CARE HOMES FOR OLDER PEOPLE
Tanfield Care Centre 2 Hexham Road Whitley Wood Reading Berks RG2 7UG Lead Inspector
Marie Carvell Unannounced Inspection 30th May 2007 10:50 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 DS0000039942.V335829.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. DS0000039942.V335829.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Tanfield Care Centre Address 2 Hexham Road Whitley Wood Reading Berks RG2 7UG 0118 9015355 0118 901 5356 jogarland/purser@reading.gov.uk www.reading.gov.uk Reading Borough Council 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) Joanne Claire Purser Care Home 31 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (23), of places Physical disability (12) DS0000039942.V335829.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. A maximum of 3 service users can be admitted aged 50-60 years of age. A maximum of 3 service users can be admitted aged over 60 years of age. 6th December 2005 Date of last inspection Brief Description of the Service: Tanfield Care Centre is a Reading Borough Council care home. It is purpose built and situated in Whitley, a suburb of Reading. The home is registered to provide personal care and accommodation for thirty one service users, (twelve in the Intermediate Care unit, eight in the E.M.I. unit, and eleven in the Assessment and Intervention unit). The home is equipped with a passenger lift and aids and equipment to assist the more dependent service users. Twelve of the bedrooms have en-suite facilities. The aim of the home is to provide a homely and comfortable atmosphere; a lifestyle that satisfies their social, cultural, religious and recreational interests and needs; promote and maintain service users’ health; and to ensure the independence and individuality of the service users is respected. An occupational therapist, physiotherapist and a rehabilitation manager have been employed by the Health Authority to work in the Intermediate Care unit alongside local authority care workers. The current scale of charges as at May 2007 are between £64.65 and £440.95 per week. Service users receiving intermediate care (Rehabilitation or Assessment and intervention) have six weeks in the home free of charge, four weeks at the minimum charge and are then assessed. There are additional charges for Hairdressing, chiropody (except service users who are diabetics), toiletries, newspapers and private phone lines. DS0000039942.V335829.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission has, since 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘key Inspection’. The inspector arrived at the service at 10.50am and was in the service until 5.30pm. It was a thorough look at how well the service was doing, and took into account detailed information provided by the service’s acting manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection. Four service users, relatives of one service user, one care manager (social worker), two General Practitioners and three Health and Social Care professionals, who work in the home as part of the healthcare team, responded to surveys that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standards of the service. Time was spent with several of the service users, the acting manager, a student social worker on placement and staff on duty. A tour of the premises was carried out and a sample of records required to be kept in the home were examined, including the case tracking of four service user’s files. Feedback was given to the acting manager at the end of the visit. What the service does well:
The majority of service users are admitted to the home for either a short programme of intensive therapy in order to gain independence following an injury or illness known as The Rehabilitation Scheme or to the Assessment and Intervention Scheme, which gives service users discharged from hospital, extra time to recover from illness or injury, whilst making the right decision about how and where their future care needs can be met, as long term care needs become clearer. This may be that the service user returns home, returns home with additional support, moves into sheltered accommodation or moves into a care home. Service users feel that they are treated with dignity and respect. Staff were observed to interact with service users in a respectful and appropriate manner. The inspector gained the impression that there is a good rapport in the home between service users and the staff team. Service users described the staff team as ‘very good’, ‘champion’, ‘always helpful’ and ‘nothing is too much trouble’. Comments made on a survey completed by relatives of one service
DS0000039942.V335829.R01.S.doc Version 5.2 Page 6 user stated ‘ The staff engender a feeling of well being among service users by anticipating and responding to their needs’. Service users spoken to confirmed that the home meets their expectations and preferences well. Service users are encouraged to maintain contact with friends, family and the local community. Comments made on service user surveys included activities are arranged by the home that they are able to take part in. Three surveys stated ‘sometimes’ and one service user stated ‘never’. In discussion with one of the two part time activity organisers, a wide range of activities are arranged. Activities arranged are displayed on notice boards around the home and a record kept of these events. One activity organiser, who works ten hours per week, works mainly on the dementia care unit. Service users described the food provided as ‘very good’ and ‘always a choice’. Menus demonstrated that a varied and balanced diet is offered to service users. The home has a complaints procedure in place and this is displayed on notice boards throughout the home. This is considered by the inspector to be good practice. Leaflets explaining the home’s complaints procedure are given to all service users. The complaints procedure is available in various formats. The location and layout of the home is suitable for its stated purpose. The home is maintained to a good standard. There is a separate healthcare team, working in the home but employed by the Primary Care Trust, and consists of a part time nurse coordinator, part time registered nurse, two part time occupational therapists, a part time occupational therapist assistant, a part time physiotherapist, a part time physiotherapist assistant and administration support for three days per week, to meet the needs of the service users receiving intermediate care. Each member of staff has a training and development programme. Training is well organised in the home and service users benefit from a well trained staff team. All staff complete mandatory training courses as well as specialist training as appropriate to meet the needs of the service users. One of the assistant managers is the home’s training coordinator. The inspector gained the impression that staff morale is good in the home. In discussion with staff on duty it was felt that the home is well managed and run in the best interests of the service users. Staff on duty said that they enjoyed working at the home and felt well supported by the manager and that their views were listened to and taken into consideration. Service users who were able to express an opinion were positive about the care that they receive, the management of the home, the staff team and facilities available. DS0000039942.V335829.R01.S.doc Version 5.2 Page 7 During the inspection the home’s fire alarm system was activated. The staff team responded to the event in a calm manner and all staff demonstrated a clear understanding of fire evacuation procedures. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000039942.V335829.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 DS0000039942.V335829.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): Standards1, 3 and 6. Quality in this outcome area is good. All service users are fully assessed prior to moving into the home and are given the opportunity to visit the home. Dedicated accommodation is provided, together with specialised facilities, equipment and staff are provided, to service users admitted to the home for intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of service users are admitted to the home for either a short programme of intensive therapy in order to gain independence following an injury or illness known as The Rehabilitation Scheme or to the Assessment and Intervention Scheme, which gives service users discharged from hospital, extra time to recover from illness or injury, whilst making the right decision about
DS0000039942.V335829.R01.S.doc Version 5.2 Page 10 how and where their future care needs can be met, as long term care needs become clearer. This may be that the service user returns home, returns home with additional support, moves into sheltered accommodation or moves into a care home. The nurse coordinator undertakes all assessments for service users requiring intermediate care and the manager or deputy manager undertake the assessments of prospective service users to the dementia care unit. The multi disciplinary assessment procedures are clear and detailed and form part of the care plan. Service users are supported and encouraged to be involved in the assessment process. Information is gathered from a range of sources including other relevant professionals, and with the individuals agreement, carer’s interests are taken into account. Admissions to the home only take place if the service is confident that it has the resources to meet the assessed needs of the individual. Comments made on surveys completed by four service users stated that they had not received enough information about the home before they moved in so that they could decide if the home was the right place for them. Comments made on a survey completed by relatives of one service user stated that they felt that they ‘always’ receive enough information about the home to make decisions. This was also confirmed from discussions with service users during the inspection. From discussion with the acting manager, the inspector considers that the home is able to provided a service to meet the needs of individuals of various religious, racial or cultural needs. All staff receive training in equality, diversity and the rights of individuals, during their induction training. DS0000039942.V335829.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. Service users’ health, personal and social care needs are well met. Service users feel that they are treated with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users’ health, personal and social care needs are well met. A multi – disciplinary team meeting is held each week, for service users receiving intermediate care and individual service user’s care plans are discussed and updated as necessary. Since the inspection, the acting manager has advised the Commission that all care plans for the service users’ on the dementia care unit will be reviewed by the end of July, contact sheet recordings will be developed to validate care plans and to evidence that the individual needs of service users are being met. The acting manager has arranged with the training department for care staff to
DS0000039942.V335829.R01.S.doc Version 5.2 Page 12 receive training in recording practices. Appropriate risk assessments are in place. The acting manager has advised the Commission that behavioural guidelines for one identified service user, will be reviewed, updated and incorporated into the service user’s care plan. The acting manager has also advised the Commission that one service user’s guidelines regarding management of seizures, will be reviewed, with the service user’s general practitioner. This will be incorporated into the service user’s care plan. Service users who are admitted to the home for intermediate care are generally responsible for their own medication, following a medication assessment undertaken by a registered nurse. There are detailed policies and procedures in place regarding medication including a self medication procedure. Service users’, who are responsible for their own medication administration, have lockable cabinets in their rooms. Staff who administer medication have received appropriate training. Medication administration records were seen to be well maintained with no obvious gaps in recordings. Medication was stored appropriately. Comments made on service user and relatives’ surveys stated that service users ‘always received the care and support they needed’. Three service user surveys stated that they ‘always’ received the medical support that they needed and one service user survey stated ‘never’. Comments made on surveys completed by healthcare professionals included ‘The team working between health and social services staff is generally very good’, ‘Agency staff sometimes lack certain skills/knowledge regarding the emphasis of the rehabilitation scheme’, ‘Whilst the health team are on duty the health care needs are met by that team e.g. organising the doctor’s round, ordering medication, assessing for self medication, undertaking dressings etc. The healthcare team assess for the occupational therapy and physiotherapy needs of the service user. The care staff follow through and report any problems to the health team. The care staff follow the care plans to promote independence’. The healthcare needs of the service users on the dementia care unit are met by the community nursing team. Comments made on surveys completed by two General Practitioners included ‘This care home is well run and has a congenial and happy atmosphere’, ‘ I think Tanfield is one of the best care homes that I visit’. Comments made on a survey completed by a care manager (social worker) for service users receiving intermediate care included ‘ In my experience the staff and nurses at Tanfield are very effective in identifying health problems and getting prompt and appropriate support for service users. There is a strong feeling of a multi disciplinary approach to support service users needs, with service users views listened to and acted upon’. A brief handover takes place each morning between the nurse coordinator, staff nurse and care staff to discuss service users receiving intermediate care and between senior staff and care staff at the start of each shift on the dementia care unit.
DS0000039942.V335829.R01.S.doc Version 5.2 Page 13 Service users feel that they are treated with dignity and respect. Staff were observed to interact with service users in a respectful and appropriate manner. The inspector gained the impression that there is a good rapport in the home between service users and the staff team. Service users described the staff team as ‘very good’, ‘champion’, ‘always helpful’ and ‘nothing is too much trouble’. Comments made on a survey completed by relatives of one service user stated ‘ The staff engender a feeling of well being among service users by anticipating and responding to their needs’. All service users were observed to be appropriately dressed and well groomed, it was noted that staff pay particular attention to the needs service users who wear spectacles, hearing aids and dentures. DS0000039942.V335829.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. Service users are encouraged to maintain contact with friends, family and the local community. Routines are flexible to meet the wishes of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users spoken to confirmed that the home meets their expectations and preferences well. Service users are encouraged to maintain contact with friends, family and the local community. Comments made on service user surveys included activities are arranged by the home that they are able to take part in. Three surveys stated ‘sometimes’ and one service user stated ‘never’. In discussion with one of the two part time activity organisers, a wide range of activities are arranged. Activities arranged are displayed on notice boards around the home and a record kept of these events. One activity organiser, who works ten hours per week, works mainly on the dementia care unit. DS0000039942.V335829.R01.S.doc Version 5.2 Page 15 The inspector, observed at various times during the inspection, activities taking place on the dementia care unit, including music, singing and service users assisting with the setting of tables for lunch. Daily records did not evidence activities or social events undertaken by individual service users. The acting manager has advised the Commission that this has been addressed. Service users are able to attend a wide range of activities in the community including attendance at places of worship, local day centres, bingo, library and visits to places that are of interest to individuals. Holly Communion is brought to the home on a monthly basis, the mobile library visits regularly and a hairdresser visits the home weekly. Community groups are encouraged to visit the home. The majority of service users have friends and family who are able to visit regularly. Visitors to the home are welcomed, but are asked not to visit in the mornings, as this is the time when most service users are receiving physiotherapy and other treatments. Service users are able to smoke and consume alcohol in their rooms, unless it has been risk assessed as being too great a risk to themselves or other service users. All the units have kitchenettes, for service users to prepare drinks and snacks at any time. The inspector joined a small group of service users for the midday meal. The meal was hot, tasty and served attractively. The day’s menu was displayed and service users said that there was always a choice of meals. Service users described the food provided as ‘very good’ and ‘always a choice’. Menus demonstrated that a varied and balanced diet is offered to service users. Although records of food provided to service users are maintained, the inspector was unable to examine records of food provided to the service users on the dementia care unit. Special diets are prepared as necessary. Since the inspection the acting manager has advised the Commission that details of food eaten will be recorded in daily records and guidelines from dieticians/speech and language therapists, regarding special diets will be incorporated into care plans, for service users on the dementia care unit. DS0000039942.V335829.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): Standards 16 and 18. Quality in this outcome area is good. Service users and their relatives are confident that their concerns and complaints will be taken seriously and acted upon. Policies and procedures are in place to protect service users from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure in place and this is displayed on notice boards throughout the home. This is considered by the inspector to be good practice. Leaflets explaining the home’s complaints procedure are given to all service users. The complaints procedure is available in various formats. Two service user surveys stated that they did not know how to make a complaint and two stated that they did. Service users who were asked said that they would speak to a member of staff or to the acting manager if they were unhappy about something, and felt confident that complaints would be taken seriously and dealt with. Since the last inspection the home has received fourteen complaints, these were well documented and evidenced the complaint, action taken and the outcome clearly stated. DS0000039942.V335829.R01.S.doc Version 5.2 Page 17 It is evident that this home encourages service users to express their views and wishes. The Commission has not received any information concerning complaints about this service since the last inspection. There are policies and procedures in place to protect service users from abuse including the homes whistle blowing policy. All staff receive training as part of their induction training. Not all staff spoken to were familiar with the homes whistle blowing policy. DS0000039942.V335829.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): Standards 19,20,21,22,23,24,25 and 26. Quality in this outcome area is good. The home provides safe, well maintained and comfortable accommodation, which meets the need of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The location and layout of the home is suitable for its stated purpose. The home is maintained to a good standard. Since the last inspection corridors and some communal areas have been redecorated, the hairdressing room has been extended and the path at the front of the home has been tarmaced. Service users expressed their satisfaction about the premises, facilities and gardens. Communal areas are homely and comfortable. External lighting has been increased to improve security. Hot water outlets in bedrooms and bathrooms are maintained at recommended temperatures. All windows are fitted with
DS0000039942.V335829.R01.S.doc Version 5.2 Page 19 window restrictors and radiators are covered. A call alarm system is fitted in all bedrooms, bathrooms and communal areas of the home. Bedrooms are appropriately furnished and service users are encouraged to personalise their rooms. Most service users have a television set. Bathrooms and toilets are fitted with appropriate aid and adaptations to help maintain independence. Thirteen bedrooms have en-suite facilities. All areas of the home were seen to be clean and free from unpleasant odours. It was evident from discussion with one of the two housekeeping staff on duty, that staff work hard to keep the home clean, pleasant and hygienic. The laundry is well equipped and staff have received training in infection control, COSHH and health and safety. Policies and procedures are in place. In discussion with the laundry assistant it was clear that a system was now in place to ensure that, whenever possible, laundry is returned to the correct service users. DS0000039942.V335829.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): Standards 27,28,29 and 30. Quality in this outcome area is good. Service users needs are met by the numbers and skills mix of the staff team. Robust recruitment procedures are in place to protect service users from harm. Service users benefit from a well trained staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There appears to be adequate staffing levels to meet the needs of the service users. There is always a minimum of six care staff on duty from 7.30am until 10pm. Since the last inspection staffing levels at night have been increased to three waking night staff, with one of the three being a ‘lead officer’. In addition there is a team of housekeeping, laundry, catering and maintenance staff. There is a separate healthcare team, working in the home but employed by the Primary Care Trust, and consists of a part time nurse coordinator, part time registered nurse, two part time occupational therapists, a part time occupational therapist assistant, a part time physiotherapist, a part time physiotherapist assistant and administration support for three days per week, to meet the needs of the service users receiving intermediate care. In addition a community psychiatric nurse, although not part of the Tanfield healthcare team, attends the multi-disciplinary team meeting each week.
DS0000039942.V335829.R01.S.doc Version 5.2 Page 21 The home currently has vacancies for care assistants X 247 hours, housekeeping X 21 hours and a residential care officer X 37 hours. The acting manager advised the inspector that following a recent successful recruitment drive, he is confident that four or five of these posts will be filled. Vacant hours are covered by existing staff working additional hours or by agency staff. In one eight week period, 129 individual shifts included agency staff. Staff were observed to be professional and courteous in their approach to colleagues, service users and visitors. The inspector was advised that 48 of the care staff have completed NVQ level II training, several members of the care team are due to complete or commence the training later this year. All new staff complete a detailed induction programme within six to twelve months of employment. From a sample of staff personnel files it was evident that there are robust recruitment procedures in place. The acting manager has advised the Commission that a recent photograph will be placed on all staff files. Each member of staff has a training and development programme. Training is well organised in the home and service users benefit from a well trained staff team. All staff complete mandatory training courses as well as specialist training as appropriate to meet the needs of the service users. One of the assistant managers is the home’s training coordinator. Communication systems in the home are well organised, with staff handovers taking place at the beginning of each shift. Staff meetings take place and minutes of the meetings were available for examination. The inspector gained the impression that staff morale is good in the home. DS0000039942.V335829.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): Standards 31,32,33,35,36, 37 and 38. Quality in this outcome area is good. Service users benefit from a well managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is currently on maternity leave and during her absence the home is being managed by the experienced and well qualified deputy manager. Both the manager and deputy manager work normal office hours of 9am until 5pm, from Monday to Friday. In addition two full time assistant managers, three residential care officers and administrative support for 30 hours per week complete the senior staff team.
DS0000039942.V335829.R01.S.doc Version 5.2 Page 23 In discussion with staff on duty it was felt that the home is well managed and run in the best interests of the service users. Staff on duty said that they enjoyed working at the home and felt well supported by the manager and that their views were listened to and taken into consideration. Service users who were able to express an opinion were positive about the care that they receive, the management of the home, the staff team and facilities available. Policies and procedures are in place to protect service users’ monies held in safekeeping in the home. Well maintained records are kept of all transactions, which are supported by written receipts. All care staff receive regular planned supervision and annual appraisals of performance are carried out. Supervision sessions are well recorded. There is a current annual development plan in place (Team Planning Framework). Feedback is actively sought from service users about services provided to them. Relatives, advocates and care managers are sent a satisfaction questionnaire to be completed before reviews of service users on the dementia care unit and service users receiving intermediate care are asked to complete a questionnaire when leaving the home. Policies and procedures are regularly reviewed and updated as necessary. Not all reports written by the responsible individual, following monthly unannounced visits to the home, were available in the home for examination. The last report available was dated January 2007. However, the acting manager confirmed that the responsible individual, visited the home on a regular basis and this was confirmed by staff on duty. A sample of records relating to health, safety and welfare were examined and found to up to date and well maintained. During the inspection the home’s fire alarm system was activated. The staff team responded to the event in a calm manner and all staff demonstrated a clear understanding of fire evacuation procedures. DS0000039942.V335829.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 3 X 3 X X 4 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 3 3 DS0000039942.V335829.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP33 Regulation 26 Requirement That a written report is available in the home, following an unannounced visit to the home by a provider representative, each month. Timescale for action 31/07/07 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 All staff receive training/updating in the home’s whistle blowing policy. DS0000039942.V335829.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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
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