Inspection on 19/11/07 for Summer Lane Care Home

This inspection was carried out on 19th November 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 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

Summer Lane Care Home 06/11/08

Summer Lane Care Home 01/03/07

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Summer Lane Care Home Diamond Batch Worle Weston Super Mare North Somerset BS24 7AY Lead Inspector Melanie Edwards Key Unannounced Inspection 09:30 19 , 20 and 21st November 2007 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Summer Lane Care Home DS0000068380.V351822.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. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summer Lane Care Home Address Diamond Batch Worle Weston Super Mare North Somerset BS24 7AY 01934 529190 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) Summer Lane Care Home Ltd Mrs Susan Ann Packham Care Home 90 Category(ies) of Dementia - over 65 years of age (45), Old age, registration, with number not falling within any other category (45) of places Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate in the Balmoral Suite up to 45 people in category OP, who require nursing care, of whom up to 5 may be 60 - 64 years of age. May accommodate in the Waverly Suite up to 45 people in category DE(E) who may require nursing care of whom up to 5 may be 60 - 64 years of age. January 2007 Date of last inspection Brief Description of the Service: Summer Lane Nursing Home is a purpose-built home that opened in September 2005. The Home is in a residential area close to local facilities and the M5 motorway. Weston-super-Mare town and the seafront are a few miles way. Summer Lane is comprised of two units: Balmoral on the ground floor which caters for older people with general nursing needs, and Waverley on the first floor which caters for people with nursing needs due to their Dementia. Each unit is divided into clusters of bedrooms around smaller lounges and kitchendiners. A spacious lounge leading off the foyer is used for entertainments and meetings. There is a large central garden. Downstairs bedrooms on the inner side of the square all have French windows facing onto this garden. Downstairs bedrooms on the outer side of the home have French windows leading on to small patio areas and a secure walkway around the outside of the building. There is also a large enclosed garden at the back of a property for use by people on the upstairs wing. This wing has a spacious patio roof garden that is accessible from the activities room. A local GP provides a weekly surgery at the home as well as additional health care support needed. A Consultant Psychiatrist also visits the Waverley wing on a regular basis. Fee levels range between £467 and £625. Fees exclude hairdressing, chiropody, newspapers and toiletries. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over three days. Nicola Hill a Regulation Inspector, and Sue Fuller, a Pharmacist Inspector assisted with the inspection on the first day. We met over sixty of the eighty-nine residents living at the Home. The acting manager, ten care assistants and two chefs were consulted about roles, responsibilities, training needs, and how they assist residents. Staff were observed assisting residents with their needs on each day of the inspection. The lunchtime meals were observed being served on two days of the inspection. A selection of records relating to the running and management of the Home were looked at. Nine resident’s care records and care plans were checked. The majority of the environment was seen and the only areas that were not checked were a small number of bedrooms. An ‘AQAA’ (an annual quality assessment document that all Homes are required to use) was completed by the acting manager. The Home was operating within the required conditions of registration set down by the Commission. The conditions of registration detail the type of care and the needs of residents, and the numbers of residents who may stay at the Home. What the service does well: Residents are provided with a good standard of care and staff work hard meeting their needs and wishes. Residents’ plans of care are helpful and informative and demonstrate needs are met. Residents are cared for by staff who have done a good range of training and have good development opportunities. Residents with dementia are cared for by staff who have a good understanding of what dementia is, and how they should support the residents. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 6 Residents are provided with a good standard and variety of food as well as a varied range of social and therapeutic activities both in and out of the Home. The environment is highly suited to meet the needs of residents. The design of the building and the equipment and adaptations in place make the place very homely, yet very suitable for residents. The purpose built Home manages to be very suitable for the needs of residents who have Dementia, and residents who need general nursing care. 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. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 7 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. Summer Lane Care Home DS0000068380.V351822.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 Summer Lane Care Home DS0000068380.V351822.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. Quality in this outcome area is good. The needs of residents’ are being well assessed and well met by the Home. Prospective residents and their representatives have the information they need to make an informed choice about living at the Home. However the statement of purpose is not up to date, in reference to the first floor part of the Home and the use of the secure keypad system. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how prospective residents and their representatives are helped to find out about the Home a copy of the service users guide and statement of purpose was read. The statement of purpose and the service users guide contain a range of information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aim to meet residents needs is included. The complaints procedure is in the service users so residents know how to complain about the service. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 10 However the statement of purpose does not explain the reasons for the use of keypad entry systems on the first floor. This information is needed to demonstrate the reasons why residents who have Dementia, and live on the first floor need this protection. There should also be a procedure in place for residents who do have Mental Capacity, to be able to exit and enter the Unit if they so wish. There is a colour brochure with photographs of the Home and other useful information. There is also a website that tells people about the Home. The assessment records of nine residents were read to check how effectively their needs are being assessed. There was an assessment for each resident of the risk the person may face of falling. There was also an assessment carried out of the persons skin vulnerability, and the risk of the person getting a pressure sore. There was a moving and handling assessment for each person setting out how best to help them with their mobility. There was also a dietary assessment recording what the person’s nutritional needs are, and how to help them meet those needs. The assessment records were informative, and showed the residents and their families had been asked out about their range of physical, mental and social needs. The assessment records related clearly to the care plans, and showed a detailed assessment of the persons needs had been carried out and that plans of care had been written based on the initial assessments. There were many comments of satisfaction expressed by residents and relatives about the care they receive and how they feel their needs are being met Examples of comments made included, ‘staff always seem friendly and caring when ever I visit, The atmosphere in the home always seem cheerful and they make time to talk to residents and relations ’, ` I think the staff do a wonderful job with very challenging clients’, `they get the emotional support they deserve’, and, ‘I have witnessed staff to be very caring and responsive to the residents ’. These comments were reflective of many comments made, and show residents relatives, and `significant others’, are satisfied with the service. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. Residents’ care plans generally demonstrate how needs are met. Medication practises and procedures are partly safe. Residents are treated in a respectful and polite way by the staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Nine residents care plans were read to check how well residents are supported to meet their needs. The care plans were informative and detailed how to meet the care needs of the person. The care plans stated what actions staff must follow to assist the resident to meet their needs. Care plans included information about each resident’s physical, psychological, social. Communication and spiritual needs. They had been written from an initial assessment of what the person’s needs were and what support and help they need. This assessment process helps ensure residents’ needs are clearly identified. However there are two residents who have been identified as needing to have their medication given to them covertly for their own health Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 12 and wellbeing. If this practise is to take place it should be done in by following an up to date care plan that sets out how and why this needs to be done .The registered nurses should also make sure they follow the National Midwifery Council guidance, on administering medication in this way. The care plans had been reviewed and updated regularly by registered nurses. This helps to demonstrate residents’ health needs are being monitored and kept under review. A G.P was observed attending to resident’s health care needs on the second day of the inspection. This is good evidence demonstrating how residents’ health needs are monitored by the Home. A chiropodist also came for appointments attending to residents foot care. The residents, and relatives consulted said that the staff are very helpful, kind and caring, when they assist them with their needs. There were many comments made about the staff including, `nothing is too much trouble for the staff’, and `they are always friendly and welcoming ’. The staff were observed to be very welcoming warm and friendly to residents and visitors on each day of the inspection. Staff were observed assisting residents in a very polite and very friendly manner. Domestic staff and laundry staff were also observed talking to residents in a very kind, and respectful way. Staff knocked on bedroom doors before entering bedrooms. This is a good way for the staff to help to protect residents’ rights to privacy. Three registered nurses were asked how they support residents to meet their health care needs. The nurses explained they assess and monitor residents’ health needs, and registered nurses will call a GP if required. There was also supporting information in residents’ care plans that demonstrated residents are well supported with their physical health care needs by the GP, the dentist, and the chiropodist. All residents are asked to register with a local doctor’ surgery. The registered manager (Ms Ndanga) said that the home have very good support from the doctors. A doctor visits the home each week. The pharmacy supplies medicines using a monthly monitored dosage system. A homely remedy policy has been agreed with the doctor so that staff can treat minor ailments. A self-medication policy is available but staff said at the present no residents are able to look after their own medicines. Ms Ndanga said that staff always check whether people wish to and are able to look after their own medicines as part of pre-admission assessment. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 13 Secure medicine storage is available on each floor of the home. Each floor also has two medicine trolleys so that medicines can be transported safely around the home. Both floors have medicine fridges and temperature records show that these are kept within the safe range for medicines. Suitable storage is available for medicines needing additional security and records showed that these medicines have been kept safely. Blister packs indicated that medicines had been given as recorded by staff. Spot checks of medicines supplied in standard packs also showed that these have been given as recorded. We watched the lunchtime medicines being given to residents in one area of the home, and saw that these were given safely. The pharmacy provides printed medicines administration record sheets. Photographs of the residents are kept with medicines administration record sheets to help safe administration. Lists are available of all nurses’ initials so that it is clear who has given the medicines. Staff have completed the administration record clearly. An audit tool has been designed so that the manager can check that records are completed correctly and nurses spoken to confirm the importance of this to show that medicines have been given safely. Records are kept of the receipt of medicines into Summer Lane. However medicines received for two people in weekly dose boxes had not been recorded. In one of these boxes it appeared that medicines had been added to the original box labelled by the pharmacy. Staff must administer medicines from the labelled container supplied by the pharmacy and any discrepancies must be confirmed. This is so that staff can check that medicines are correct before they give them to a resident. Several residents on the ground floor are prescribed creams and ointments but their application is not recorded on the medicines administration record sheet because they are kept in bedrooms and applied by care staff. Action is needed to make sure that records are kept of all prescribed medicines administered. Several residents upstairs in the home are prescribed medicines to be used as directed. In some cases there was no clear written guidance for staff as to when these medicines should be used or of the maximum dose that could be given in a day. Action is needed to address this to make sure that these medicines are always given appropriately and that residents’ health is protected. Summer Lane Care Home DS0000068380.V351822.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): 12,15. Quality in this outcome area is good. Residents are offered a varied nutritious diet and a range of social and therapeutic activities that are suitable for their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home employs two activities co-ordinators who work five days a week, and a third activities organiser who works for half of the week with residents. One of the activities co coordinators who works with residents with Dementia demonstrated a good knowledge and sensitivity to the needs of the residents. Specifically she was observed engaging residents with limited communication, in a range of social activities that they looked to be very much enjoying. On the afternoon of the second day of the inspection a local musician entertained residents. Residents were singing along to the music, and looked relaxed and as if they were enjoying the entertainment. There are copies of the timetables of social activities for residents to see throughout the Home to ensure they know what activities are taking place. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 15 Residents can take part in a range of social activities as well arts and craft classes and regular trips out into the local community. There is also an activities room used for a range of arts and crafts and social activities. Several residents have their own cats that live with them at the Home. The residents who have cats at the Home said how much they appreciated this A hairdresser service is also provided during the week, and a number of residents have their hair attended to on a regular basis. Residents’ meals are served to them from six dining rooms, on each floor, or in their rooms if preferred. At meal times dining tables are covered with tablecloths and there are table settings and condiments at each table. The staff helped residents with their meals in a calm, patient and discreet way. The Home operates a rotating menu, and menu choices were well balanced and varied. All of the residents who were consulted commented positively about the quality of meals that are offered. To inspect the quality of food provided a portion of both lunchtime meal choices were tasted on each day of the inspection The meal choices on each day were very tasted, well cooked and well presented There was a choice of homemade puddings, fresh fruit salad, or yoghurts for dessert. Residents can also choices other options if they don’t like the two main meals choices, and several residents were observed having alternative meals. Special diets are also well catered for. Residents who need to eat a soft diet, are given food that is well presented on the plate. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. Residents are well supported to make complaints about the service. There is training and procedures in place to help to protect residents from the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the complaints procedure on display in the reception area. This includes the name of the Commission for Social Care Inspection for anyone who wishes to contact the Commission directly. The contact details of the registered provider of the Home are included, if residents or representatives wish to contact them to complain. Residents knew who to complain to if they were unhappy .The staff knew how to support residents with Dementia if they thought they were unsatisfied or unhappy by the service. The record of complaints received, was looked at to see how the Home responds when complaints are made. There had been one written complaint received since the last inspection relating to care practices. There was information to show the acting manager is responding thoroughly to address the complaint. There are residents meetings held. This is also a good opportunity for residents to complain if they need to. Relatives also commented that the action manager Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 17 is very approachable and they are able to go to her if they have any concerns or complaints. There is a procedure in place relating to the issue of protection of vulnerable adults from abuse. However the procedure does not make any reference to the need to contact, and be guided by the North Somerset Adult Protection team in the event of an allegation of abuse. The Home has a `whistle blowing policy’ for staff to be supported, and to feel confident to raise allegations of poor practise in the Home .All staff are given a copy of the policy, to ensure they know their rights, and are `protected’ if they do raise legitimate concerns. All staff do regular training sessions to help them in understanding the principle of the protection of vulnerable adults from abuse. Staff demonstrated a good understating of the protection of vulnerable adults from abuse, and their responsibilities to protect residents in their care. Summer Lane Care Home DS0000068380.V351822.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): 19,20,21,22,25,26,Quality in this outcome area is excellent. The Home is very safe and well-maintained .The environment is also very suitable for the needs of the residents who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Summer Lane Care Home is run as two units. Balmoral Unit is on the ground floor. This Unit is run to provide care and support for older people with general nursing needs. Waverley Unit is on the first floor that caters for older people who have Dementia. Bedrooms and communal rooms are spacious and the standard of fixtures and fittings are of a very high standard. The Home was very clean in all of the areas that were seen. There are a variety of communal rooms. These include an activities room, a hairdressing salon, and a spacious function room. Residents were observed sitting in the communal areas looking very relaxed and comfortable in their Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 19 surroundings. Bedrooms on the ground floor have `French windows’ onto either the large central garden, or a small garden by the entrance. Each Unit has been split into groups of a dozen bedrooms There is a lounge and a dining room as part of each group. All bedrooms are for single occupancy, and are spacious with en suite toilet facilities. A number of bedrooms have an internal connecting door that allows them to be used as a double bedroom with private lounge by couples that wish to share. A number of residents told us how they very much like their bedrooms. Each bedroom has a television and telephone lines are in many of the rooms. There are call bells fitted in each bedroom so that residents can summon staff for help if they need to. The building is easily accessible for people with reduced mobility. There are two passenger lifts so that people can get to the first floor easily. There are adaptations in place throughout the Home to help residents and visitors who are disabled. There is a full time maintenance worker employed to do general maintenance they were seen carrying out their duties during the inspection. The service records were seen for the fire fighting equipment, the lift, and electronic equipment. The records showed that an external contractor had serviced equipment in the last twelve months. This helps demonstrate that the Home is safe and well maintained. Summer Lane Care Home DS0000068380.V351822.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): 27,28,30. Quality in this outcome area is good. Residents are cared for by sufficient staff who are trained and competent to support residents to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On each day of the inspection the staff who were on duty were seen assisting residents in a noticeably patent and sensitive way. Residents who have Dementia, were being helped with skill and considerable patience by the staff The staff were observed on both days of the inspection assisting residents with their care needs. Staff were warm and friendly in manner, and residents evidently enjoy close relationships with them. The number of nursing and care staff on duty was reviewed to find out if residents’ benefit from a sufficient number of staff to meet their needs. There is a minimum of four registered nurses on duty and sixteen care assistants in the morning, and afternoon. There are also three registered nurses who are the Unit managers who work additional shifts for five days a week on each Unit. At night there are two registered nurses and eight care assistants on duty. There is an additional staff members employed on a daily basis to serve drinks and assist with meals for residents. The manager works nine to five hours. However she also works alongside the registered nurses and care staff to ensure she keeps up to date with matters in the Home. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 21 The acting manager has a daily meeting with senior staff, and Unit Managers. This daily meeting has been put in place by the Acting Manager to improve communication and working relationships among the staff team. This demonstrates good management and leadership in the Home. There are full time catering, domestic and laundry staff also employed although the number of these staff was not reviewed at the inspection. Staff have done a range of training outside of the Home. There are also outside speakers who come to the Home and talk to staff about a range of clinical and general issues relevant to residents’ needs and the running of the Home. The training records of three registered nurses and three care assistants were reviewed to see if registered nurses are keeping up to date with their clinical knowledge and practice. There was evidence that demonstrated registered nurses had attended clinical training sessions, and updating over the last twelve months. There is a high number of staff in the Home who have obtained National Vocational Qualifications (NVQ). A National Vocational Qualification in care trainer was having a tutored with care staff on the first day of the inspection. Catering staff and ancillary staff have completed NVQ qualifications in subjects relevant to the work that they do. In discussion with registered nurses and the care staff the staff it was evident they have a good understanding and awareness of residents range of needs. Staff also spoke very positively about the commendable range of training and development opportunities that they can do. Summer Lane Care Home DS0000068380.V351822.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): 31,32,36,37,38. Quality in this outcome area is adequate. The Acting Manager is running the Home very well. However the owners are not formally monitoring the Home and service consistently. The health and safety systems and procedures in place partly protect the health and safety of residents, staff and visitors. The staff team are being appropriately supervised in the work they do. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 23 Ms Ndanga is the acting manager of the Home. She is applying to be registered with us, as manager. She has previously been a registered manager in Care homes in other parts of the country. Ms Ndanga has worked at Summer Lane since August of this year. Since then she has put in place a number of new systems aimed at improving the overall running of the Home .She has introduced daily meetings with herself and all of the senior staff across the Home. This has been done she said to help to improve communication among a very large staff team. She also invites all residents relatives and `significant others’ to meet her and talk to her about any concerns and problems they have with the Home. Staff are provided with regular support and supervision to help them in the Work they do and in better understanding residents’ needs. Several staff talked about the system of supervision in place. They say they have regular supervision sessions, and meet with senior staff to discuss work matters, and their own work performance on a regular basis Residents’ legal rights are protected by records that are satisfactorily maintained, up to date, legible and in order. The care records seen were generally satisfactorily maintained up to date and in order. Individual records and the Home’s records were kept secure in the Home, and are available to staff when needed. However the owners of the Home have not been consistently doing the monthly-unannounced monitoring visits, called Regulation 26 visits. These visits are a legal requirement and must be carried out so that people who run a Care Home can demonstrate they are formally monitoring the quality of the service residents receive. Copies of the records of these visits must be kept in the Home and available for inspection. Other records are referenced elsewhere in the report. Ms Ndanga and the maintenance manager take responsibility for health and safety matters in the Home. They carry out regular health and safety audits of the environment to ensure it is safe throughout the Home. There are health and safety policies and procedures in place for staff to follow to ensure the safety of residents is maintained. Health and safety practices in the Home are also addressed at staff training days. A selection of recent residents accident forms were read to find out what action is taken after residents have an accident in the Home. The accident records showed registered nurses record in detail the nature of the occurrence, and all follow up action over a period of days after the event. To further safeguard residents the manager audits and monitors all accident records. The fire logbook was checked and showed weekly tests of fire alarms being Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 24 carried out. However the tests were not being consistently carried out, and there were three occasions over the last six months when they had not been done for at least two weeks. The fire fighting equipment was being checked regularly, thereby helping to maintain the safety of those in the building. There is a record to show staff had attended fire safety update training in the last twelve months to ensure they are aware of fire safety procedures. To protect all residents there is a fire safety risk assessment of the environment. The risk assessment had been reviewed to ensure it remains current to the needs of the Home. Summer Lane Care Home DS0000068380.V351822.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 2 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 X X 4 4 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 2 2 Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 4. (1) Requirement The statement of purpose needs to set out the reason for the use of keypad entry systems on the first floor. This is to demonstrate the reason why residents who have Dementia, and live on the first floor need this protection. For the two residents who have their medication given to them covertly, there must be a care plan in place setting out how to do this .The registered nurses should also make sure they follow the National Midwifery Council guidelines on administering medication in this way. Fire alarms must be checked with the prescribed frequency. The owners of the Home (or an nominated representative on their behalf) must carry out monthly-unannounced monitoring visits, to the Home, called Regulation 26 visits. Copies of the records of these visits must be kept in the Home and available for inspection. Records must be kept of the DS0000068380.V351822.R01.S.doc Timescale for action 21/12/07 2. OP7 15. (1) 21/12/07 3. 4. OP38 OP33 24. (4) c, (iv), (v) 26 22/11/07 21/12/07 5 OP9 13.2 19/12/07 Page 27 Summer Lane Care Home Version 5.2 6 OP9 13.2 administration of all medicines by staff, including creams and ointments. Clear guidance for the use of medicines that have been prescribed, `When required’ must be available for staff to make sure that they are given safely. 19/12/07 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 OP18 Good Practice Recommendations The Homes `protection of vulnerable adults’ procedure should include additional guidance for staff to follow. This is should refer to reporting allegations of Abuse to the North Somerset Adult Protection team. Summer Lane Care Home DS0000068380.V351822.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Summer Lane Care Home DS0000068380.V351822.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!