Inspection on 21/02/07 for Stratford Court

This inspection was carried out on 21st February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stratford Court 12/03/09

Stratford Court 12/12/05

Stratford Court 21/06/05

Stratford Court 02/02/05

Stratford Court 10/06/04

Stratford Court 18/12/03

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Stratford Court Stratford Road Salisbury Wiltshire SP1 3JH Lead Inspector Ms Sally Walker Unannounced Inspection 9:20 21 February 2007 st 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 DS0000028322.V324796.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. DS0000028322.V324796.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stratford Court Address Stratford Road Salisbury Wiltshire SP1 3JH 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) 01722 328855 01722 328494 The Orders Of St John Care Trust Miss Susan Tiller Care Home 48 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (48) DS0000028322.V324796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated at any one time is 48 No more than 14 service users with dementia aged 65 years and over may be accommodated at any one time No more than 6 service users aged 65 years and over with a mental disorder, excluding learning disability or dementia, may be accommodated at any one time The home may, from time to time, admit persons between the ages of 60 and 65 years of age. 12th December 2005 4. Date of last inspection Brief Description of the Service: Stratford Court was originally purpose built by the local authority as a care home for up to 48 older people. The home is also registered for up to 14 older people with dementia and up to 6 older people with a mental disorder. Two of the beds are offered to older people in the community for periods of respite care. The registered providers are The Orders of St John Care Trust and the registered manager is Miss Susan Tiller. The accommodation is arranged over two floors, with additional day care facilities located on the lower floor. The home is opposite Victoria Park in Salisbury, close to the city centre. Those residents with dementia and mental disorder live alongside the other residents. The staffing rota provided 5 care staff including a care leader during the morning, 4 care staff during the afternoons and evenings and three waking night staff. The home also employs housekeepers, cooks, kitchen assistants and a handyman. DS0000028322.V324796.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9:20am and 6:25pm. Miss Tiller was on sick leave and a manager from one of the other homes was overseeing the running of the home. However they had worked the night shift and were about to go home, so Jill Mitchener, Care Development Manager, came to assist with the inspection. A tour of the building was made. The care records, medication records, staff records and environmental risk assessments were inspected. Five residents were spoken with at length in their bedrooms. As part of the inspection process comments cards were sent to the home before the inspection for residents to comment on the service. Two residents said they received a contract. Three residents said they received sufficient information before moving in. Two residents had insufficient information. To the question; do you receive the care and support you need, 2 residents said they always did, 2 said they usually did and one said they sometimes did. Two residents said staff listened and acted on what they said and 2 said they did not. Three residents said staff were usually available when needed and 2 said sometimes. Three residents said they always received the medical support they needed and two said they usually did. Two residents said there were always activities that they could join in with and 2 said there usually were, one said sometimes. One resident said they always liked the meals, two said they usually did one said they sometimes did and one said they never did. Two residents said they always knew who to speak to if they weren’t happy, one said usually and one said never. Two residents knew how to make a complaint one said they usually knew how to complain and one said they did not know. Three residents said the home was always fresh and clean, one said it usually was and one said it sometimes was. Comments are included in the relevant part of the report. The fees for the home are between £370.00 and £486.00 per week. Items not covered by the fees include: hairdressing, chiropody, toiletries and some admission fees to events. What the service does well: In the absence of a format suitable for assessing the care and support needs of prospective residents, staff ensure they record relevant information needed to compile a care plan. Although there is no organisational policy on provision of intimate personal care by staff of a different gender, staff had spoken with residents and recorded their preferences in their care plans as a matter of good practice. There was evidence in some of the care plans that staff had spoken with residents about their preferred routines. This also included detailed personal information about how they liked their care to be provided. DS0000028322.V324796.R01.S.doc Version 5.2 Page 6 Systems were in place for the safe administration and control of medication. Residents had good access to health care professionals. The home keeps detailed records of complaint investigations, actions taken and outcome responses to complainants. The home is familiar with the Safeguarding Adults policy and procedure. Staff had good access to gaining NVQs. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000028322.V324796.R01.S.doc Version 5.2 Page 7 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 DS0000028322.V324796.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The organisation’s current paperwork does not allow the home to carry out full and detailed assessments of prospective residents. As a result individual assessors use their own skills to ask the type of questions needed to gain the relevant information in order to compile care plans. They also make their own notes of the often complex care needs of some people who may have a dementia or mental health needs. EVIDENCE: The requirement that the organisation’s latest paperwork was used for carrying out pre-admission assessments had been addressed to a degree. However the organisation now states that new documents are being trialled. Current formats used are mainly to determine funding in the form of a tick list. Other documents cover some personal history, preferred routines, health and medical history. The format does not assist in determining the often complex care needs of potential residents who may be in the category of dementia or mental DS0000028322.V324796.R01.S.doc Version 5.2 Page 9 health for which the home is registered. However those carrying out assessments have their own set of relevant questions and write their own notes to cover the more personal details needed to compile a care plan. Some of the responses to the comment cards included: “visited home before deciding and questions were answered on the visit”, “no information given [before moving in]” and “don’t know [if contract received]. DS0000028322.V324796.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There had been some improvements in the detail noted in care plans. Some changes in need prompted changes to the plans. Residents’ health care needs were being met but it was not always possible to determine this from the records. Residents can administer their own medication following a risk assessment. Staff respect residents right to privacy. EVIDENCE: The requirement that significant changes in need identified in the daily report prompted an immediate review and revision of the care plan was in progress. Clear guidance to staff on how that need was to be met was part of the requirement. Mrs Mitchener had already identified improvements needing to be made to recording. In response to this Mrs Mitchener and the organisation’s training manager were delivering training to staff on the purpose of good recording. There was still some work to do to ensure that full details are included in care plans. For example, with regard to one resident’s psychological and emotional care plan, staff had written “to offer support”. DS0000028322.V324796.R01.S.doc Version 5.2 Page 11 The record needs to be clear to identify exactly what support was needed. Where staff have written “to join in with activities”; there needed to be clearer guidance about what the resident liked to do and which activities they liked to join in with. Another care plan stated “staff to monitor”, yet there was no guidance on how staff were to monitor or when to take action. Bruising was recorded on a body map but there was no detail of size, colour or whether the skin was broken. One care plan stated that the resident preferred a weekly shower yet elsewhere in the same plan it was stated that they were to be offered a weekly bath. One of the residents said they regularly had their pacemaker checked, yet there was no mention of the appliance in their care plan. There was no reference to their taking a sublingual spray for angina. This resident said they had no problem in accessing their GP which the staff would organise. As a matter of good practice records state whether residents prefer to have a male or female staff to carry out intimate personal care. However the organisation does not have a policy of the giving of intimate personal care by staff of a different gender. Care plans identified how residents preferred to be supported with having a bath. There were records of when residents liked to get up and go to bed. There were also records of some residents’ meal preferences. The requirement that all care staff were trained in tissue viability was in progress. There is no tissue viability specialist nurse in the area so the organisation was reported to be providing the training. Tissue viability training was being provided that morning in one of the nearby homes. It was delivered by an ex-manager via a video and handouts. Eventually all care staff would benefit from the training. The training records showed that 13 staff had attended tissue viability training in March 2006. However it was not always clear from the assessments that staff always had a clear understanding of tissue viability. The organisation was reported to have been producing a recognised assessment tool. This is only now being piloted. Some care plans stated that the district nurse should be alerted when red marks appeared. Clearly too late as damage may have already occurred. One care plan did not record that a resident had a history of developing pressure sores, clearly identified in other parts of their notes. There was no record of pressure relieving equipment being in place. The only guidance to staff was to “check areas”. There was no indication of what this meant, what to check for or what to do if concerns were noted. One resident who told the inspector that they sat for long periods of time was identified as having a medium risk of developing pressure sores. There was no evidence of how this decision had been reached or whether pressure relieving equipment was in place. Another resident’s care plan stated that they were “prone to red areas”. There was no record of where these might be or whether any pressure relieving equipment was in place. It was however clear from the records that any concerns were promptly referred to the district nurse. The requirement that all residents DS0000028322.V324796.R01.S.doc Version 5.2 Page 12 have their risk of developing pressure damage assessed has been actioned only in that records had been made in the care plans. However the requirement remains. Not all risks to residents were being recorded. One resident had a form with no entries on it, not even that no risks had been identified or the reason. However moving and handling risk assessments were fully recorded with each residents monthly weight statement. High energy drinks were in evidence. The member of staff with delegated responsibility for the administration and control of medication showed the inspector the arrangements. Residents are able to administer their own medication following a risk assessment. They have lockable storage in their bedrooms in which to keep their medication. There was a list of staff who were deemed competent in administering medication. Staff’s ongoing competence was being regularly monitored. Care plans and healthcare records were variable in identifying specific monitoring and guidance regarding medication. One resident had been given an injection by the district nurse. The reason for this was not recorded. One resident had been prescribed medication via a patch applied to a different area of the body at each dose. There was no record of this in their care plan nor any record of where the current dose patch was situated. Not all of medication prescribed when required was identified in residents care plans. One resident was taking codeine phosphate prescribed when required. There was no record of what prompted this medication to be given. A member of staff said it was for pain and bowel management and the resident took it twice a day. However the GP visit sheet stated that the resident was being “weaned off” the medication in December 2006. Warfarin levels were being regularly monitored by the district nurse and GP and results or dosage changes were recorded on file and in the medication administration record. The care plan also identified why this medication was prescribed. The medication was administered via a monitored dosage system. Two trolleys were used to administer the medication to the residents on both floors. The requirement that medicines requiring cold storage were kept between 2ºC and 8ºC at all time, monitored and deviation addressed immediately had now been actioned. The fridges had been replaced and daily temperatures recorded. DS0000028322.V324796.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. A 20 hour post for activities for 48 residents means an allocation of less than half an hour each week for each resident. Some residents attend their clubs in the town. The home joins in with the activities of other homes in the organisation. Visitors were welcomed. Those residents who were able to decide and choose, followed their own routines. Most of the residents said they liked the meals. EVIDENCE: The home has a member of staff who provides activities for 20 hours each week. Given that the home is registered for 48 people, 20 hours a week is very little for activities, particularly one to one time. Some of the activities and regular visits were published on the notice boards, for example, Holy Communion. Many of the organisation’s homes in the area visited each other regularly to join in with each other’s activities. The home had its own minibus and regularly took residents for small trips in the locality. One of the residents said that the home had recently celebrated Chinese New Year with tasting of Chinese food and making paper lamps. Whilst it is recognised that the activities post was not yet filled, there were no activities that were planned DS0000028322.V324796.R01.S.doc Version 5.2 Page 14 specifically for those residents with a dementia or with mental health needs. Some of the care plans and in particular the social histories gained during the assessment process identified residents interests. Some of the residents joined in with the day service activities. Two residents were waiting for transport to go to their clubs in the town. They both said they enjoyed these visits and looked forward to a day out. One of the residents said they had a key to their bedroom door but not to the front door. They said it was not an issue because the staff would let them out or in again when they went out. They said they often got a bus or a taxi into Salisbury. Another resident said they regularly went out but there was no record of this in their care plan or risk assessment. Those residents who could choose spent their day as they wished and followed their own routines. Other residents relied on staff for direction as to how they spent their day. Visitors were made welcome and generally visited residents in their bedrooms. Some of the residents made use of the sitting area outside the front door. This area was also used for smoking. These residents would have to ring the front door bell to gain access back inside. Some of the written comments from surveys were: “I keep myself to myself but I just feel [illegible] up and very sad that I have to be here away from my former friends [again no name given]” and “My legs are bad for walking and I do not get out to do any shopping. I sit in and feel very forgotten”. The menu was displayed on a board by each servery and dining room. There was a choice of hot lunch meals and a salad. There was a hot pudding, yoghurt or fruit. The display was written in very small writing; not all of the residents would have been able to read the menus. Residents were given a choice at the meal. One of the residents spoken with said the food was “OK”. Another said there was no cooked breakfast and that the meals “were not brilliant”. Residents said they would have their breakfast in the dining room or on a tray in their bedrooms. Particular individual diets were on a notice board in the serveries, for example, a list of foods that could be eaten and those that could not. One resident said that they had found the soup to be very nourishing. They liked having their meals in their bedroom and talked about their favourite meals. One written comment was: “roast potatoes are often too hard for many of us to cut or eat, although we have pointed this out, nothing has changed”. DS0000028322.V324796.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place for residents and their families to make complaints about the service. The home is familiar with instigating the Safeguarding Adults process. EVIDENCE: The home worked to the organisation’s complaints procedure. The policy and procedure was displayed around the home on notice boards. A record of complaints was held. Mrs Mitchener confirmed that she had investigated some complaints and responded to complainants with an outcome and details of action taken. Following the inspection, Miss Tiller, the manager, said that one of the police officers from the Safeguarding Adults Unit was due to update staff on the local policy and procedure in a training session. The home is familiar with the system for reporting allegations of abuse. DS0000028322.V324796.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a plan to upgrade much of the building over the next few weeks. Residents’ bedrooms were personalised to reflect their personalities. Whilst cleaning staff hours were now allocated to the afternoons as well as the mornings, some areas not always visible need attention. Odours were addressed with deep cleaning. EVIDENCE: Mrs Mitchener confirmed that a programme of redecoration was taking place over the coming few weeks. Those areas to be completed were the upstairs corridor and dining room and new carpet laid to the entrance area. The requirement that the old single glazed windows to the bathrooms were replaced by modern double glazed windows was in progress. Mrs Mitchener reported that the organisation’s property department had done an audit of the home and all the outstanding refurbishment issues were being addressed. The DS0000028322.V324796.R01.S.doc Version 5.2 Page 17 installation of the windows was to start the following week and be completed by the end of March 2007. The remaining vanity units were also to be replaced as part of this year’s budget. One of the comment cards stated: “I was very disappointed what when the wash basins were being replaced, the supply ran out before my room was reached, even though I had earlier made a specific request for new taps. The home can get very hot and uncomfortable in the summer. I hope that the planned installation of air conditioning will not be subject to similar delays”. Another resident wrote: “The room buzzers do not always work which sometimes makes it difficult to call staff in an emergency”. Residents’ bedrooms were comfortable and they had individually decorated them with small personal items. All of those residents visited in their bedrooms had their call bells within easy reach. Oxygen prescribed for individual residents use was stored in their bedrooms, including unused cylinders. The doors were marked to show oxygen present. One cylinder was noted by the front door later in the inspection. Immediately outside was an area used by residents to smoke. Mrs Mitchener immediately removed the cylinder to the resident’s room. She later confirmed that staff had explained the risks to the resident and arranged for a portable supply to be prescribed. Mrs Mitchener had also immediately removed the spare cylinders to the oxygen store on site. The resident’s care plan and risk assessments were also immediately updated. The requirement that cleaning staff must be allocated throughout the home to ensure that it is cleaned to infection control standards had been actioned. However it was noted that the undersides of a bath hoist had a build up of limescale and dried brown material. During the afternoon, one of the cleaning staff was deep cleaning the carpets in an area that had previously had an odour of urine. One of the residents said that the laundry person provided a good service with their laundry being returned the following day. DS0000028322.V324796.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. A head of care has been appointed and a cleaner is now covering the afternoons. This has reduced the pressure on care staff to carry out administrative and cleaning duties. Staff had good access to NVQs and mandatory training. Some training in mental health and dementia was being planned. All staff are expected to undertake the Alzheimers Society training pack. The home’s recruitment records did not show a robust system. EVIDENCE: The requirement that consideration must be given to the numbers of care staff in relation to the needs of residents and the aims and objectives in the statement of purpose was in progress. A head of care post had been created. On the morning of the inspection there was one care leader with 5 carers. During the afternoons there were 4 care staff with a care leader and 3 care staff with a care leader during the evenings. At night there were 3 waking night staff. The rota showed a decrease in these numbers at the weekends. Mrs Mitchener said that this was because the full shifts had not yet been covered. Day and night staff hours were being recruited. A housekeeper was now working during the afternoon where previously housekeeping staff were only employed during the mornings. This meant that care staff had to do these duties as well as care. The housekeeping staff also worked 1.00pm to 7.00pm at the weekends. DS0000028322.V324796.R01.S.doc Version 5.2 Page 19 The staff personnel files were inspected. One staff who had transferred from another of the organisation’s homes did not have all of the documents and information required by regulation. There was no photograph, no proof of identity, no Criminal Records Bureau certificate or Protection of Vulnerable Adults check and no proof of identity. Mrs Mitchener said she would investigate whether the information was still retained at the other home. Another file had no medical questionnaire but 3 references. All new staff were required to undertake induction. Mrs Mitchener’s review of the staff’s individual training records showed that not all of the night staff had recent mandatory training. This was being addressed. The requirement that a staff training programme was in place for working with people with mental health problems was in some progress. A half day workshop was on the organisation’s current training bulletin. The training manager had met with the local mental health team to discuss providing a more extensive training programme in mental health. The inspector advised that mental health training must be one of the core subjects on the training matrix, given that the home is registered for up to 6 beds for people with mental health needs. The head of care had set up individual training records for all staff. An exmanager had provided training in dementia. All care and support staff were required to undertake training in Dementia. This was a training pack authorised by the Alzheimers Society and marked by them. Support staff undertake half day training. There was no ongoing training plan for working with people with dementia. Some training had been provided in house but there was no outsourced training. Some of the managers in the organisation had been involved in a video link session with a nationally recognised expert in dementia. All staff have access to NVQs. Five staff held NVQ Level 3 and 6 held NVQ Level2. Written comments from residents included: “[Staff listen and act on what is said] most of the time. Depends on numbers of staff on duty”, “very happy so far, kind and considerate staff”, “the home often seems to be short staffed and this leads to delays in issuing medication etc., and perversely to tea being served far too early. “The cleaners are always friendly and helpful” The organisation has no policy on the giving of intimate personal care by staff of a different gender. However staff had clearly asked each resident of their preferences and recorded the outcome on individual files. DS0000028322.V324796.R01.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Miss Tiller has been registered since June 2006. The home is run in the best interests of the residents. Systems are in place to assess the home with regard to health and safety for residents and others. EVIDENCE: Miss Tiller was registered as manager on 28th June 2006. Previously she had managed two homes for the organisation. Miss Tiller holds the Registered Managers Award. As part of the home’s quality assurance system, suggestion boxes were placed at various points in the home. The home also had regular residents meetings to talk about the meals, outings and activities. The minutes were posted on DS0000028322.V324796.R01.S.doc Version 5.2 Page 21 the notice boards. Questionnaires were sent to the home by the organisation in July each year as part of the quality assurance system. Relatives or their relatives were asked to comment on the service and fill out the forms. The home collated the responses and wrote an action plan, which was copied to the organisation. One resident’s survey form to the Commission stated: “there are regular residents meetings that are helpful”. Another said “some problems with noisy neighbouring residents acknowledged but nothing changes”. Another wrote: “a recent appointment has improved things considerably”. Assessments of the environment and staff duties and tasks had been carried out and were regularly reviewed. Individual risk assessments with residents could be found in their care plans. DS0000028322.V324796.R01.S.doc Version 5.2 Page 22 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 DS0000028322.V324796.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18(10(a) Requirement The person registered must consider the numbers of care staff provided in relation to the needs of residents at all times and the aims and objectives detailed in the statement of purpose. (The care staffing levels had not increased but a head of care post and afternoon housekeeping had reduced the pressure on care staff). The person registered must ensure that all care staff are trained in Tissue Viability. (This was in progress but care plans showed little understanding of preventative measures). The person registered must ensure that significant changes in need identified in the daily report prompt an immediate review and revision of the care plan with clear guidance to staff on how that need is to be met. (This was in good progress). The person registered must DS0000028322.V324796.R01.S.doc Timescale for action 31/07/07 2. OP8 18(c)(i) 30/06/07 3. OP7 15 21/02/07 4. OP8 13(4)(c) 21/02/07 Version 5.2 Page 24 ensure that written assessments are carried out with regard to residents’ risk of developing pressure sores. (Although training had been undertaken, the care plans did not show understanding of preventative measures). 5. OP3 14 The person registered must ensure that the organisation’s latest paperwork is used for the carrying out of assessments. (This was outstanding from the previous inspection. The organisation is currently trialling a new format). The person registered must ensure that all the documents and information required by regulation are in place before staff commence duties, even if those staff have transferred within the organisation. The person registered must ensure that a staff training programme is in place for working with people who have mental health problems. (A programme is being established). 21/02/07 6 OP29 19(1)(b) 21/02/07 7. OP30 18(1)(i) 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The person registered should consider increasing the number of hours provided for activities to enable residents to have opportunities to continue with those social interest identified in the assessment process DS0000028322.V324796.R01.S.doc Version 5.2 Page 25 DS0000028322.V324796.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000028322.V324796.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. 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