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Inspection on 28/11/07 for Sunningdale House, Perranporth

Also see our care home review for Sunningdale House, Perranporth for more information

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Needs are assessed prior to an individual moving into the home. Residents are protected by a robust recruitment procedure. The resident`s generally value the support and care that they receive from the care staff. Visitors are able to come to the home at any time. The communal spaces in the home are comfortable and homely.

What has improved since the last inspection?

The new dining room has been completed and is use since the last inspection.

What the care home could do better:

Prospective residents require more detailed information to enable them to make an informed choice of home. The individual`s plan of care does not set out the health, personal and social care needs in an individualised way. They are inadequate to direct and inform care. Resident`s health care needs must be fully met.The activities provided do not meet the individual and collective needs of all the residents. Planned improvements in the menu need to be implemented promptly. There are procedures and policies to safeguard residents, these must be operated in the best interests of the residents. The home is not as clean and hygienic as it should be, there are inadequate cleaning hours to meet the resident`s needs. There are areas of the home that require tidying up and furniture that needs to be replaced. The staffing numbers and skill mix needs to be reviewed to ensure that the resident`s needs are being met. The cleanliness, upkeep and maintenance of the home is reduced to the lack of hours dedicated for these roles. There are managerial and administrative issues that require prompt attention to ensure that the home is run in the best interests of the residents. The health and safety of residents and staff must be safeguarded.

CARE HOMES FOR OLDER PEOPLE Sunningdale House Boscawen Road Perranporth Cornwall TR6 0EP Lead Inspector Kerensa Livingstone Key Unannounced Inspection 28th November 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000008907.V349576.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. DS0000008907.V349576.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunningdale House Address Boscawen Road Perranporth Cornwall TR6 0EP 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) 01872 571151 01872 572633 Welling Ltd Alison Watson Care Home 36 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (36) DS0000008907.V349576.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user may be admitted aged 55 years to 64 years Date of last inspection 10th November 2006 Brief Description of the Service: The registered provider for Sunningdale House is Welling Ltd; the responsible individual is Mr Alan Beale. Sunningdale House provides care for up to 36 older people. This includes registration for six people with dementia and six people with a mental disorder. The Registered Manager Alison Watson has left the home to become an Area Manager for the company. There is a new Manager Maria Boyden, who is due to make her application to become the Registered Manager. The home is situated near the centre of Perranporth with easy access to shops and other local community facilities. The home has a small sloping front garden overlooking the boating lake. The car park is steeply sloping and there is ramped access from this to the main entrance. There is a stair lift to the bedrooms on the first floor. The majority of bedrooms in the home are en suite. The home has a choice of communal areas including a sun lounge. The home provides some day and respite care. The front door to the home is locked at all times. The visiting arrangements are flexible. DS0000008907.V349576.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that was undertaken by two inspectors over one and a half days. The Manager completed an Annual Quality Assurance Assessment (AQAA) after additional time was allowed, prior to the inspection. The inspectors met with the residents, Manager, staff and relatives. The Inspectors looked at records, care documentation, Policies and Procedures and inspected the environment. Case tracking and direct observation were used. Pre inspection questionnaires were circulated prior to the inspection to residents, visitors and relatives; thirteen were returned completed. The last inspection was a random inspection, this was conducted on the 23rd of January 2007. The Commission for Social Care Inspection has been told by the Registered Manager that they have left their post to undertake Area Management responsibilities, confirmation of the management arrangements for the home have been requested from the Registered person. What the service does well: What has improved since the last inspection? What they could do better: Prospective residents require more detailed information to enable them to make an informed choice of home. The individual’s plan of care does not set out the health, personal and social care needs in an individualised way. They are inadequate to direct and inform care. Resident’s health care needs must be fully met. DS0000008907.V349576.R01.S.doc Version 5.2 Page 6 The activities provided do not meet the individual and collective needs of all the residents. Planned improvements in the menu need to be implemented promptly. There are procedures and policies to safeguard residents, these must be operated in the best interests of the residents. The home is not as clean and hygienic as it should be, there are inadequate cleaning hours to meet the resident’s needs. There are areas of the home that require tidying up and furniture that needs to be replaced. The staffing numbers and skill mix needs to be reviewed to ensure that the resident’s needs are being met. The cleanliness, upkeep and maintenance of the home is reduced to the lack of hours dedicated for these roles. There are managerial and administrative issues that require prompt attention to ensure that the home is run in the best interests of the residents. The health and safety of residents and staff must be safeguarded. 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. DS0000008907.V349576.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000008907.V349576.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents require more detailed information to enable them to make an informed choice of home. Needs are assessed prior to an individual moving into the home. EVIDENCE: The Statement of Purpose and Service User’s Guide is a brief combined document that is available in the home. This document does not include the required information as detailed in Regulations 4, 5 and National minimum standard 1, for example the qualifications and experience of the staff and Manager, the home’s smoking or locked door policies. An information file is located in the home. Prospective residents are not currently being provided with detailed information to enable them to make an informed choice, residents confirmed this stating they were not provided with a Service user’s Guide prior to making a decision to move into the home. The Service User’s DS0000008907.V349576.R01.S.doc Version 5.2 Page 9 Guide does not include a full copy of the most recent inspection report or service user’s views of the home. A statement of terms and conditions is provided to new private residents. The room occupied sometimes differed from the one recorded on the contract, the contract is not updated to reflect this. There is little information in the contract about the rights of the service user and/or their representative. The contract states that the home can ask the resident to leave without any notice, but the resident must give one months notice unless this is agreed by the home. Full assessments are taken place prior to the resident moving into the home. This had been undertaken by different staff. The inspectors were informed that each prospective resident is assessed to make sure that the services and facilities are appropriate to meet the needs of the individual. The prospective resident and their relatives or representatives are invited to participate in the assessment. This standard is not applicable as this service does not provide intermediate care or rehabilitation services as there are no specialised facilities, dedicated accommodation and designated staff. DS0000008907.V349576.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The individual’s plan of care does not set out the health, personal and social care needs in an individualised way. They are inadequate to direct and inform care. Resident’s health care needs must be fully met. EVIDENCE: A plan of care is compiled for each person, these are prescriptive and task based e.g. all staff, morning staff, evening staff, and night staff. They are not person centred, they do not fully inform and direct care staff on how to support the service user’s own capacity for self care and to meet their needs. The role that the staff are expected to play is not detailed in the plan of care. One plan of care was dated May 2003. The care plans inspected were signed to say they had been reviewed monthly, however they did not always reflect the changing needs. In the care plans inspected there was little evidence that the plan of care is drawn up or reviewed with resident and/or representative involvement. Residents and their relatives did not feel that they had been consulted about DS0000008907.V349576.R01.S.doc Version 5.2 Page 11 the plan of care. Needs are identified, however these are not included in the care plan e.g. pain, difficulties swallowing. The Manager is committed to making improvements in the planning of care. Residents are registered with the local Primary Healthcare team and are able to walk to the local surgery to see their General practitioner. Continence assessments were not available for inspection for people who required them, this information was lacking from the care plan. There is evidence of involvement with the mental health services, however there was no evidence that an individual’s health is monitored and preventive and restorative care given. Mental health and physical risk assessments e.g. falls were noted to be lacking. Communication with the primary Healthcare team is reported to be good and healthcare needs met. Some interventions were observed not to be undertaken regularly and the frequency not recorded in the plan of care. A couple of relatives expressed concerns about the frequency of bathing. The medicines are stored in a locked room; there are medicine trolleys on the ground and first floor. A monitored dosage system is used and a copy of the original prescription is kept. There were no controlled drugs in the home. There is a designated locked drugs fridge, this is stored in the staff room. On the day of the inspection the temperature had been checked on twenty-one out of the previous twenty-eight days. The storage system in the clinical room takes up a lot of space resulting in a new delivery of medicines being observed left on the floor. There was no soap or hand towels provided at the sink for staff in this room. The member of staff administering medicines must administer medicines according to the home’s policies and procedures. Training has been arranged for seven staff that are administering medicines on the 5th of December. There are Policies and Procedures relating to this area, however they were not formally inspected. Residents felt that, in the main, the routines of daily living suited their expectations and preferences. Residents stated that their privacy and dignity was generally respected. One person commented that staff sometimes talked across them rather than listening to what they had to say. Another person stated that at times they felt ignored. Post is delivered unopened to the residents and are able to take telephone calls in private. Each room has a door lock and key can be provided depending on the person’s risk assessment. DS0000008907.V349576.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities provided do not meet the individual and collective needs of all the residents. Visitors are able to come to the home at any time. Planned improvements in the menu need to be implemented promptly. EVIDENCE: Residents and relatives commented during and prior to the inspection that staffing had a profound impact on them being able to exercise choice over their daily routines. Information about some activities is provided on the notice board, however there was no diary of events for November that is circulated to the residents. Information is gathered about the individual’s social activities and interests. The Chaplain visits the home once a month. The maintenance person undertakes activities for one hour three times a week; over the previous month some of the activities included bowls, colouring in Christmas cards, Skittles, bag and ball, quoits. Residents stated that they used to enjoy regular trips out from the home, one person stated ‘we never have outings’. The inspector was informed that there used to be a company car used for trips out and that this is no longer available. A hairdresser visits regularly and the residents enjoy this service. There is a keep fit session held twice a week and DS0000008907.V349576.R01.S.doc Version 5.2 Page 13 an ‘Arts and Crafts’ session once a week, the residents seem to really enjoy this. The activities provided meet the needs of some of the residents, however some residents are not benefiting from any opportunities for stimulation. Several residents stated they would like to be able to go out for a walk or a short trip in a wheelchair, but this had not been possible. Visitors were observed to visit the home and to be welcomed. Residents stated that the arrangements for visiting were satisfactory and suited their families and friends. The front door of the home is locked, the visitors are assisted by a staff member to get in and out of the building. Residents felt that generally the staffing impacted on their ability to determine their own routines of daily living and this reduced how much they felt in control of their day-to-day lives. Personal possessions can be bought into the home. Residents are encouraged to manage their own finances for as long as they wish to. The lunch on the day of the inspection was Roast Chicken, roast potatoes, roast root vegetables, Brussels sprouts and gravy followed by bread and butter pudding, yoghurt or ice cream. There is a fish dish or jacket potato as an alternative. One person commented that they had preferred having a menu to choose their meals. Staff were observed to offer the main meal without the vegetables to residents and an alternative is offered if the dish of the day is not liked. The menu is written weekly on Wednesdays the inspector was informed. On the day of the inspection the menu had not been updated. There have been long standing concerns from the residents about some of the meals, it was identified at last years inspection. A meeting has just been held with the new Manager and changes are being made to the menu with the Chef. The evening meal is a choice of soups, salads, savouries, sandwiches and a pudding. Fresh fruit is available. The cook reported that specific diets are catered for. The dining room is an attractively decorated room with views out over the boating lake, several people commented that the number of chairs and tables in this room made it difficult to move around or to have a private conversation over lunch. Food records are kept this must include detail of all the food consumed. The Chef has completed the foundation food hygiene training. Staff are being provided with in-house food hygiene training. DS0000008907.V349576.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are procedures and policies to safeguard residents; these must be operated in the best interests of the residents. EVIDENCE: There is a policy which includes the complaints procedure for the home, this requires updating to include the Department of Adult Social Care and new contact details for CSCI. A record of all complaints and concerns is kept in a complaints register. The register included records of recent complaints and concerns, how they had been responded to and resolved. The home reports having dealt with ten complaints during the last year. The Commission for Social Care Inspection has received two complaints. The concerns include a variety of issues such as lost laundry, staff speaking another language in front of residents, cleanliness of rooms, personal hygiene and the meals provided. One person stated that they had been told that if they did not like the way the home was run, they could leave. Residents were generally aware of whom to speak to, one person commented that they were unsure whether their concerns would be acted upon. There is a procedure for the Protection of Vulnerable Adults and the home has a copy of the local procedures. All staff are provided with training on the Protection of Vulnerable Adults in the home. The Registered persons must ensure that the home and local procedures are followed in event of an DS0000008907.V349576.R01.S.doc Version 5.2 Page 15 allegation of abuse being made. The AQAA states that almost all the staff have completed the POVA training provided by Cornwall County Council. DS0000008907.V349576.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The communal spaces in the home are comfortable and homely. The home is not as clean and hygienic as it should be; there are inadequate cleaning hours to meet the resident’s needs. There are areas of the home that require tidying up and furniture that needs to be replaced. EVIDENCE: Sunningdale House is located in a pleasant residential area near the centre of Perranporth, with the local facilities and services nearby. The main reception area and corridors are spacious, attractive and well-maintained. The car park at the front is very steeply sloping to the front door. There is a ramp from here to the main entrance, which has a small step, for people using wheelchairs or with poor mobility. Many of the ground floor rooms have doors that open out onto the communal paved patio area, which circles the home. DS0000008907.V349576.R01.S.doc Version 5.2 Page 17 The home is overlooks the boating lake. The records of routine maintenance, renewal of fabric and decoration of the premises are kept by the provider, these were not available at inspection. There are plans to develop the sloping garden at the front of the home to make it accessible to the residents. Residents reported that they were able to spend time outside in the summer. The front door to the home is locked, relatives and residents require assistance to gain entry or to leave the home. There is a flat on the second floor which is not registered this is used to accommodate staff, there is no designated separate entrance and tenants walk through the main area of the home. Personal accommodation was homely and comfortable. Several rooms were noted to need redecoration and a bath was labelled as out of action. Tables in individual rooms were observed to be worn and in need of replacement. Some rooms did not have an attachment for the call bell or comfortable seating for two people. In bedrooms, there was dust on the surfaces. Several people commented on the need for more cleaning time in the home. Individual rooms have a door lock and keys are provided unless their risk assessment suggests otherwise. Double rooms are only occupied by two individuals who make an express choice to share e.g. a couple. Residents liked their rooms and particularly the view to the front of the home. One bath was observed to be used for storage and equipment was stored in the hall on the first floor. Some areas were noted to be cluttered and in need of tidying up. The inspector was informed at inspection that cleaning hours had been cut and the home was not as clean as it used to be. The registered person has advised that the cleaning hours had not been cut but some had been reallocated to do laundry and that this has returned to the previous arrangements since the inspection. The arrangements for bed making was observed to ad hoc, with some rooms not being made up until later in the day and the result seemed to be rushed. The housekeeping staff were observed to work very hard during the inspection. One bathroom was noted not to have hand washing facilities. Some hand washing facilities had no soap and/or hand towels. The laundry is situated away from the kitchen, however soiled laundry is carried through the staff room. On the second day of the inspection odours were present whilst staff were having a meal break. The floor is impermeable. There are two washing machines and a tumbler drier, all of industrial standard. A sluicing sink provides a disinfectant wash for soiled articles. A designated laundry person had identified to improve the laundry service following complaints about the laundry service. Therefore a new system has been introduced, however on the day of the inspection there was a basket of unnamed clothing, shoes and belts and the storage of clean duvets and pillows meant it was not possible to store individual baskets on the appropriate shelves. The AQAA states that the home is kept clean and hygienic, however concerns were expressed prior and during the inspection about the cleanliness DS0000008907.V349576.R01.S.doc Version 5.2 Page 18 of the home; ‘the cleaning is very poor’. Gloves and aprons are provided for the staff. DS0000008907.V349576.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 28 & 29 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing numbers and skill mix needs to be reviewed to ensure that the resident’s needs are being met. Residents are protected by a robust recruitment procedure. The resident’s generally value the support and care that they receive from the care staff. EVIDENCE: On the day of the inspection there were five staff on duty until 10.30, four staff for the remainder of the day until 7pm and then 3 staff until 9pm. There are two waking staff on duty at night. Most comments received prior and during the inspection commented that more staff are under pressure to perform their duties. A four-week rota was provided at inspection, however there were shifts in the previous weeks that stated ‘agency’ with no name. Maintenance hours are not recorded on the rota, but are reported to be three mornings a week Domestic hours for the whole home are ten hours per day with two staff, one upstairs and one downstairs, this reduces to one person at the weekend. The laundry has a dedicated member of staff on six days a week and this is for four hours a day. The Chef is on duty for six hours a day. No staff under twentyone years of age are left in charge of the care home and no one under 18 provides personal care. One person commented that ‘they were sometimes left unattended far too long’ and another said there are ‘usually’ staff when you DS0000008907.V349576.R01.S.doc Version 5.2 Page 20 need them. Residents stated that they are not able to go out if they wish, due to the lack of staff to accompany them. The recruitment records for recently appointed staff contained required documents – application forms, Criminal Records Bureau disclosures, two references and evidence of identity. Staff receive a statement of terms and conditions of employment. One person commented that ‘mostly the staff are very good’. The inspectors were informed that ten out of the sixteen care staff have completed their National Vocational Qualification level 2 in care, this is sixty two percent. Two are doing National Vocational Qualification level 2. The Manager was observed supporting a new staff member with their induction. There is a training programme, however there was a little evidence of role specific training for example mental health, dementia care. Most of the training provided at Sunningdale is in house, based upon a DVD, questionnaire and discussion. The Manager who has just commenced in post is clearly very committed to training and is an internal verifier and has the Assessors D33/D34. DS0000008907.V349576.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are managerial and administrative issues that require prompt attention to ensure that the home is run in the best interests of the residents. The health and safety of residents and staff must be safeguarded. EVIDENCE: The Commission for Social Care Inspection has been told by the Registered Manager that they have left their post to undertake Area Management responsibilities, confirmation of the management arrangements for the home have been requested from the Registered person. A letter was written requesting this information on the 24th of October. The new Manager has commenced in post and fully assisted with the inspection process. The new manager has National Vocational Qualification level 4 in Care and the DS0000008907.V349576.R01.S.doc Version 5.2 Page 22 Registered Manager’s Award. Visits are conducted monthly by the registered person these must evidence discussion with residents, relatives and staff. Two of the most recent reports provided at inspection did not demonstrate discussion with the residents. The designated Manager’s office is too small for confidential meetings, this results in communal areas being utilised. The new Manager has held two residents meetings and a staff meeting since commencing in post. Residents were positive about the new Manager saying that they found her approachable and more accessible. Formal feedback has not been sought from relatives residents and other stakeholders. As part of the annual development plan of the home a continuous self monitoring process is needed to ensure that the home is run in the best interests of the residents. The inspectors were informed that the registered persons do not act as an appointee for any residents for their benefits or manage any savings accounts for residents. The home does provide a safe keeping service for residents’ spending money. The records detail amounts paid in, for example by family members with power of attorney, amounts paid out, for example for hairdressing, and a running balance. Two staff sign all entries. Cash is held as individual amounts. A sample of these individual amounts were checked against the records and found to be accurate. Spot checks are conducted by the registered manager. Care records were observed to be stored in an open reception area. There is a visitor’s book in the reception area of the home. The accident book pages are removed as required, however they are then all filed together. A communication book is in use with resident’s names in it. The AQAA detailed maintenance information including that the hardwiring electrical check was conducted in April 2005, PAT testing Dec. 2006, lifts, hoists & chair lifts in June 2007. The fire equipment was serviced in June 2007 and gas appliances in April 2007. A random check of the maintenance records seemed to demonstrate that the health and safety of staff and residents is being safeguarded. There is a designated maintenance person three mornings a week. The Manager reviews all accidents that take place in the home. A fire safety enforcement order was issued in February 2007, the inspectors requested evidence at inspection that this work had been done, and this was not provided. Several external fire doors were observed to have three different types of locks on. One door had to be opened by a key, which was positioned too high for some people to reach. The inspectors were informed that regular fire alarm, emergency lighting and fire equipment checks are conducted. There DS0000008907.V349576.R01.S.doc Version 5.2 Page 23 is a designated Moving and Handling trainer, evidence was requested of the trainer’s certification, and this is yet to be provided. Environmental factors such as first floor unrestricted windows, hot surfaces and uncovered piping must be risk assessed. DS0000008907.V349576.R01.S.doc Version 5.2 Page 24 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X 1 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X 1 1 DS0000008907.V349576.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4, Sch. 1 Requirement The registered person shall compile a statement of purpose including the matters listed in Schedule 1. The registered person shall produce a written service user’s guide including a standard form of contract. The registered person shall after consultation with the service user prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. This shall be made available to the service user, be kept under review and the resident be advised of any revision. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of residents. The registered person shall consult with residents about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation. DS0000008907.V349576.R01.S.doc Timescale for action 01/03/08 2. OP1 5 01/03/08 3. OP7 15 01/02/08 4. OP8 12 01/02/08 5. OP12 16(2) 01/03/08 Version 5.2 Page 26 6. 7. OP26 23(2d) 18(1a) 17(2) Sch. 4 OP29 8. OP31 8, 9 9. OP33 24 10. OP37 Data Protection Act 1998 11. OP38 23 12. OP38 13(4a) The registered person shall ensure that all parts of the care home are kept clean. The registered person shall ensure that at all times suitably qualified, competent and experience persons are working in the care home in such numbers as are appropriate for the health and welfare of residents. All staff must be recorded on the duty roster and reflect who actually worked. The registered person is required to inform the Commission when they appoint some one to manage the care home. The registered person shall establish and maintain a system for reviewing the quality of care at the home and a report of any review shall be forwarded to the Commission and made available to residents. States that anyone who processes personal information must comply with eight principles, for example make sure that personal information is secure. Confidential information must be locked away securely. The registered person shall after consultation with the fire authority provide adequate means of escape. The registered person shall ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated e.g. hot water, unrestricted windows. 01/02/08 01/02/08 01/01/08 01/03/08 01/01/08 01/02/08 01/03/08 DS0000008907.V349576.R01.S.doc Version 5.2 Page 27 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. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Refer to Standard OP1 OP2 OP9 OP10 OP15 OP15 OP19 OP19 OP24 OP26 OP30 OP31 OP38 Good Practice Recommendations For service user’s views of the home to be included in the Service User’s Guide. For all residents to be provided with a contract including the terms and conditions between the resident and the home. For the fridge temperature to be checked at least once daily. The registered person should review the arrangements for residents’ laundry to ensure that items of laundry are returned to their owner and not mislaid. For the lead chef to undertake Intermediate Food Hygiene training or equivalent. For residents to have a clear choice of meal at lunch time rather than an alternative if they do not like what is available. For clear information to be available about the home being kept locked and access. For the programme of routine maintenance, renewal of fabric and decoration to be forwarded to the Commission. For the furniture including tables in resident’s room to be audited and replaced as required. For an audit to be conducted of the hand washing facilities, soap and paper towels provision in the home. For staff to be provided with role specific training to ensure that they have the skills to perform their role. For consideration to be given to provide the Registered Manager with suitable office space. For the moving and handling trainer’s certificate to be forwarded to the Commission for Social Care Inspection. DS0000008907.V349576.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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