Inspection on 16/01/08 for Summerhill

This inspection was carried out on 16th January 2008.

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

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Summerhill The Dunterns Alnwick Northumberland NE66 1AL Lead Inspector Alan Baxter Key Unannounced Inspection 10:00 16 , 17th January 2008 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 Summerhill DS0000070430.V354523.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. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summerhill Address The Dunterns Alnwick Northumberland NE66 1AL 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) 0208045501893 Raycare Limited Mrs Beverley Common Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Old Age, not falling within any other category, - Code OP, maximum number of places 29 The maximum number of service users who can be accommodated is 29 (new service). 2. Date of last inspection Brief Description of the Service: Summerhill is registered to provide care for 29 frail elderly persons. It does not provide nursing care. Summerhill is an adapted and extended two storey building, situated on a quiet residential street within walking distance of the town centre of Alnwick, and close to shops, local transport and amenities. It has recently been refurbished to a good standard. It has a passenger lift. All but one of the bedrooms are single bedrooms, and all bedrooms have en-suite facilities. The home has a very attractive garden with patio area to the rear. The home has its own transport. Weekly fees range from £419 to £480. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people using this service experience good quality outcomes. Before the visit: We looked at: • Information we have received since the home was registered under its current owners on 2nd August 2007. • How the service dealt with any complaints & concerns since registration. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 16th and 17th January 2008. During the visit we: • • • • • • Talked with people who use the service, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the home was registered. We told the manager what we found. What the service does well: Very positive feedback was received from residents, relatives and staff. One resident said: “The girls are fantastic, always there for us”. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 6 Another resident said: “I am well looked after and happy living at Summerhill”. A relative said “This is a wonderful place to live, we cannot speak highly enough of the care given to my mother. She is very happy and her health has improved greatly since being here”. Another relative said, “…we are lucky to have so many good staff…”. A staff member said “We give a high standard of care……staff all have the correct attitude to their work”. The home provides good, clear information about what services it can offer to anyone thinking of being admitted as a resident. The home meets all the health needs of its residents. Residents are able to have control of their lives, and are encouraged to make their own decisions, wherever possible. Residents are treated with respect at all times, and their privacy is protected. All complaints are taken seriously and are dealt with properly and promptly. Residents are given well-cooked, well-presented and nutritious meals. Relatives and friends are encouraged to visit and are made welcome. The home is kept in good repair. The home is clean, comfortable and hygienic. The home is well managed. Although the home is under new ownership, the staff team is unchanged. This gives continuity of care for the residents. Staff are experienced and well trained. The health and safety of the residents is taken seriously. What has improved since the last inspection? Staffing levels have improved. They are now high enough to provide for good one-to-one care of the residents. The home now records feedback from residents, relatives and others more regularly and in better detail. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 7 Fire safety has improved. Fire equipment is being checked and tested more regularly, and fire doors are no longer being wedged open. Quality assurance systems are now taken more seriously and have a clear influence on improving the service being given. Staff training is being given a higher priority, and is better recorded. Social activities have improved, and more emphasis is being put on supporting individual hobbies and interests. Staff supervision is more regular and is better recorded. 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. Summerhill DS0000070430.V354523.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 Summerhill DS0000070430.V354523.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): Standards 1,3 and 6. Quality in this outcome area is good. The home gives good, clear and detailed information about the home to anyone thinking of coming to live there. The manager carries out good assessments of the needs of potential new residents, and makes sure the home can meet their needs, before accepting them into the home. The home does not provide Intermediate Care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 10 The home has a very detailed and comprehensive statement of purpose/service user guide, which reflects the new ownership of this established residential home. This stresses the home’s values of upholding residents’ rights, dignity, independence and choice. Commendably, the home’s minimum staffing levels are clearly stated. All 9 residents who returned surveys said that they had received enough information about the home before moving in. All 7 relatives who responded said that they ‘always’ or ‘usually’ get enough information to help them make decisions. The home’s registered manager carries out reasonably comprehensive general assessments of all potential new residents, well in advance of admission. This gives her plenty of time to decide whether the home can meet all the person’s needs, before they are admitted. On admission the manager carries out, where necessary, more detailed assessments, such as diet, skin care, and social needs. The home has experienced problems in getting assessment documents from new residents’ social worker or care managers sent through promptly. She intends to raise this issue assertively with all future referrals. All six staff members who returned surveys said that they are always given up to date information about the needs of the people they care for. The home does not provide Intermediate Care. Summerhill DS0000070430.V354523.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): Standards 7,8,9 and 10. Quality in this outcome area is good. Residents’ care plans are of an acceptable standard, and are currently being further refined and improved. The health care needs of all the residents are kept constantly under review and are being met at all times. The home has good systems in place for the ordering, storage, administration and return of residents’ medicines. The privacy and dignity of the residents are protected by the sensitive care given by the staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 12 The home uses the ‘activities of daily living’ approach to assessing care needs and planning how best to meet those needs. The care plans seen were generally of an acceptable quality. The best examples seen were of a good standard, and showed a sensitive and individualised approach to giving care. Others were less well focussed and less detailed. Every care plan is evaluated each month, and there was some evidence of the updating of care plans. It was agreed that all care plans must reflect the current care being given. The use of ‘problem care plans’ is being phased out, as they distract from the ‘activities of daily living’ approach, and are insufficiently detailed. Of the 7 relatives who returned surveys, 5 said the home always meets the needs of the residents; 2 said ‘usually’. The physical and mental health needs of residents are assessed before they come into the home, and regularly after that. Where a problem or need has been identified, a care plan is set up, and this is looked at every month, to see what progress is being made. The home has appropriate assessment documents for all areas of health, including assessment of the risks of pressure sores, of malnutrition (residents are weighed monthly) and of the possibility of falls. These are re-assessed monthly. There was ample documentary evidence of the use made of doctors, district nurses, occupational and physiotherapists, chiropodists etc. and of the appropriate referral to specialists, where necessary. There is a weekly exercise class for residents and all staff have had ‘falls awareness’ training. Residents and relatives confirmed that health needs are being properly attended to: in a survey, 8 said that they ‘always’ receive the medical support they need; one said ‘usually’. A relative commented: “The staff seem willing to look after very demanding/ seriously ill residents for as long as they can, even though their care needs are great. This is supportive of the residents and their families”. The home assesses whether a resident can safely keep responsibility for storing and taking their own medicines. If a resident does keep this Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 13 responsibility (there is only one person doing so, at the time of this inspection), then secure storage space is provided in the person’s bedroom. Where staff are to take responsibility for medications, then residents are asked to give their written consent to this. Only staff that have had the appropriate training are allowed to give out medicines. The Medication Administration Records (MAR) is well kept, with no unexplained gaps. It comes in printed form from the Pharmacy the home uses, and any handwritten entries or amendments by staff are signed and dated. There have been no medication errors reported. Although no resident is currently prescribed ‘controlled drugs’, the home has the appropriate recording and secure storage systems in place, should there be a demand for this. Residents conversed with said that they are treated with respect by staff at all times, and that staff protect their privacy and dignity. Care records showed sensitivity to the residents’ need for privacy, and talk about them respectfully. Summerhill DS0000070430.V354523.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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. Residents are given stimulating activities as a group, but are also encouraged and supported in following their own hobbies and interests. Residents are part of the local community, use all local services and facilities, and can have visitors at any time. Residents are encouraged to exercise choice and control about their daily lives. Residents have an appetising and nutritious diet, with plenty of choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a very good commitment to providing residents with social activities and other social stimulation. There is a monthly activities programme that provides activities each weekday morning and afternoon. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 15 Examples of activities include keep fit, crafts, coffee mornings, poetry readings, current affairs with newspapers, and pampering sessions. Staff generally follows the programme, with any changes noted in the home’s activities diary. This is good practice. The home has recently bought a computer system that allows residents to play “virtual reality” games of tennis, ten-pin bowling, golf and boxing, using a small remote control. This has proved highly popular, as it does not require any physical strength, dexterity or agility. The home also has a large screen mini projector, which is used to show residents’ own photographs, when they so wish. The home organises frequent trips out, hiring local minibuses as needed, usually once or twice each week. The proprietor pays for such trips. This is commendable. Trips to the countryside, the coast, the theatre, and to other places of interest have taken place.. The home has a concessionary pass to the local Alnwick Gardens, giving them free access at all times. The home also regular visiting entertainers, including a singer who visits monthly, a local historian who comes quarterly and gives talks and slideshows, and weekly visits from the ‘keep fit’ class leader, and from the local ‘pat a dog’ service. Residents are also encouraged to lead their own social lives and to follow their own hobbies and interests. One resident has a personal computer, for example. More detailed individual social care plans have recently been introduced. These showed that the staff are providing support and assistance with residents’ individual hobbies and interests by, for example, providing transport to a bowling club for one resident; providing gardening equipment and bulbs for other residents who garden, and flowers for a resident who arranges them. Of the 9 residents who returned surveys, 8 said that the home ‘always’ arrange activities that they can take part in; one said ‘usually’. The home is within walking distance of the town centre. Some residents go into town independently, others with help from staff (this may include the use of a mini bus), to use its local facilities such as shop, pubs, theatre, library etc. The manager is seeking to make links with other local residential establishments to increase the social networks available to the residents. This is good practice. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 16 There are regular visits from the local Catholic and Anglican clergy, and a weekly communion service in the home. A relative commented: “We are practising Catholics and my mother is able to attend Mass every day she wants to.” Care records clearly showed that residents are encouraged to make their own decisions as to how they spend their day, and to be as independent as possible. The home’s manager is doing training about the Mental health Capacity Act. The two senior care staff have already completed this training. This means that all the senior team will be up to date about this important legislation that protects the rights of its residents. The home operates a monthly menu, which it intends to review and revise in conjunction with the residents every six months. It offers a cooked breakfast daily, if required. Lunch is a three-course meal, with fruit juice or soup; two different main courses; and a choice of two desserts plus a cheeseboard. The tea meal offers a hot or a cold option, plus cakes. The manager stated that residents could ask for alternatives to the menu at any time. This is good practice. The menus seemed quite varied and to be nutritious. Of the 9 residents who returned surveys, 4 said they always enjoyed the meals in the home, 5 said they usually did. One commented: “There is always a nice choice of meals, and a good variety of food on offer”. There was evidence that the staff do actively seek the residents’ views on the food provided and that they act upon the feedback. For example, the residents said that there were too many sandwich teas, and shortly after, more teacakes and crumpets were added to the menu. The home has recently introduced ‘taster’ sessions on Friday nights, where residents are offered small amounts of new and/or foreign foods for them to try. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18. Quality in this outcome area is good. Residents know that any complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse and neglect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A clear and simple complaints policy and procedure is given to all residents when they come into the home. It is also displayed in communal areas around the home. No formal complaints have been received in the past year. The manager speaks to all residents every week and records any feedback in the ‘comments, complaints and concerns’ book. (See standard 33,Quality Assurance, below.) Eight of the 9 residents who returned surveys said that they know who to speak to if they are unhappy about anything, and all 9 said they knew how to make a complaint. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 18 All 7 relatives who responded to a survey said that they knew how to make a complaint, if they needed to. Six said that the home responds properly when a concern is raised. The home has a policy and procedure for protecting its residents from abuse or neglect. This includes clearly displayed information as to who/where an allegation of abuse should be referred to, with the phone number of the relevant local social services office. No allegations of abuse have been received. Nearly all the care staff have had training in how to protect the residents from abuse. The other staff will have had this training by the end of February this year. The manager is currently arranging more detailed training in protection for herself and senior staff. All 6 staff who returned surveys said that they knew what to do if a resident or someone else has concerns about the home. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 19 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): Standards 19 and 26. Quality in this outcome area is good. Residents are provided with a safe, well maintained, comfortable and homely physical environment. The home is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The building was partly toured. It’s location and layout is suitable for its stated purpose. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 20 Those areas seen were safe, accessible and well maintained. The home is comfortable and very homely. There is a programme of routine maintenance in place. The grounds are kept tidy and safe. They are very attractive and are accessible to all the residents. Plans are in place to repair the potentially unsafe flooring in the kitchen and part of the adjacent corridor, as part of a complete refurbishment of the kitchen, due soon. A ‘loop’ system for the hard of hearing has recently been installed in the main television lounge. All areas of the home seen were in a clean and hygienic condition. There were no offensive odours in the home. Systems are in place to control the spread of infection, including the training of staff in their induction period, and the provision of protective clothing. The laundry is appropriately sited and is provided with suitable hand-washing facilities. Of the 9 residents who returned surveys, 7 said the home is always fresh and clean; 2 said it usually is. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. The home operates with enough staff to give residents a very personal service. The home does not have enough qualified carers, currently, but it is training more staff to meet its target of qualified staff. Residents are protected by the home’s careful practices when employing new staff. The good levels and range of training being given to staff also protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is currently being staffed at the following levels: 8am to 2pm, 4 carers (including senior carer); 2pm to 8 pm, 3 carers (including senior carer); 8pm to 8am, 2 carers (including senior carer). Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 22 These levels are sufficient to provide a personal service to the current resident group. In addition, domestic cover is provided between 8am and 2pm every day; and catering cover between 9am and 2pm every day. The manager is supernumerary to the rota. Of the 6 staff who responded to a survey, 4 said there are always enough staff to meet the residents’ needs; one said ‘usually’; and one said ‘sometimes’ and said that the home is sometimes short-staffed due to sickness. Several relatives suggested that the home should employ some older staff. The home does not have the required 50 of its care staff trained to National Vocational Qualification (NVQ) level 2 in care. Currently, only 7 of the 20 carers (35 ) have NVQ 2. However, another 8 carers have started their NVQ level 2 courses, and one has started an NVQ level 3 course. When these staff have gained their qualification, the home will then meet its target for qualified staff. The home keeps excellent records on staff recruitment. They are comprehensively completed. All the required area, such as application forms, employment histories, work references and Criminal Record Bureau (CRB) forms are in place on each staff member’s personal file. The manager is currently reviewing the wording of all references to the Rehabilitation of Offenders Act 1974 (from which the home is excepted, as it cares for vulnerable people, so all previous offences must always be declared) to make sure there is no confusion. Staff confirmed that the recruitment and selection processes had been thorough. It is obvious from the staff training records and certificates that there has been a major investment in staff training over the past twelve months, and that this commitment to having a fully trained staff is continuing into 2008. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 23 Staff induction training is taken very seriously and is completed in depth and over an appropriate time period. It is fully recorded and is in line with current standards. There is a clear annual staff training plan in place. The majority of staff have had the areas of training that are mandatory, such as fire safety, moving & handling and food hygiene: all the rest have been booked onto the appropriate course in the next few months. All have had first aid training. All ten carers who give out residents’ medicines are being given ‘safe handling of medications’ training. This will be complete by the end of March 2008. It is also planned that all staff will receive training in the care of people with Dementia over the coming year. Training in podiatry and in falls awareness is also planned. This is good practice. All 6 staff who returned surveys said that they are given training that is relevant; that helps them understand and meet the needs of residents; and that keeps them up to date with new ways of working. One said, “Yes, lots of training courses available, in house and at other places”. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 24 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): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. The home is well managed by an experienced and suitably qualified person. Effective quality systems are in place, to make sure that the home is being run in the best interests of the residents. Residents’ financial interests are protected. Staff are appropriately supervised. The health and safety of the residents and of the staff are promoted and protected. This judgement has been made using available evidence including a visit to this service. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager, Mrs Beverly Common, is suitably qualified and experienced. There are clear lines of accountability within the home. There are several quality assurance systems in place in the home. Perhaps the most important one is the manager’s weekly discussion with every resident about how they feel the home is running. She carries the ‘comments, complaints and concerns’ file, and records all feedback. This includes any expressions of dissatisfaction, however, minor, and the file also records what steps she has taken to improve the situation. Various examples of feedback were seen. All these issues were recorded as having been dealt with and resolved, promptly and to the residents’ satisfaction. Annual surveys are sent out to all residents, relatives and professionals. The most recent results available showed generally very positive feedback, but a number of areas for improvement were also identified. All were seen to have been taken seriously, and all appear to have been resolved to the satisfaction of the residents. A random sample of residents’ financial records was checked against the cash being held on their behalf. All were found to be accurate. Accounts were clear and up to date, and receipts are kept. The staff supervision records showed a clear two-monthly frequency for supervision. This is in line with the required frequency. Records showed that the process is taken seriously both parties, and detailed minutes are kept. The responsibility for the supervision of carers is delegated to team leaders. Annual appraisals are given to all staff. Of the 6 staff members who returned surveys, 5 said that they meet regularly with their manager for support and feedback; one said they meet often. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 26 Maintenance and servicing certificates and contracts are kept up to date for gas and electrical servicing, lift maintenance and servicing, waste management, fire equipment etc. The accident book is completed in good detail and includes ‘follow-up’ entries by the manager. There is a monthly analysis of entries, to identify any trends. Where, for example, a clear pattern of falls is identified, the person’s doctor would be informed. The fire logbook is kept up to date. It was agreed that monthly visual checks of fire fighting equipment would be recorded. All staff have either had, or are being booked to attend, training in infection control, moving and handling, and health and safety. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 27 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 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 4 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No (first inspection under current registration). 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. Standard Regulation Requirement Timescale for action 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 OP28 Good Practice Recommendations At least 50 of care staff must hold National Vocational Qualification (NVQ) level 2 in care. Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Summerhill DS0000070430.V354523.R01.S.doc Version 5.2 Page 30 - 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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