Inspection on 15/01/08 for Templecroft

This inspection was carried out on 15th January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Templecroft 19/10/06

Templecroft 31/01/06

Templecroft 09/08/05

Templecroft 18/11/04

Templecroft 19/05/04

Templecroft 06/01/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Templecroft 42 Scartho Road Grimsby North East Lincs DN33 2AD Lead Inspector Eileen Engelmann Key Unannounced Inspection 15th January 2008 10:00 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 Templecroft DS0000002894.V357828.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. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Templecroft Address 42 Scartho Road Grimsby North East Lincs DN33 2AD 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) 01472 752684 01472 7500143 surinder.khurana3@ntlworld.com Dryband One Limited Mrs Ann Elizabeth Martin Care Home 40 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (40) of places Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2006 Brief Description of the Service: Templecroft Care Home is situated in the town of Grimsby on a regular bus route and within walking distance of the main shopping areas. The home provides accommodation and care for up to forty people over the age of sixtyfive, and up to fifteen of these people may have dementia. District nurses provide any element of nursing care that may be required. There are two floors with a passenger lift and stair access. There are three lounge areas and a large dining room with individual tables set out. Patio doors open from the dining room onto a paved courtyard that has a raised pond and an area for tables and chairs. The home is in the process of having a conservatory built, which should be completed by Spring 2008. The home has seven shared bedrooms and twenty-six single rooms, eight of which have en-suite facilities. The home has two bathrooms with bath hoists fitted, a shower room for more able service users and an unassisted bathroom that is rarely used. All these rooms have toilets in them. The home has further single toilets throughout, near the lounge and dining areas. There is a goodsized car park at the front of the building. The environment is homely, clean and well presented. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home, and copies are on display in the entrance hall of the home. The latest inspection report for the home is available from the manager on request. Information given by the manager on 15/01/08 indicates the home charges a fee of £345.00 to £385.45 per week depending on a person’s care needs and the type of accommodation chosen. There are no additional charges other that those for hairdressing, private chiropody treatment, toiletries and newspapers/magazines. A full list of prices for these additional services is available from the manager. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. Information has been gathered from a number of different sources over the past 14 months since the last key visit in October 2006, this has been analysed and used with information from this visit to reach the outcomes of this report. This unannounced visit was carried out with the manager, staff and people using the service. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files, and records relating to the service. Informal chats with a number of people and staff took place during this visit; their comments have been included in this report. Questionnaires were sent out to a selection of relatives, people living in the home and staff. Their written response to these was adequate. We received 0 back from relatives (0 ), 2 from staff (10 ) and 15 from people using the service (75 ). We also received telephone calls from relatives who live some distance away, who wished to comment on the home and its service. The manager completed an Annual Quality Assurance Assessment and returned this to the Commission within the given timescale. The Commission for Social Care Inspection has received one formal complaint in the past 12 months around poor domestic cleaning in one bedroom and a poorly fitted pressure mattress. The complaint was passed on to the provider to investigate and the issues were resolved. One safeguarding of adults allegation (abuse) has been made since the last key visit in October 2006. This was referred to the North East Lincolnshire Social Service team. Their investigation showed there was no evidence of wrongdoing and the issue was resolved. What the service does well: People in the home are provided with a warm, safe and comfortable place to live that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free. The home is welcoming and has a relaxed atmosphere. People living there said they are happy with their bedrooms and can bring in their own possessions, making it feel more like home. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 6 People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. People living in the home said they are offered a good choice of meals and they enjoyed the quality of food. Specific wishes are catered for and they have plenty to eat and drink throughout the day. Relatives of the people living in the home said that they are made to feel welcome by the people working in the home and that they can visit when they please. What has improved since the last inspection? What they could do better: Staff need to go to training sessions about dementia, conditions of old age and challenging behaviour, which will help them understand more about the different needs of the people using the service. This will make the service better as the staff become more confident in what they do and how they do things. The person who owns the home must make sure that the service is looked at on a regular basis to see if it is meeting the needs of the people using it, is working within the guidelines of good practice and is looking after the wellbeing of the people living in the home and the people who work there. We would like to thank everyone who completed a questionnaire and/or took the time to talk to us during this visit. Your comments and input have been a valuable source of information, which has helped create this report. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 7 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. Templecroft DS0000002894.V357828.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 Templecroft DS0000002894.V357828.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): 3, 4 and 6. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff training is not robust and does not ensure that staff have the necessary specialist skills and abilities to meet the needs of people coming into the home. EVIDENCE: The majority of people who completed a survey said they received sufficient information to make an informed choice about the service before coming into the home. One individual said ‘everything was explained to me and I can talk to the staff if I have any questions’. At the last visit in October 2006 a requirement was made that ‘The registered person must ensure that the people or their representatives receive formal confirmation that, having regard for the assessment, their needs can be met in the home’. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 10 Checks at this visit show that the requirement is not fully met and so it will remain on this report. Checks of four people’s care records showed that each of them had a copy of a letter from the manager saying the home could meet their needs, but these were written and dated for the day of admission to the home. This formal written confirmation from the home should be completed and given to the person wishing to come into the home, before the person has made the decision to accept the placement. Each person has their own individual file and four of those looked at had a need assessment completed by the funding authority or the home before a placement is offered to the person. The home develops a care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the person and their family. People and their relatives are very pleased with the care and support given by the staff. The majority of those who responded to the surveys said the home met the needs of people living there and commented that ‘the carers are always considerate’, ‘I cannot fault the home in anyway’ and ‘the staff are good in every way, helpful and kind’. Information from the Annual Quality Assurance Assessment and discussion with the people living in the home indicates that all of the people are of white/British nationality, although there are people with different faiths and religions. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. In February 2007 the home registered with us to accept placements for people with dementia and, although the current numbers of placements in this category of care are small, the manager is aware of the need to introduce more robust staff training around dementia and challenging behaviour to ensure the staff are able to meet people’s needs. Information from the training files and training matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, or they are booked onto training in 2008. Discussion with the manager indicates that she is aware that staff need access to more specialised subjects that link to the needs of people using the service. She is currently looking at different training providers to see where these courses can be sourced. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 11 The responsible individual must make sure that staff have the skills and knowledge to deliver the services and care which the home offers to provide. This will help to develop a consistently high standard of care, which maintains and promotes the people’s health, safety and wellbeing. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, personal and social care needs of people using the service are being met by the service and staff. EVIDENCE: Information from the surveys indicates that the majority of people who responded are satisfied that the staff give appropriate support and care to those living in the home. People said they are able to make their own decisions about their daily lives most of the time; that staff treat them well and listen and act on what they say. Comments from the relatives were that ‘the home gives people excellent care, staff are friendly and it really is a “home from home” environment’. One person told us that ‘my relative is really settled in the home, they are well looked after and their health has improved tremendously since going into Templecroft’. At the last visit in October 2006 a requirement was made that Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 13 ‘The registered person must ensure that people who are self-funding have care plan reviews with appropriate people present to discuss the ongoing effectiveness of the plan’. Checks at this visit show that the manager has a plan of reviews for all people in the home to be carried out over 2008 and evidence is in the care plans that reviews were held in 2007. The requirement has been met. The care of four people was looked at in depth during this visit and included checking of their personal care plans. The content of the plans is basic, easy to follow and on the whole completed to an acceptable standard. It was discussed with the manager that there are a few areas in the care plans that staff need to take more time over and these include • Making sure that all the information areas on the admission sheets are completed in full. Areas seen to be missing are information around care after death, religious beliefs and marital status of people. • Where risk assessments are completed for moving and handling, nutrition and other risk areas, these must be reviewed on a regular basis, ideally every month when the plan is evaluated by the staff. We recommended that the manager carry out a monthly audit of the plans; to ensure the plans are up to date. Two areas of good practise within the care plans are: The meticulous recording of professional visits, reasons for the visits and the outcomes, and The life histories and admission information that go part way to making the records person centred; these give some indication of the personal wishes, needs and life choices of each individual using the service. People said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the people and relatives indicate they are satisfied with the level of medical support given to the people living at the home. One person said ‘we have only to tell the staff that we are not well and we are seen to immediately’. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. It was noted by us that there are no pressure sore risk assessments in the care plans, but the manager told us that a new format has been created for these and they should be in place within the next month. Information given to us indicates that no one at the home has a pressure sore and there is a good relationship with the District Nurse team who provide staff with advice and help around this area of care. At the last visit in October 2006 two requirements were made that Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 14 ‘The registered person must ensure that medication is transcribed correctly and clear instructions are in place for one service user regarding controlled medication used for breakthrough pain’. ‘The registered person must ensure that the service user who self-administers a part of their medication is risk assessed’. Checks at this visit showed both requirements have been met. One of the people case tracked during this visit self medicates and a risk assessment is completed in their care plan. We recommended to the manager that the person’s GP should be part of the risk assessment process. Checks of the medication records showed that overall these are well maintained and kept up to date and the controlled drugs and register are monitored carefully, stored correctly and records are accurate. As a good practise measure we recommended that two staff sign next to transcribed (handwritten) medication instructions. This is to signify they have checked that the instructions contain the right medication name, strength of medication, route to be given, form of medication (tablets, liquid, cream etc.) and when it is to be administered. People and relative comments show they are very satisfied with the care and support offered by the staff. Chats with people using the service revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Individual comments were that ‘my relative is happy and well cared for’ and ‘staff are friendly and helpful’. Observation of the service showed there is good interaction between the staff and people, with friendly and supportive care practises being used to assist people in their daily lives. Privacy screens are provided in the double rooms unless the occupants have requested otherwise. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with choice and diversity in the meals and activities provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: The home has two members of staff who are given time each afternoon between 2pm and 3.30pm to carry out activities. Information about forthcoming events is on display in the entrance to the lounges. Although there is not a written programme of events, the activity book shows that people are able to attend a variety of sessions each week and outside entertainers and reminiscence groups are booked every month. The mobile library visits every six weeks and the ‘Pat-a-dog’ scheme is warmly received every month. People told us that ‘there are enough things for me to do’, ‘I can join in when I want to’ and ‘we have something arranged for us every week’. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 16 Information from peoples’ files indicates that there are a number of individuals who follow different spiritual faiths, including Catholic and Church of England. The manager said that there are regular church visitors (monthly) within the home and people could go to the local church services and religious celebrations as requested. The home provides special meals and cakes for birthdays and helps people celebrate all major Christian festivals such as Easter, Harvest Festival and Christmas. Discussion with the people living in the home indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. Relatives and visitors to the home are very positive about the service and the staff. Written and verbal comments given to us showed a high level of satisfaction. Individuals said ‘there is a friendly and happy atmosphere amongst the people and staff’, ‘staff are patient, kind and polite to people and visitors’, ‘good atmosphere and my relative is kept involved and has a good rapport with the staff’. Information about advocacy services is on display in the home and discussion with the manager indicated that no one at the home is currently using an advocacy service, although these have been accessed in the past. People spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. People spoken to are satisfied that they can access their personal allowances when needed. Staff have attended training on the Mental Capacity act and the manager told us that the local council is setting up equality and diversity training sessions for care homes, which she is hoping to access for staff. Comments from the people living in the home and their relatives are on the whole very positive about the meals and kitchen service provided. Individuals said ‘the dining room is very clean and the food is excellent’, ‘I love the meals and have a good appetite’ and ‘we get three good meals a day and the cooks are wonderful’. The lunchtime meal was well presented and offered a good choice of food, a menu was on display in the lounge and the dining room was welcoming and spacious. Staff were organised when serving the meal and they told us that everyone in the home is able to eat their meals without needing assistance. Discussion with the cooks indicated that they both have their basic food hygiene certificates and have attended additional training sessions on specialist diets and nutrition. One individual told us she is looking into doing an NVQ in nutrition and both people attend the mandatory training provided by the home. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a satisfactory complaints system with some evidence that peoples’ views are listened to and acted upon. EVIDENCE: The home has a complaints policy and procedure that is included in the statement of purpose and service user guide. It is also on display within the home and all fifteen of the survey responses from people using the service showed individuals have a clear understanding about how to make their views and opinions heard. Those people spoken to said ‘we would talk to the staff or Ann (the manager) if we had any problems’. Checks of the records in the home showed that there have been five formal complaints made to the service since the last inspection. The manager has investigated each problem and taken appropriate action to resolve the matters. Her written responses to the complaints are kept on file. We received one formal complaint from the relatives of a person using the service. Their issues were with poor cleaning of the bedroom and a poorly fitting pressure mattress. We passed the complaint on to the provider who contacted the Community team for a more appropriate pressure mattress. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 18 Appropriate action was also taken to ensure cleanliness of the bedroom improved. The issues were resolved at the time of this visit. One safeguarding of adults referral (abuse) was made to the local social services team. This was around staff not responding promptly when a person living in the home needed medical attention. The investigating team found no evidence to suggest the staff acted inappropriately and no further action was needed. The investigation is now closed. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of resident’s money and financial affairs. The staff on duty displayed a good understanding of the safeguarding of adults procedure. They are confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. The majority of staff have received training in Safeguarding of Adults and refresher training is planned for 2008. We recommended to the manager that staff receive further training in dementia care and challenging behaviour to ensure they can meet the needs of the people using the service. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of environment within the home is good, providing people with a comfortable and homely place to live. EVIDENCE: Observation of the premises during this visit showed that there is a maintenance programme in place with redecoration and refurbishment taking place on a rolling system. A conservatory is being built off the dining room, which is due for completion by spring of 2008. Warning signs and wire fencing (to the outside of the premises) prevent people from entering the building area. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 20 People commented that ‘the home provides a safe environment, the rooms are kept extremely clean and the atmosphere is pleasant’. Improvements to the home since the last visit in October 2006 include a new ‘rise and fall’ bath to the downstairs bathroom and new carpets to the lower corridors and staircase. We were concerned that some of the bedroom doors did not appear to be closing properly. The maintenance man dealt this with promptly on the afternoon of our visit. The home has three lounges, which are homely and comfortable and they link together to form a spacious seating area for people living in the home. The chairs in these areas show signs of being well used and should be considered for renewal as they detract from the overall pleasant appearance of the home. The managers office has been reduced in size in order to provide people with a separate smoke room off the dining area. The office is extremely full of paperwork and equipment, with insufficient storage space for all the documents held there. We had to work at the manager’s desk as there is not enough space for two people to sit at a desk in the office, this made it difficult for her get on with her duties during our visit. The provider should consider how the manager could be provided with adequate facilities to carry out her duties, store essential paperwork correctly and talk to families, visiting professionals or potential customers in a quiet and confidential area. The environment is clean, warm and comfortable and few malodours were present. Comments from the day of this visit indicate that the people using the service find the home to be clean and tidy and they are satisfied with the laundry service provided by the home. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Training and development of the staff must be improved to ensure they have the skills and knowledge to meet the needs of the people living in the home. Failure to do so may result in the health, safety and wellbeing of people being put at risk. EVIDENCE: Comments from the people using the service, relatives and staff are on the whole very positive about the staffing levels within the home, and individuals feel that there is a good standard of care being given to the people living in the home. Information from annual quality assurance assessment about the number of staffing hours provided, and information gathered during the visit about the dependency levels of the residents, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the minimum hours asked for in the recommended guidelines. At the last visit to the home in October 2006 a recommendation was made that ‘The home should continue to work towards 50 of staff trained to NVQ Level 2’. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 22 At the last visit in October 2006 at requirement was made that ‘The registered person must ensure that required mandatory training and updates are arranged and induction evidences competency rather than just signed off as new staff having completed the specific sections’. Checks at this visit found both recommendation and requirement have been met. There is an induction course for new members of staff and this is monitored by the manager and signed off once she is confident they understand their role and responsibilities. 50 of the care staff have achieved an NVQ 2 or 3. The home has a mandatory staff training programme in place and information from the staff training matrix indicates that the majority of the staff are up to date with this or are booked onto refresher training for 2008. The manager is aware of the need to expand the range of training to include sessions on conditions relating to old age, dementia and challenging behaviour. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police (CRB) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is satisfactory overall and the home reviews aspects of its performance through a programme of consultations, which seek the views of people using the service, staff and relatives. EVIDENCE: Ann Martin has been the registered manager of Templecroft for 17 years. She has achieved her Registered Managers Award and regularly attends training updates through the company’s manager development programme and outside agency sessions. Ann is aware of the improvements needed to the service and has planned how these are to be achieved. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 24 Staff told us they feel supported by the manager and there is an open door policy so they can go to her at any time if they need advice or help. The home does not have a recognised Quality assurance system in place within the home and checks of the records showed that formal quality audits for the service are not in place. Previous discussion with the operations manager indicates that this is something he is hoping to introduce within the next few months. The registered person has improved the standard of policies and procedures within the home and these have been introduced into the service in recent weeks. The registered person is completing monthly visits to the home and recording these on Regulation 26 reports, which are available in the home for inspection by the appropriate authorities. Staff and resident meetings are taking place and offer individuals an opportunity to voice their opinions and ideas about the service. Satisfaction surveys are going out to people using the service and their representatives, and the feedback and action taken is recorded by the service on an Annual Development Plan. Checks of the financial records showed that people are able to have personal allowance accounts in the home. These records are hand written and detail the transactions undertaken and the money held for each person, the manager updates these each week. Information from the manager indicates that the majority of people have a family member or representative who looks after their monies and these individuals make sure the personal allowances are sent/brought into the home. One account was checked and found to be up to date and accurate at this visit. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices or are due to attend later in the year. Risk assessments were seen regarding fire, moving and handling, bed rails and daily activities of living. Discussion with the manager indicated that she has just received new formats for generic risk assessments for a safe environment within the home. She is hoping to complete these within the next two months and review them yearly. Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. 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 OP3 Regulation 14(1)(d) Requirement The registered person must ensure that people using the service or their representatives receive formal written confirmation that the home, taking into consideration the assessment, is able to meet their needs. This must be given to people prior to their admission. This is so people can be assured their needs can be met by the service before committing themselves to placement within the home. (Given timescale of 30/11/06 was not met) The registered person must make sure that staff, individually and collectively, have the skills and experience to deliver the services and care which the home offers to provide. Timescale for action 01/04/08 2. OP4 12(1) 01/06/08 3. OP30 18 So people can be confident that their needs relating to old age and dementia are recognised and managed appropriately. The registered person must 01/06/08 ensure that there is a training DS0000002894.V357828.R01.S.doc Version 5.2 Page 27 Templecroft programme in place that ensures staff fulfil the aims of the home and meet the changing needs of the people using the service. Specialist training on the elderly and diseases relating to old age and dementia must be included in the training programme. So the health, safety and welfare of the people in the home is protected and promoted, and staff have the skills and knowledge to provide a high standard of care. The registered person must 01/06/08 make sure that effective quality assurance and quality monitoring systems are in place, which seek the views of people and measure the success in meeting the aims and objectives and statement of purpose of the home. So the home can demonstrate that it is offering a quality service and value for money to the people using the service, and is listening to their views and opinions and taking action to meet its aims and objectives and produce favourable outcomes for people. 4. OP33 24 Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 28 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. Refer to Standard OP7 OP8 OP9 Good Practice Recommendations The manager should carry out regular audits of the care plans; to ensure staff are completing these in full and that risk assessments are reviewed on a monthly basis. The manager should ensure that pressure sore risk assessments are completed for each person on admission and reviewed on a continuing basis. The manager should make sure that where staff are hand writing medication onto the sheets (transcribing), there should be two staff signing the entry to indicate they have both witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. The registered person should make sure that staff receive further training in dementia care and challenging behaviour, so they can meet the needs of the people using the service. The registered person should consider replacing the lounge chairs, as they are looking worn and well used. The registered person should consider improving the office facilities for the manager to make sure there is sufficient space for document storage, efficient working practises and discussions with families, staff, visiting professionals and potential customers in a quiet and confidential area. The manager should make sure that generic risk assessments are completed for the home by the end of March 2008. 4. OP18 5. 6. OP19 OP19 7. OP38 Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Templecroft DS0000002894.V357828.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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