Inspection on 15/07/08 for Tara`s Retreat Residential Care Home

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Excellent service.

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

Tara`s Retreat Residential Care... 23/07/07

Tara`s Retreat Residential Care... 20/03/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Tara`s Retreat Residential Care Home High Street Sandridge St Albans Herts AL4 9DQ Lead Inspector Pat House Unannounced Inspection 15th July 2008 11:00 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 DS0000068418.V368420.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. DS0000068418.V368420.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tara`s Retreat Residential Care Home Address High Street Sandridge St Albans Herts AL4 9DQ 01727 850527 01727 853927 tarasretreat@bmcarehomes.co.uk 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) B & M Care Limited Mrs Annette Sudbury-Smith Care Home 46 Category(ies) of Dementia - over 65 years of age (46), Old age, registration, with number not falling within any other category (46) of places DS0000068418.V368420.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd July 2007 Brief Description of the Service: Taras Retreat Care Home provides accommodation for up to 46 older people who may also have a dementia. The home was purpose built and opened in 2006. The building has two floors and there is a passenger lift for the use of residents, as well as staircases. All bedrooms are for single occupancy and have en-suite facilities. The home is wheelchair accessible throughout. There are secure gardens all around the home with gazebos and seating areas and the site is surrounded by open countryside. There is ample parking provided at the front of the home. Situated in the rural Hertfordshire village of Sandridge, the home is near to local shops and amenities and close to the city of St Albans. The home can be reached by public transport or by road. The M1, M25 and A1 motorways are all approximately 15 minutes drive away. Current fees for the home range from £660 to £700 per week. There are additional costs for services such as hairdressing and chiropody and details are explained in the individual service user’s contract. Copies of the home’s Statement of Purpose and Service User’s Guide are available from the office together with the last CSCI inspection report. DS0000068418.V368420.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 3 star. This means the people who use this service experience excellent quality outcomes. The information in this report is based on an unannounced visit to the home by one regulation inspector carrying out the work of the Commission. For the purposes of this report the Commission will be referred to as ‘we’. The manager was on duty during the inspection and we spoke with staff members and with residents, both in communal areas and individually in their bedrooms. We inspected all areas of the home briefly and examined a selection of records. Since the last inspection the manager has completed and returned a selfassessment questionnaire, sent out by the Commission. This is the Annual Quality Assurance Assessment document, called the AQAA in this report. We have included information from this document in this report. Quality surveys have also been distributed to residents and staff at the home. Currently nine residents and three care workers have returned these forms to the Commission and comments from these have been included in this inspection report. What the service does well: The home is very well kept and all areas are decorated and furnished to a high standard. The gardens are extremely attractive and residents said how much they enjoyed the outside facilities and the surrounding views of the countryside. Without exception the residents we spoke with or received information from said they could think of no improvements they would make at the home and they praised the staff and management. There are a wide range of imaginative activities provided each day for residents to enjoy and it was significant that the televisions were not switched on in either lounge during the visit although residents said they could watch programmes if they wished. The staff we spoke with also said how happy they were working at the home and said they felt supported by the management team and their colleagues. DS0000068418.V368420.R01.S.doc Version 5.2 Page 6 Over 50 of care staff are already trained to NVQ level 2 or above and the residents we spoke with confirmed that staff members were professional and worked to a very high standard. The care planning is very thorough in the home and all records we saw were up to date and were meaningful, enabling care staff to be clear about the needs of individual residents. Details showed how all health needs were being met and residents we spoke with confirmed the records were accurate. Residents said how much they enjoyed the food provided and the meal we saw during the inspection was clearly a ‘highlight of the day’ and was made a really pleasurable experience by the quality of the food and the positive way it was served by the staff. Overall there is a very happy atmosphere in the home and all the positive areas noted above mean that residents in the home enjoy their daily lives and have all aspects of their health promoted by the management and staff. 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. DS0000068418.V368420.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 DS0000068418.V368420.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3, 4 and 5. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the written information provided about the home and the procedures for visits and assessment will ensure that the service can meet their needs. Those needing more specialist dementia care can also be sure that these services will be appropriately provided and constantly reviewed. EVIDENCE: The home has an up to date written Statement of Purpose and Service User’s Guide and copies were seen displayed during the inspection visit. In the returned survey forms, residents confirmed they had received these documents together with written information about the home. The manager confirmed in the returned AQAA that any prospective resident has a full assessment completed before entering the home, often by two of the senior staff. We spoke with two residents who had entered the home recently DS0000068418.V368420.R01.S.doc Version 5.2 Page 9 and both said they had visited the home before moving in, and one said they had spent a week there before making a decision. Both residents also said they had visited other homes before choosing Tara’s Retreat. We looked at these residents’ records and saw detailed and appropriate written assessments, which accurately reflected their needs and which had formed the basis of the initial care plan. The manager explained that since the last inspection visit, further consideration had been given to the home’s provision for residents with a dementia. As a result, the dementia unit is now housed on the ground floor, providing easy access to the gardens. Those residents and staff we spoke with felt this change has been very successful and had improved the daily lives of those who are more confused. Residents we spoke with on the first floor were equally happy with their environment. The staff we spoke with said that training in dementia care is included in induction training and that most staff have now completed a more advanced dementia course. Senior staff said that care planning is also being reviewed and a new format may be introduced which will enhance dementia care services. The care plans we looked at on this unit contained ‘Life Histories’ mostly completed by relatives, and individual likes and dislikes were then seen reflected in current planning. People we spoke with were able to confirm that the care staff in the home always supported their preferences and choices for their daily lives. DS0000068418.V368420.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home ensure that residents are treated with respect and that their individual needs are documented and reviewed so that all their care needs can be met in a way they prefer. The system for administering medication in the home is thorough and helps to protect people who use the service from harm. EVIDENCE: We spoke with residents on both floors of the home and then tracked a selection of their care plans. In all cases the care planning was detailed and relevant to the person concerned. Most records had been signed by the resident or their relative and records contained details of the regular reviews which had taken place, many including family members. Written risk assessments had been completed on all plans, covering individual requirements such as going into the garden alone and covering the risk of falling. In one case the resident concerned had been referred to the local Falls DS0000068418.V368420.R01.S.doc Version 5.2 Page 11 Clinic. One resident had told us that they managed their own insulin injections to control diabetes. We saw details of this process included in their care plan and this showed the appropriate District Nurse involvement and a risk assessment had been completed. Another resident had their colostomy care detailed and plans showed when the Stoma Nurse came to the home to check procedures. One plan had instructions from a Speech and Language Therapist who had assessed the resident concerned after they had choked on some food. These instructions suggested that the food provided for this resident should be “cut up or liquidised. “ We saw the daily records for this resident, which complied with the instructions, but we did suggest that further instructions should be sought from the assessor so that it is made clear exactly which food textures this resident can safely eat. The senior staff confirmed they would do this. The plans we looked at also contained body charts, records of regular weight checks, of optician and other Health professionals’ visits, of wishes at the time of illness or death and had completed inventories of possessions brought into the home. One plan had details of a piece of equipment used by the resident to get in and out of bed independently. The staff we spoke with confirmed that, currently, only two residents needed a hoist on some occasions to help with transfers, but said that, to ensure everyone’s safety, there were always two members of staff involved when this equipment was used. The care plans seen were very detailed and gave clear instructions to staff of individual needs on a day by day basis. We spoke with one resident in the ground floor lounge who said they were waiting for a doctor’s visit. The daily record book showed in turn that the G.P. had been contacted and was calling that morning. We spoke with some care staff who said that it was the senior care workers who wrote in the plans but that they worked with the seniors to ensure that information was up to date and covered all requirements. We saw lists on the wall in the care workers’ stations, which showed the names of individual key workers. Each member of staff looks after between two and four residents and the staff and residents we asked said that the system worked well. One resident said that people’s needs were “very well catered for” in the home and a group of residents we spoke with in a lounge said that the care staff were “all very good” and said that call alarms were always answered promptly so that they felt they were “in good hands” at all times. We saw care staff knocking on bedroom doors before entering and all the interaction we observed between care staff and residents was appropriate and respectful. Residents told us that personal care was provided in a way they wished and one partner of a married couple explained how they worked with care staff to look after their spouse. At lunch-time we accompanied one senior member of staff who was administering medication from the drugs trolley. The staff member confirmed that only seniors are involved with medication. Most of the medication is DS0000068418.V368420.R01.S.doc Version 5.2 Page 12 provided in blister packs but we spot-checked some, which was in individual packaging. The amounts checked were accurate and all the records were well documented and the system for this administration was robust ensuring the safety of residents. The home has a written policy on the administration of medication, which we looked at. This policy was comprehensive, but we just suggested that it include a policy for non-prescribed drugs. The manager said she would add this. The manager said that an external company came to the home regularly to retrain senior staff in this administration. We saw evidence on staff files that their competency in administering medication is checked by the manager every six months and is signed off on each occasion. In the AQAA the manager also states that residents are supported to administer their own medication whenever this is appropriate and that risk assessments would be in place in this event. The manager also said that residents in the home were registered with a range of local doctors but that everyone had their medication reviewed at least annually and that since entering the home, several residents have been able to reduce their need for some medication after such reviews. DS0000068418.V368420.R01.S.doc Version 5.2 Page 13 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 excellent. This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they will be supported to choose how they spend their days but will have a wide range of activities provided which should be able to meet their needs. Procedures followed in the home mean that residents remain part of the community and the food provision adds to their enjoyment and general wellbeing. EVIDENCE: We went in to the ground floor lounge at the start of the inspection and watched two care workers leading a gentle exercise session. There was a large group of residents taking part and both the staff and those taking part were very enthusiastic about the activity. We were told later by staff that the activity co-ordinator was not at work that day but that care staff also took part in providing activities for the residents. The manager told us that the coordinator had been on an accredited activity training course and that four of the care staff were due to attend the same course the next day. This means that, although the home has one co-ordinator who will plan events, there are DS0000068418.V368420.R01.S.doc Version 5.2 Page 14 additional care workers who are enthusiastic about providing stimulation for residents. This is especially relevant in this home where the differing range of residents’ abilities and needs mean that a wide range of activities are needed to cater for all interests. One resident told us that people in the home were given information about the planned events the day before they happened and that care staff also reminded them on the day. We also saw a list of events arranged for the week on a notice board. The list showed that films were shown at weekends and also summarised the weekend television programmes, which could be watched. Notices also showed where reading books could be accessed and listed the events, which would take place in the garden. One resident who was registered blind confirmed they had regular deliveries of ‘Talking books’ and ‘talking news’. In the afternoon we heard a care worker telling a resident that a craft session was shortly going to take place and in another lounge we heard two residents discussing what they would join in with that afternoon. One group of residents we spoke with said that they enjoyed all the events and they had regular quizzes and manicures and hand massage sessions. One resident confirmed that there was a wide range of activities provided but that they were free to take part or not, as they chose. We also noted that the television was not switched on at any time in either of the lounges. We asked some residents about this and they told us that staff always asked if anyone wanted the television on, but mostly people did other things in the day. The residents we spoke with also said they chose the music they listened to in the communal areas. The manager told us that residents themselves also provided events and that some had given talks in the home, including talks on Egypt and on Canterbury. One notice board had details of events and clubs, which could be attended in the local community and the manager said that local schools and Guide groups came into the home especially at Christmas. A local Church provides an interdenominational service every month in the home and Church volunteers also visit. Residents we spoke with said they enjoyed the visits from the ‘Pat-a-dog’ volunteer visitor and that they now had their own pet rabbit in the garden. Two residents took us out in the garden and showed us the rabbit and several residents were sitting in the garden and said how much they enjoyed the country views and well kept grounds. People we spoke with said they could go out whenever they wanted and that visitors were welcomed at any times. They also said the home had a mobile shop where essential items could be purchased twice each week. We saw a pay telephone on a trolley in a main corridor, which was accessible to all residents. In the AQAA the manager said that there were plans to install raised beds in the garden so that residents could grow flowers and vegetables. A sensory garden may also be provided in the grounds. Returned surveys confirmed that DS0000068418.V368420.R01.S.doc Version 5.2 Page 15 residents were very happy with the activities and facilities in the home, although one resident said they would like “more to do in the evening”. People we spoke with praised the food provided in the home. Comments included that the food “is very good”, that there is “a good variety even though I am diabetic” and the “food is lovely”. We saw the mid-day meal served on both floors and one resident commented that they were “ enjoying the meal immensely”. The food we saw served looked nutritious and was served hot and the tables were attractively laid with napkins, condiments and flowers. Residents said they chose their meal the day before but that there were “lots of options”. We overheard one resident ask for a completely different meal, which was then provided and one resident asked for a hot drink, instead of the cold drinks provided and this request was accommodated. One resident asked for ‘seconds’ of the main course as they said they enjoyed it so much. We briefly watched the meals served and eaten on both floors and the atmosphere in both cases was of people enjoying the eating experience, which is an important factor in maintaining well being. We spoke with one resident who had a meal provided in their bedroom and they said this was served hot and that staff help was always provided if it was needed. We saw jugs of water and glasses in all the bedrooms visited and bowls of fruit and jugs of drinks were available in the communal areas. We talked to the staff in the kitchen and saw the menu plans. The menus were well balanced and based on fresh and seasonal food. The chef has written details of the dietary needs of all residents and information about special needs were also displayed on wall charts. The chef confirmed that any special dietary requirements would be catered for, whether for health or religious reasons or just out of personal preference. The kitchen was very clean and the chef said that more shelves were going to be provided for increased storage. We saw records of appropriate food and appliance daily temperature checks and the chef is aware that records need to be kept of the food consumed by all residents. DS0000068418.V368420.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. This judgement has been made using available evidence including a visit to this service. Procedures followed by staff at the home mean that people who use the service can be confident that any concerns they might have will be listened to and that, while in the home, they will be protected from the risk of abuse. EVIDENCE: We saw details of the home’s Complaints procedure displayed in the home and the residents we spoke with said they would not hesitate to voice a concern if they had one. The surveys returned to the Commission also indicated that the staff and residents were all aware of the procedure for making a complaint. The home has written policies on Complaints, Whistle Blowing and Safeguarding Adults. Those staff we spoke with were aware of these policies and of their implications. All staff receive training, which covers these areas and the manager confirmed that staff follow the Hertfordshire County Council joint guidelines for reporting safeguarding issues. There had been one safeguarding incident referred for investigation since the last inspection. This investigation has now concluded and no further action is required. The manager has arranged for staff to receive an update of Safeguarding and local procedures training in the near future so that senior staff can continue to feel confident when dealing with such issues. DS0000068418.V368420.R01.S.doc Version 5.2 Page 17 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 excellent. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from living in a home in which all areas are kept very clean and hygienic and which is maintained to a very high standard. EVIDENCE: We visited all communal areas of the home briefly and went into some of the bedrooms on both floors. Every part of the home we visited was extremely clean and fresh smelling and the residents we spoke with said that standards of cleanliness in the home were always very high. We spoke with one of the domestic staff who confirmed they had all the equipment they needed and that they felt that enough domestic staff were employed at the home. This ancillary worker had also received training in Infection Control and Health and Safety enabling them to confidently maintain good hygiene standards in the home. All the communal bathrooms and toilets we saw had liquid soap and soft paper DS0000068418.V368420.R01.S.doc Version 5.2 Page 18 towels for residents’ use, as recommended in current guidelines for infection control. One resident who had lived in the home for four months said they were “very impressed” with levels of cleanliness in the home. The bedrooms and communal areas were furnished to a high standard and residents had brought many of their own possessions into their own rooms to personalise them. Most bedroom doors had pictures on the outside to enable all residents to find their own room easily. The pictures varied according to what was relevant to the individual resident and some had pictures of an animal, some flowers and some had a photograph of the person concerned at a younger age. The manager confirmed that all bedrooms contained lockable space for residents to use and that a key to their bedroom door were available to any resident who wanted one. We used the lift during the visit and this worked easily and had clear instructions displayed so that residents could use this facility independently where appropriate. The hairdressing room was not locked but there were no hazardous substances left available in this room. One ground floor bathroom was being used to store equipment at the time but staff said that this room was not being used while awaiting some repairs. In the AQAA the manager states that there are plans to install a chair lift in the home to enable residents with some mobility problems to remain independent. The door to the garden was open during the visit and some residents were sitting in the gardens, which were being beautifully kept and looked colourful and attractive. Residents we spoke with outside said how much they enjoyed the gardens. DS0000068418.V368420.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service have their needs met by a well trained and professional work force and are protected by the robust recruitment procedures in operation at the home. EVIDENCE: We spoke with residents about the numbers of staff usually on duty in the home and we were told that there were “usually enough” staff on duty during the day and at night. One residents said they could “always find a carer” and another resident said that, although they had not used the call alarm, others had and they had heard the alarm and “the staff came right away”. Residents felt that staff training must be good as the staff were “so good”. One resident said that “ all staff were approachable and supportive” and in the returned surveys, the staff team were praised and people said they were “very good”, “work hard” and “meet all their needs”. The staff members we spoke with also felt that enough staff were generally on duty in the home. We were told that communication was good so that everyone was aware of the residents’ changing and individual needs and that the staff worked as a team. One care worker said, in comparison to other DS0000068418.V368420.R01.S.doc Version 5.2 Page 20 homes she had worked in, that “working in Taras’s Retreat was Heaven”. One senior staff member said the home was “a lovely place to work” and another experienced care worker said this was “the best home she had worked in”. The staff were clearly content in their roles which makes for a happy staff team. In turn this means that the service provided to residents by the staff is positive. We observed many instances of staff and resident interaction during the visit and all instances were good and clearly provided reassurance to even the more confused residents. Even when passing through a communal area, we saw staff take time to smile and acknowledge the residents there and talk to individuals as they went. The staff we spoke with also said they felt supported in their work and felt their views about the running of the home were listened to. One staff member said they had a mild disability but that the manager and colleagues had supported them and that they had completed all the previous staff training courses, and had more booked and were due to start NVQ training the following month. This care worker was clearly a valued member of the staff team and was praised by the residents we spoke with. In the returned AQAA the manager said that she aimed to ensure that the work force at the home had a variety of skills and was multi cultural in content and outlook, and could support all the individual needs of the residents in the home. We saw evidence that staff at the home were provided with a wide range of training courses and these included all the topics considered as basic training for care staff. Some staff needed updates of Moving and Handling training but the manager said this training would be completed in August. The care staff we spoke with said they were encouraged to undertake NVQ training and some said they would be starting this training later in the year. Currently more than 50 of staff are trained to NVQ level 2 or above. We checked a selection of staff recruitment records during the visit. In all cases we saw evidence that all appropriate checks had been in place before the candidate started work at the home. This ensures that residents are protected by a robust recruitment procedure. DS0000068418.V368420.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the home is well managed and run in the best interests of the residents. Procedures followed by staff at the home ensure that the welfare of both staff and residents is promoted at all times. EVIDENCE: The manager of the home is registered with then Commission and the staff and residents we spoke with said they felt supported by the manager and said that their views and concerns were always listened to and acted on. Comments in the returned surveys stated that the management of the home is very effective. Regular staff and residents’ meetings are held and minutes of these DS0000068418.V368420.R01.S.doc Version 5.2 Page 22 meetings are completed. The minutes are then displayed for residents and staff to read. The home uses the owning company’s Quality Assurance programme and has a written Quality Policy, which was available for inspection. The manager confirmed that quality surveys are sent out to residents, staff, relatives and other Health professionals on an annual basis. The manager said that results of the surveys are used to plan future changes and improvements in the home. In the AQAA the manager states that the home has a “suggestion box” and comments put in the box are also used to make improvements in the home. Planned changes as a result of listening to residents and staff include putting blinds in all residents’ bedrooms and installing a watering system for the home’s hanging baskets. The manager said that she is currently updating the home’s Health and Safety policy and general risk assessments and that she monitors the home’s accident, incident and complaints records monthly so that any significant trends in the home can be addressed. We saw a current insurance certificate displayed in the home and, in the AQAA the manager confirmed that a manager makes regular unannounced inspections at the home from the company’s head office. The manager said that it is not the home’s policy to hold any of the residents’ money and that relatives usually handle these finances. However, there are currently three residents who have money kept at the home, for a variety of appropriate reasons. The home has a written Residents’ Finance Policy which is followed by the manager and we saw evidence that receipts were obtained for all money spent and all transactions were signed for. The home has a written Fire Prevention Policy and records of fire safety checks were in order. The residents we spoke with confirmed that the fire alarms were tested regularly and staff confirmed that regular fire drills took place at the home. DS0000068418.V368420.R01.S.doc Version 5.2 Page 23 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 DS0000068418.V368420.R01.S.doc Version 5.2 Page 24 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. 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. Refer to Standard Good Practice Recommendations DS0000068418.V368420.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000068418.V368420.R01.S.doc Version 5.2 Page 26 - 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. 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