Inspection on 28/11/07 for Straven House

This inspection was carried out on 28th November 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

Straven House 22/02/07

Straven House 08/02/06

Straven House 22/04/05

Straven House 02/12/04

Straven House 11/05/04

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Abbey The

Snydale Care Home

Whiteley House

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Straven House Queens Road Ilkley West Yorkshire LS29 9QL Lead Inspector Nadia Jejna Key Unannounced Inspection 28th November 2007 10:30 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 Straven House DS0000001170.V355860.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. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Straven House Address Queens Road Ilkley West Yorkshire LS29 9QL 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) 01943 607063 01943 600708 www.bupa.co.uk BUPA Care Homes (GL) Ltd Mrs Lorraine Anne Moss Care Home 24 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (21), Physical disability over 65 years of age (1) Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for MD(E) is only for the use of the service user named in connection with the variation application of 13.1.05 22nd February 2007 Date of last inspection Brief Description of the Service: The home is an adapted detached property set in its own grounds on the outskirts of Ilkley. Accommodation is provided on the ground and first floors. There is a passenger lift, which can be used by residents to access the first floor and the lower ground floor where the dining room, kitchen and laundry are located. There are large attractive gardens but not all areas are accessible to residents; three patio areas have been provided, one of which has raised flower beds and another which can be accessed via the dining room has views across the valley. Ramps are available in the gardens and provide level access for wheelchair users into the building. A local bus route is nearby and Ilkley town centre is within walking distance although this is a steep road. The home is registered to provide care to twenty-four residents of either sex over the age of 65, care can be provided for up to two people with dementia and one person with a physical disability. Nursing care is not provided. Two shared rooms are used as singles therefore occupancy is limited operationally to twenty-two. Information about services provided by the home is kept in a file in the reception area as well as in residents’ rooms. Information packs will be posted to people on request. At the time of writing this report the homes charges for residential care range from £364 per week to £645. Items not covered by the fee include newspapers, hairdressing and chiropody. The manager provided this information in November 2007. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit started on 28th November 2007 and was unannounced. It was completed on 30th November. Feedback was given to the manager during and at the end of the visits. The purpose of this visit was to make sure that the home was being managed for the benefit and well being of the people using the service. People living in the home, their visitors and staff were spoken to. Records were looked at such as staff files, complaints and accidents records. Before the visit was planned the provider was asked to complete an annual quality assurance assessment (AQAA) of the service. This asks them to look at what they do well, what was in place to prove this, what improvements had been made over the last twelve months and what was planned for the year ahead. Other information asked for included what policies and procedures are in place, when they were last reviewed and when maintenance and safety checks were carried out. Questionnaires were sent to people living in the home, their relatives and healthcare professionals before the visit took place. These people were selected using information provided in the AQAA. At the time of the visit four people who live in the home, five relatives/visitors, three healthcare professionals and two staff had returned surveys. The information from these was used to inform the visit and is referred to throughout the report. What the service does well: Care is provided to people in a comfortable and well-maintained home. It is decorated and furnished to a good standard. People said that they can bring in their own belongings to personalise their rooms and that the home was always clean tidy and did not smell. This makes it a pleasant, comfortable and homely place to live. Visitors said that they could visit at any time, were made welcome and offered refreshments by staff. The atmosphere in the home was warm and friendly. It was clear that there were good relationships between staff, people living in the home and their visitors. People living in the home, their visitors and healthcare professionals said that: Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 6 • • • • • • • They had been given enough information about the services provided by the home. One person said they and their relative had been well supported when they moved into the home. They were satisfied and happy with the care and services received. The staff were kind, caring and polite. Their privacy and dignity was respected. They can choose how and where to spend to their time and whether or not they want to join in with the planned social activities. They enjoyed their meals and the food was good. What has improved since the last inspection? What they could do better: The manager could look at making sure that the information gained in the pre admission assessment for somebody: • Identifies whether or not they have dementia and if this is the main reason why they need twenty-four hour care and support. • If the numbers and skill mix of staff available will be suitable to meet their needs. The organisation could look at the numbers of staff on duty in order to make sure there are enough on duty at all times to meet people’s needs. They must Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 7 take into account people’s psychological needs, the amount of support needed with personal care as well as the size and layout of the building. This will help to make sure that peoples health, safety and well-being is monitored and their needs are met. The manager must make sure that people are given their medication as prescribed by their doctors. This will make sure that their health and well being is maintained. 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. Straven House DS0000001170.V355860.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 Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can make an informed choice about the home through visits and the information they are given. There is a risk that the needs of people with dementia will not be met because the numbers and skill of mix of staff is not enough to meet them. EVIDENCE: Information for residents and visitors is available in the reception area, along with a copy of the most recent inspection report. Files of useful information about the home and the services it provides are placed in every bedroom. The manager has revised the Statement of Purpose to make it easier for people using the service to follow and understand. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 10 I spoke to a visitor whose relative had been living at the home for a few months. They chose the home after looking round a few. The family and their relative came to look round a few times and the person’s care needs were assessed during one of these visits. They said that they had been given all the information they needed to make an informed decision. They said their relative is on treatment for early Alzheimer’s disease and this was why they needed to be in a care home. Their preadmission assessment did not mention this. The section that looks at the individual’s mental state and cognition said that there is some short-term memory loss. They were under the care of a psycho geriatrician. The manager was reminded that the information from the preadmission assessments must be used to make sure that the person’s care needs can be met by the home. This must include looking at the numbers and skill mix of staff available. The home’s conditions of registration must be taken into account. The home is registered to admit two people with dementia as their main reason for needing twenty-four hour care. Information given by the manager and looking at care plans suggested there were at least four people in this category of care. The numbers of staff on duty has not been adjusted to take their physical and psychological care needs into account and there is a risk they might not be met. Information from surveys and talking to people said that: • They had been given enough information about the services provided by the home. • One person said they and their relative had been well supported when they moved into the home. • They were satisfied with the services received. Straven House DS0000001170.V355860.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 adequate. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are set out in care plans. But links between the health care assessments and guidance in the care plans are not always being made. This means that there is risk people’s healthcare needs might not be identified or met. EVIDENCE: Since the last inspection in November 2006, the organisation has introduced a new system of care planning to all of its care homes. Training and guidance about how to use it has been given to staff. The aim is to make sure that all people living in their care homes have detailed, individual, person centred care plans that provide staff with all the information needed to meet their needs. After the training sessions had taken place all the care plans had to be switched over to the new format within a set timescale. Staff have worked very hard to meet the deadlines set by the organisation and are still getting used to the new systems. The manager has a system for auditing care plans and making sure they are detailed and individual. She has identified that some of them need to be more ‘person centred’. Staff spoken to had a good Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 12 awareness of people’s needs and abilities and said that they used the care plans regularly. Four care plans were looked at. They showed that: • Where possible people had seen their care plans. • Not all the documents had been dated and signed by the person writing them. • Healthcare assessments are carried out. Some of the plans would benefit from additional information about the individuals needs, abilities and preferences. For example: • The night plan for a person with a history of anxiety did not show that they took sedatives every night to help them settle and sleep. • The care plans for people with dementia did not say how it affected them and how staff could help them. The care plan for somebody who was taking medication specifically for Alzheimer’s disease did not say they had the disease. All areas of personal care and support needed were around problems with poor memory and being disorientated. • Nutritional assessments are carried out but the outcomes are not always reflected in the care plans. In two cases the assessment showed that the individuals should have been receiving enriched foods and advice sought from their GP’s. This is clearly set out in guidance provided by the organisation but it had not been followed. The chef enriches all foods served as standard practice but was not aware that these people needed to be given additional enriched foods. Medication records and stocks were looked at. These showed that there was a problem with drugs that should be given regularly but were not in the pre packed monitored dosage system cassettes. For example: • Two people had over a month’s supply of tablets in the stock cupboards that would not have been there if they had been given as prescribed. • Somebody had over two weeks stock left over of a tablet that is a regular prescription. • Another person had not been given their weekly medication because it was out of stock; but the medication record clearly showed it had been received in good time for it to be given as prescribed. • The medication administration record (MAR) showed one person had missed four doses of their night medication because it was out of stock. But it is a regular medication that they have been taking for a long time and the systems for ordering prescriptions should have made sure that new stocks were received in good time. The manager was made aware of these issues and advised that action must be taken to make sure people receive their medication as prescribed by their GP’s. When feedback was given the manager said it would be dealt with straight away and she had asked the supplying pharmacist to provide support and advice. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 13 Accident records are kept. Staff are adding what time person last seen before accident and by whom. Not all accidents are being reported to CSCI as required under regulation 37. Some people have had a high number of falls. The manager said they have been referred via district nurses and community matron to the falls prevention team. One person had been seen by a physiotherapist and given a new walking aid. Information from people living in the home and returned surveys said that: • People’s privacy and dignity was respected. Healthcare professionals said they saw people in their own rooms. • People usually got the care and support they needed. • People were treated with respect. • Relatives were kept up to date about changes in the person’s condition such as illnesses or accidents Straven House DS0000001170.V355860.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 excellent. This judgement has been made using available evidence including a visit to this service. People’s choices are respected and contact with family and friends is encouraged. EVIDENCE: Relatives and visitors said that they could come at any time and they were always made to feel welcome. The atmosphere in the home was warm and friendly. It was clear that there were good relationships between people living in the home, their visitors and staff. People said that they could choose how to spend their time, when to get up, when to go to bed and where to eat their meals. They said that the staff were kind and attentive and did what they could to meet their needs. An activities organiser has been in post for the last six months. Their background includes working with older people and occupational therapy. They have done some in house training and would like to do more especially around activities for people with dementia. There is a regular programme of activities through the week. It includes armchair exercises, reminiscence sessions, singa-longs, quizzes and bingo. Everybody is encouraged to join in but people can Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 15 choose whether or not they want to. The activity organiser will visit people who stay in their own rooms and do things with them such as hand massage and reading. Once a month they take a group of people to a community centre in the town centre for coffee and to meet other people. Plans for Christmas activities are well under way including an Xmas Fayre, trips out and themed evenings such as a ‘Mexican night’ and entertainers coming in to the home. The manager said that people have asked for a ‘social evening’ where they can sit with a drink and chat – the first one is planned for mid December. One person prefers to have activity sessions later in the day and arrangements have been made for a carer to be with them at set times through the week to facilitate this. Once a month there is a communion service for people who want to take it and local clergy visit the home regularly. One person goes to their church every Wednesday afternoon. Menu plans are in place and these are changed at regular intervals. People can choose what they want to eat and alternatives are always available if they do not want what is on the menu for that day. The chef speaks to people and is aware of individual’s likes and dislikes and will accommodate these and any special diets or preferences. Meals are prepared using fresh produce and residents enjoy home baking most days. The kitchen was clean, tidy and well organised. The last environmental health inspection gave the kitchen an excellent 5 star rating. Meals were nicely served and people said that they enjoyed their food. Straven House DS0000001170.V355860.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. This judgement has been made using available evidence including a visit to this service. People can be confident that their concerns will be listened to, taken seriously and acted on. EVIDENCE: A complaints procedure is in place. It is made available to everybody in the Statement of Purpose and the useful information file that is kept in every bedroom. Complaints leaflets are readily available people to use. People said that they knew what to do and who to speak to if they had any concerns. Complaints and compliments records are kept. Since the last inspection in February 2007 there have been four complaints from people living in the home. They were about a variety of issues and the manager dealt with them appropriately. For example: • One was about the hours provided/worked by activity organiser; the individual wanted to do things after 3pm. After a meeting with them an agreement was made that a nominated person would do activities with them later in the day. • Somebody said that their room was not being cleaned properly. The manager arranged for the rooms to be cleaned when people are in their rooms so they know it is being done. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 17 • There was a complaint about the use of agency staff and the risk of a medication error that had been averted because the person knew what tablets they should be taking. The organisation has adult protection policies and information in place and the home has got copies of the local authority adult protection procedures. Most staff have received training around abuse. The manager said that newly employed staff had not done it yet. The manager has attended a two day managers course around adult protection provided by the local authority adult protection unit. Staff said that they would report suspected or actual abuse to the person in charge. Straven House DS0000001170.V355860.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, 24 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in clean, comfortable, well maintained home that is suitable to their needs. EVIDENCE: The building is well maintained. The main entrance has steps but there is ramp access to a door at the side of the building. The three patio/garden areas are accessible to people of all abilities. One of these areas has raised flower beds and people are encouraged to look after these. A lift connects the different floors of the home so people do not have to use the stairs. Most areas of the building are accessible to wheelchair users. The two communal lounges on the ground floor and the dining room in the basement have been furnished and decorated to a high standard, providing comfortable places to sit. One of the lounges has lovely views over the town of Ilkley. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 19 The home was clean and tidy. A new housekeeper has been employed since the last inspection. People were happy with their rooms and said that they were kept clean and free from smells. The rooms seen were nicely decorated and furnished. It was clear that people can bring their own belongings, and furniture where possible, to personalise their rooms. Some of the bedrooms en suite facilities include baths. There is adequate provision of communal toilets and assisted bathrooms. One of the bathrooms has been fitted with a special bath that is height adjustable and can be used by people of all abilities. A new nurse call system has been installed. Disposable gloves and aprons are available and there is adequate provision of liquid soap and disposable towels for staff use. This helps to make sure staff follow good infection control practice. People said they were satisfied with the laundry services. Clothes and linens seen were clean, well laundered and ironed. Straven House DS0000001170.V355860.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. This judgement has been made using available evidence including a visit to this service. At times there are not enough staff on duty. There is a risk that the health, safety and well being of people will not be maintained. EVIDENCE: Following the inspection in February 2007 a recommendation of good practice was made that the manager should review staffing levels regularly. This was so that she could be sure enough staff are on duty to meet the needs and numbers of people living in the home. The size and layout of the building should be taken into consideration when doing this because staff can be busy in different wings and not available to respond to people. At that time there were eighteen people living in the home with three staff on duty from eight in the morning till eight at night and two night staff. The AQAA said that the organisation ‘maintains the correct number of staff agreed with the inspectorate and taking account of the individual needs of people’. But written agreements about staff numbers are no longer made. The Regulation about staffing says that ‘there must be enough staff on duty to meet the needs and numbers of people’, they are not set because peoples needs change and it is up to the care service to monitor this and alter them accordingly. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 21 When the visits were made there were twenty-two people living in the home and three staff on duty. The manager said that this was appropriate. She was recruiting kitchen assistants and a hostess to serve meals and drinks to ‘free up’ care staff from this duty. She said there have been staffing problems because of sickness and agency staff were being used. Information received before and during the inspection was: • People said that staff were available, sometimes, when they needed them. Some people said sometimes they waited a long time for call bells to be answered. • More consistency with the agency staff used would improve the care provided. • Often there did not appear to be enough staff on duty. • A health care professionals survey said that sometimes staff were hard to find when they visited the home. • The staff were always helpful and cheerful, even when they were very busy. • A returned survey said ‘the demands of some residents means staff cannot be there for others.’ • A returned survey said ‘an extra member of staff through the day would be helpful.’ • People were not having baths in the mornings because there were not enough staff available. From looking at care plans it was clear that some people living in the home need a lot of physical and psychological support, for safety reasons and to monitor their whereabouts because they walk around a lot and are at risk of falling. This is in addition to people who need two staff to help them with personal care. Three staff files were looked at. These showed that the required pre employment checks were in place before they started working in the home. One of the application forms needed more information about dates of previous employment so that gaps in employment could be identified and discussed. The files showed that they had all been enrolled on the organisation’s induction training that is equivalent to the Skills for Care common induction standards. One of them had not done care work before and said that they had been extra to numbers for the first three weeks, working with experienced carers while they learned about the home, the people living in it and what their role would be. They said that staff had been very helpful and supportive. Information from the AQAA, the manager and staff files looked at showed that: • Out of seventeen care staff, twelve of them had achieved an NVQ (National Vocational Qualification) at level 2 or higher. • All staff had received training or updates around moving and handling people safely and fire safety. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 22 • • • Some staff had received training about food hygiene, first aid, health and safety, infection control, palliative care and dementia. Some staff had done training about the Mental Capacity Act and there were plans for all staff to receive it. Senior care staff had been trained to monitor peoples blood pressure and what ‘normal’ readings where so they knew when to get medical help. The manager has identified where gaps in training are for different members of staff and will make sure that it is provided to them. She has also arranged for training sessions in the New Year about tissue viability and looking after skin. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is running the home in the best interests of people living there. There are areas where the organisation can improve outcomes for people, such as looking at the staffing levels. EVIDENCE: The manager is now registered with the CSCI after successfully completing the registration process. She has almost completed the registered managers award. The manager’s office is now on the ground floor. She said this has been a very positive move because it has made it easier for people to approach her and she is more ‘in touch’ with the daily life of the home. During the visit people who live in the home and visitors were calling in at the office to speak to her. Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 24 People said that the manager was approachable and helpful. Residents and relatives meetings are held at least every three months and records kept. Regular staff meetings are also held. Staff said that the management team was supportive and people worked well together. The organisation is accredited with the Investors In People quality assurance award. There are systems in place to support, monitor and audit the quality of services provided. For example, policies and procedures which are reviewed regularly and the organisation’s Quality and Compliance department. The last survey of the views of people using the service was in November 2006. The results were discussed with people living in the home at a ‘residents meeting’. An action plan was put in place to deal with issues raised. For example, general cleanliness – a new housekeeper has been employed and weekend cleaning staff. Questionnaires have been sent out to people as part of this year’s customer satisfaction survey. The results will be made available to all interested parties. The home does not act as appointee or agent for anybody. If somebody wanted the home to hold money in safekeeping for them there are systems in place to do this and appropriate records would be kept. If this is requested the money will be kept in an account. Staff will draw money out for people when they want it. Computerised records are kept of all transactions, receipts issued for money received and signed records kept when money is returned to somebody. Information from monthly visit reports by the responsible individual said that formal staff supervisions and appraisals are being provided at regular intervals. Information from the AQAA said that: • All maintenance and safety checks were carried out and kept up to date. • Regular Health & Safety meetings with a standardised agenda are held, which give staff the opportunity to communicate on Health and Safety issues. The minutes from these meetings go to the Regional Manager. Straven House DS0000001170.V355860.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 3 X 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X X 4 X 4 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 3 3 X 3 3 X 3 Straven House DS0000001170.V355860.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 OP8 Regulation 37 Requirement The manager must make sure that accidents and incidents that affect the safety or well being of people living in the home are reported to CSCI in writing as soon as possible. The manager must make sure that the information and outcomes of the health care assessments are used to identify where an individual needs additional support from healthcare professionals. Appropriate care plans and guidance for staff on how to meet these needs must be put in place. Particular attention must be paid to people who are at risk of losing weight. The manager must make sure that steps are taken so that medications are dealt with safely. People must be given their medications as prescribed by their doctors so that their health and general wellbeing is maintained. The organisation must make sure that there are enough staff DS0000001170.V355860.R01.S.doc Timescale for action 20/12/07 2. OP8 12 (1)(2) (3)(4) 13 (1)(b) 20/12/07 3. OP9 13 (2) 30/11/07 4. OP27 18 (1)(a) 20/12/07 Straven House Version 5.2 Page 27 on duty at all times in order to meet the needs and numbers of residents living in the home. The size and layout of the building should also be taken into consideration when doing this. This will make sure that peoples health, safety and well-being is monitored and maintained and that their personal, social and psychological care and support needs are met. 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. 4. 5. Refer to Standard OP3 OP4 OP7 OP29 OP30 Good Practice Recommendations The manager should make sure that the information from the pre admission assessment is used to make sure that the home can meet their needs. The care plans should be more detailed, providing staff with clear guidance about an individual’s personal, physical, health and social care needs are to be met. The manager should make sure application forms request a full employment history, with dates so that any gaps in employment can be identified and explored. The manager should make sure that all staff receive training that equips and helps them to maintain the health, safety and welfare of people living in the home and themselves. Training about specialist care needs of service users should also be provided. The manager should forward confirmation that she has successfully completed the registered managers award to the CSCI when it available. 6. OP31 Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Straven House DS0000001170.V355860.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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