment for service users who wish to self medicate and these are reflective of review. The medicine cupboard is sited in the kitchen and related records are stored here as well. This area of the kitchen is small, cluttered and when staff are undertaking tasks in the kitchen it is crowded and provides too many distractions for the safe administrations of medicines. It is strongly DS0000023025.V339276.R01.S.doc Version 5.2 Page 13 recommended that the medicine cabinet is re-sited to an area more appropriate for the safe administration of medicines. Medicine records are accurate with no omissions and photographs are used for identification. At the time of the inspection there were no controlled drugs in use, however there are systems in place if this is necessary. There is evidence in the staff training records that demonstrate most staff, with the exception of two, have undertaken accredited training in the safe handling of medicines. The further two care staff are due to undertake this in the very near future. Service users receive care from staff and health care professionals in complete privacy. Staff were observed during the inspection to knock on service users bedroom doors before entering. One comment received from a visiting healthcare professional was “they treat people as individuals and respect them, they also give care and support needed and make people feel that they still matter”. Service users spoken to at the time of the inspection confirmed that care staff ensure their privacy and dignity is maintained at all times. Preferred terms of address are identified at the initial assessment and the inspector saw evidence of this in care plans. The homes induction programme includes training regarding privacy and dignity. The Statement of Purpose and Service Users Guide include information about maintaining the privacy of service user’s. Service users can have a key to their rooms if they wish to use this facility and it is felt to be safe. DS0000023025.V339276.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 and 15. Quality in this outcome area is adequate. Systems in the home ensure that where appropriate service users are supported to exercise choice and control over their lives and service users are enabled to continue with an active social life should they wish. Individuals are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user. Service users are encouraged to bring personal possessions in with them allowing personal space to reflect the character and interests of its occupant. The presentation and standard of food is good and meets the nutritional needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One comment given about the activities provided in the home service user questionnaires was, “My relative enjoys the weekly bingo sessions. If similar activities could be offered I think these would be appreciated”. Within the care plans the social care needs are not always identified and a requirement has been issued for improvement in this area. DS0000023025.V339276.R01.S.doc Version 5.2 Page 15 Care plans show routines of daily living and include bathing, rising and retiring times. The care plans were reviewed and discussions with service users indicate that that there are some appropraite activities available and service users living in the home enjoy an active sociall ife. Examples of activities carried out in the home are bingo and quizzes. Trips to outside places of interest have included trips out to garden centre, the pub and local places of interest. Service users informed the inspector that they were encouraged and supported to continue with the activities that they enjoyed prior to entering the home. Examples of involvement in the home by local community groups and individuals are visits by mobile hairdressers, the local brownies who recently held a cream tea event for service users in the home and regular visit by the local church. Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. Family and friends are invited to participate in some of the social event organised. The home has enabled service users to be able to be partially independent with incorporating the facilities of a kettle, fridge and storage where they can provide hot drinks and snacks for their guests and themselves if they wish and are assessed as able. Service users and/or their families are encouraged to look after their own financial affairs whenever possible. If this is not practicable a chosen solicitor will be responsible for an individuals financial dealings. An invitation to bring in personal items of furniture and other belongings is included in the service users guide and this was evident during a tour of the premises. When questioned about service users having access to their personal records, the inspector was informed that this could be facilitated if it was requested. Care staff help prepare the lunch time meal and this was observed on the day of the visit. Then the homes chef will arrive at 11:00am to complete the meal. Service users are offered three meals a day. The inspector had the opportunity to join the service users for lunch. This was relaxed, unrushed and well organised. One individual told the inspector “when you order your menu you can choose what you want”. All meals seen were attractively presented and plentiful. In discussions with service users it was confirmed that meals are always of a high standard and there are sufficient snacks and drinks available throughout the day. The inspector was told that service users could take their meals in their rooms if they wish and this was the choice of two individuals on the day of inspection. The nutritional needs of service users are assessed and there is evidence of regular monitoring in all care plans seen. DS0000023025.V339276.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 and 18. Quality in this outcome area is good. The home has an effective complaints procedure to ensure that service users or their representatives are listened to. Policies and procedures to protect service users from abuse are in place, including financial protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users confirmed that they knew who to speak to if they had concerns and that they were confident that they would be listened to if they did have any concerns. The home has a complaints procedure, which is accessible to service users and their representatives. This is up to date, January 2007 and contains details of how the complainant can contact the Commission for Social Care Inspection. The complaints log is kept by the main entrance, however there is no complaints procedure within the log. This is recommended. The registered manager stated that because the home is small concerns and complaints are dealt with straight away. Committee members visit the home monthly and talk to individuals. They can raise concerns or complaints during these visits also. The Commission has received no complaints about this service. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. DS0000023025.V339276.R01.S.doc Version 5.2 Page 17 The registered manager is aware of the POVA register and would submit staff for inclusion if it became necessary. The home uses the Bucks Multi Agency POVA policy and an organisational policy in conjunction with this. This includes guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. The CSCI has not received any concerns or complaints about the service and no information about a referral about protection. Training records demonstrate that care staff are up to date with POVA training and this forms part of their induction. The registered manager does not act as appointee for any service users. There are systems in place to look after small amounts of personal allowance or for the safekeeping of service users valuables. DS0000023025.V339276.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 and 26. Quality in this outcome area is good. The standard of the environment within the home is good, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is adequate, ensuring the safety and comfort of service users. Standards of cleanliness at the home are good meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is not purpose built but has been converted with an additional extension to provide sufficient accommodation for eleven service users to live comfortably. The home is arranged over 2 floors with a lift to the first floor. DS0000023025.V339276.R01.S.doc Version 5.2 Page 19 The service users are provided with good sized bedrooms, 7 with en-suites with showers and the rest have an assisted bathroom and toilets close by. Communal space consists of one lounge and a dining room. These are bright, spacious and are both set in a homely and attractive fashion. The internal decoration of the home is of a good standard and there are personal touches around the home such as flowers, plants, books and pictures. The kitchen is clean and well looked after. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. The garden are is sheltered and is maintained well. It has areas for service users to sit and is easily accessible. There are good adaptations to the home to support service users mobility that includes grab rails, electronic door openers and bath aids. The home has good protocols in place to ensure that it is kept clean and hygienic. However, in the downstairs corridour there was a distinctive odour that needs to be eliminated. The laundry area is sited away from food preparation areas and the care staff are responsible for the care of service users clothes and linen. DS0000023025.V339276.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. Staffing numbers are adequate, and ensure that the assessed needs of the service users are met. Overall there are effective recruitment procedures in place, however written references must be obtained for all staff to ensure service users are protected from harm. Service users benefit from a staff team who are up to date with their training, to ensure that staff are competent to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s staff rota demonstrates that there are adequate numbers of staff on duty at all times to ensure the needs of the service users are always met. This includes sufficient numbers of ancillary staff. The registered manager is extra to these numbers. The manager has assessed all the service users and identified that they have low needs. There is usually one waking night duty staff member on duty with one sleeping in. The home employs one domestic staff, one weekday chef and one weekend chef. The care staff assists with meal preparation, carry out laundry tasks and also undertake some cleaning tasks in the home. There are no staff working in the home who are aged under 18 years of age and there are no members of staff under the age of 21yrs left in charge of the home. DS0000023025.V339276.R01.S.doc Version 5.2 Page 21 The home continues to support staff on NVQ training and the home has achieved 80 of the staff who have obtained an NVQ 2 or above. Following the previous inspection it was identified that application forms does not request the applicants full work history and they do not require them to submit a CV. There was no record kept of the applicants work history being recorded as routine or explored in the interview process and a requirement was issued for employees full work history to be recorded and any gaps explored before employment. This was difficult to assess, as there have not been any new care staff recruited since the previous inspection. However the home has recently recruited a weekend chef. This file contained all the necessary pre-employment checks with the exception of one reference. However the registered manager said that she had contacted the second referee by telephone and received a verbal reference. There was no record of this in the file. A requirement has been issued for improvement in this area. Following the previous inspection it was identified that the induction process wis not recorded in the employees file or the topics identified as included in the training programme and a requirement was issued for improvement in this area. It is pleasing to see that this has been compied with. All new employees are provided with an induction process and thre is a rolling programme of training that includes all core subjects. Training records are very well maintained and this is to be commended. Training records deomonstrate that care staff are up to date with mandatory training. DS0000023025.V339276.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The home operates various methods of quality assurance resulting in the home being proactive in identifying issues that may affect the well being of services users. Protocols and systems are in place to ensure service users financial interests are safeguarded. Staff are not regularly supervised, potentially leaving service users at risk of poor practice from staff. There are several areas of the homes health and safety procedures that need to be improved to ensure the service users health, safety and welfare are protected and promoted. This judgement has been made using available evidence including a visit to this service. DS0000023025.V339276.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has been working at the home since 1985 and has obtained NVQ\level 4 certificate of training. She is deemed competent and sufficiently experienced to manage the home and has gained the Registered Managers Award. . During the last year she has updated some of the mandatory health and safety topics necessary and other training such falls and fractures, and oral health. When the manager is not working in the home the staff are able to contact members of the executive committee for support or advice. The registered manager feels that the staff team understand and can relate to the aims and purposes of the home. This is usually achieved through regular staff meetings, staff supervision and annual appraisals. There is a good programme of review and audit that has been further developed over the last year. There are audits carried out on the building, the environment and safety. Service users are regularly consulted individually by a member of the executive management committee who spends time with them to seek their opinion of the service. These records are recorded in detail. The home carries out a formal process through questionnaires to service users, relatives and professionals who have contact with the home on an annual basis. The manager does not undertake the role of appointee for any service users. Service users are encouraged to look after their own financial affairs where at all possible. The home was not managing the finances of anyone living at the home. Some service users manage their own money and others have arrangements with families and sponsors. Service users have locked storage in their rooms if they wish to keep valuables with them and all residents have a key to their room door, which can be locked if they wish. The manager does not undertake the role of appointee for any service users. Service users are encouraged to look after their own financial affairs where at all possible. The home was not managing the finances of anyone living at the home. Some service users manage their own money and others have arrangements with families and sponsors. Service users have lockable storage in their rooms if they wish to keep valuables with them and all service users have a key to their room door, which can be locked if they wish. The registered manager stated that she carries out formal supervision with care staff although this has not been on a regular basis due to time off because DS0000023025.V339276.R01.S.doc Version 5.2 Page 24 of sickness. There must be a system in place to ensure care staff continue to receive formal supervision in the absence of the registered manager. Formal supervision needs to be undertaken six times a year and should cover all aspects of practice, philosophy of care in the home and career development needs. All other staff must be supervised as part of the normal management process on a continuous basis. This will be a requirement of the report. Records were seen for fire safety. These cover the homes fire procedures, practice fire drills, fire prevention, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm system is not being undertaken on a weekly basis and a requirement has been issued for improvement in this area. There is a fire based risk assessment that is reviewed annually. Evidence of mandatory health and safety training demonstrates that staff are up to date with this training. Service reports are in place for the maintenance of hoists and the lift. There are service certificates for the gas appliances dated February 2007 , PAT testing was undertaken in May 2007, and Legionella on 30/11/2006. There are systems in place for water chlorination and kitchen hygiene. COSHH sheets are up to date and accurate. DS0000023025.V339276.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 DS0000023025.V339276.R01.S.doc Version 5.2 Page 26 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 OP12 Regulation 15 Requirement Timescale for action 30/09/07 2. OP29 19 3. OP36 18 4. OP38 23 The registered manager is required to ensure that the care plans identify all service users social care needs. The registered manager is 30/07/07 required to ensure that all staff do not commence employment until two written references have been obtained. The registered manager is 30/10/07 required to ensure that all staff receive formal supervision at least six times a year. The registered manager is 30/07/07 required to ensure that the testing of the homes fire alarm is undertaken on a weekly basis and is recorded. 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 Good Practice Recommendations DS0000023025.V339276.R01.S.doc Version 5.2 Page 27 1. 2. OP9 OP16 It is strongly recommended that the medicine storage cabinet is re-sited to an area more appropriate for the safe administration of medicines. It is recommended that a copy of the complaints procedure is kept within the complaints log. DS0000023025.V339276.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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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