Inspection on 19/10/06 for Templecroft

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Templecroft 15/01/08

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 Beverly Hill Key Unannounced Inspection 19th October 2006 09:00 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.V295658.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.V295658.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 Dryband One Limited Mrs Ann Elizabeth Martin Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 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 in no other category. 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 has seven shared bedrooms and twenty-six single rooms, eight of which have en-suite facilities. The home has two bathrooms with parker baths, 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 good-sized car park at the front of the building. The environment is homely, clean and well presented. There are four or five care staff on duty throughout the day as well as the registered manager and three waking night staff. The home also has a good complement of domestic, laundry, cooks and kitchen assistants. According to information received on 4.9.06 the weekly rate is £334. Those items not included in the fees are toiletries, chiropody, hairdressing, newspapers and some activities. The homes statement of purpose, and service user guide are displayed in the entrance. Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspectors’ visit took place over one day. Throughout the day the inspector spoke to twelve service users to gain a picture of what life was like for people who lived at Templecroft. The inspector also had discussions with the manager, care staff members who were on duty, a relative and a visiting health professional. The inspector looked at assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were living there. Also examined were activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. The inspector also checked with service users to make sure that privacy and dignity were maintained and that people could make choices about aspects of their lives, especially the times they arose and retired. The Commission for Social Care Inspection had received information that some service users got up quite early and it was checked out to make sure this was out of choice. The inspector also checked that the home ensured service users were protected and safe in a clean environment and also observed the way staff spoke to people and supported them. Prior to the visit to the home the inspector had sent out surveys to service users, family members, a selection of staff members and professional visitors to the home. The inspector received replies from eight service users, two relatives, nine staff members and one health professional and their comments were used throughout the report. There were positive comments about the staff and care provided from service users. ‘I am really enjoying my time here. It is a relief to my daughters and son that I am getting well cared for’, ‘It is excellent care and support although only occasionally they have staff shortage,’ ‘a true home from home’, ‘it is always clean and tidy, this is what my daughters made their decisions on’, ‘I am well looked after with meals’, ‘excellent facilities, people come in for different things (activities)’. Although one service user had ticked there was enough entertainment they later stated that the days were long and it would be good to have even more. Both relatives’ surveys stated they were satisfied with the care provided although one felt there did not always appear to be enough staff around. Comments from a relative on the day of inspection were very complimentary, ‘she’s happy and settled here, and putting on weight. The staff are brilliant, there always someone around and they keep you informed. When she Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 6 remembers dad has died, the staff understand and are very good’. ‘It’s a good quality service’. Staff members indicated in surveys they had support and direction from the manager and received training. However four out of the nine replies also commented on staff shortages occasionally and that they would like to have more time with service users. All felt that they cared for service users well and the staff worked well as a team, often providing support for activities in their own time, such as bingo and outings. The staff put on a show recently, which was commented on by service users. What the service does well: The home had a motivated and committed staff team, many of which had worked at the home for several years and knew the service users well. The home generally had a low staff turnover. All Service users spoken to were complimentary about the home, care and staff, ‘I was worried about coming into a home but I needn’t have bothered as it’s very nice’, ‘the staff are very understanding, more than we are at times’, ‘I can’t fault the staff they look after them very well’, ‘I am very happy here, I refuse to die until I’ve had my telegram from the Queen, I’m 99 years old’, ‘it’s a happy place, you have someone to chat to all the time’, ‘the staff are excellent, even the cleaners help us to exercise’, ‘you can have a laugh and a joke with them, they know everything about you so they know what you need’, ‘the laundry is very good and the bedrooms are spotless’, ‘we’re friends and used to live near each other, we share a big bedroom and are very happy here’. The staff team had a good relationship with visiting professionals and one spoken to stated, ‘there is always staff around and there is no pressure damage in this home’. The district nurse was referring to the good job staff do in ensuring that service users do not develop pressure sores. The home was very clean and tidy and it was clear that domestic staff worked hard to maintain the high standards. The meals provided were of a good standard, well prepared and presented and service users spoken to were very happy with them. ‘The food is lovely, they would do something else for you if you didn’t like it’, ‘the food is very good’, ‘I can’t fault the food’, ‘I’m a bit faddy but they get me what I want’, ‘I have no complaints at all about the food’. The home kept a good record of any complaints they received and dealt with them quickly. Staff were recruited appropriately with checks made prior to the start of employment. Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The home must make sure that service users or their representatives received the formal letter stating that following the assessment the home was able to meet their needs. The home must make sure that instructions for the management of medication given when required to one service user is written clearly for staff so they are aware of when to give it and the length of time that must pass before the next dose. One person self-medicated a part of their medication and whilst this was really good to ensure they still remained independent the manager needed to complete a risk assessment to ensure this is monitored. Service users who are privately funded must have reviews of their care plans with appropriate people present to ensure they are still effective. The home should continue with the good progress made with National Vocational Qualification training and ensure mandatory training and updates are completed. The induction that new staff complete needs to show evidence that they are competent in specific areas. At the moment the manager signs to say staff are competent. It is important that staff are able to evidence they have the appropriate skills to enable them to complete their role and tasks. Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 8 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.V295658.R01.S.doc Version 5.2 Page 9 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.V295658.R01.S.doc Version 5.2 Page 10 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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed prior to admission which enables the home to be sure they can meet their needs. Service users can visit the home and stay for short periods in order to assess its suitability for their needs. EVIDENCE: Four care files were examined in detail and a further one for a specific reason. All care files were for service users admitted during the previous few months. The care files showed that service users had assessments of need completed prior to admission. These included assessments completed by care management. The assessment stated what the service user was able to do for themselves and what they required assistance with and covered the full range of health and social care needs. Care files in general had a range of information in which to assist the care planning stage and there was evidence that the home completed documentation following assessment stating their capasity to meet the service users needs. It was unclear whether this had Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 11 actually been received or seen by the service user or their representative, however, the manager stated it was read out to service users or their representative during admission. Service users spoken to stated that they had the opportunity for trial visits. One person said they had respite stays and these gave them a chance to see what the home was like. The manager stated the first four to six weeks of admission were seen as a trial period before the service user made up their mind about permanent residency but this could always be extended if necessary. Templecroft DS0000002894.V295658.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally care plans were comprehensive and detailed the care required to meet needs, which was provided in a way that respected privacy and dignity. Clear instructions regarding the medication for one service user would ensure appropriate administration. The lack of a risk assessment for one service user who self-medicates, could result in insufficient monitoring. EVIDENCE: Four care plans were examined in detail and a further care plan perused for a specific issue. The care plans formulated were pre-printed sheets for each identified need and then individualised for each service user. A separate care plan was used for service users admitted for respite, which was a shortened version of the main care plan. Care plans were evaluated monthly and daily records maintained of care provided Service users funded by care management had annual reviews but the manager advised that the homes care staff sometimes were not made aware Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 13 reviews were taking place and were not invited to participate. Care staff were asked to complete a form after the review and return it to care management. The inspector could not find evidence that those privately funded had annual reviews, with relatives present and professionals as required. The manager stated discussions with family were held informally, however a review form had been developed to improve this system and to review more formally, the care for those people privately funded. Generally the health care needs of service users were met. There was evidence of professional input from community psychiatric nurses and district nurses and all service users were registered with a local GP. Risk assessments were completed for a range of issues such as falls, nutrition, moving and handling, pressure sores and smoking. Specialist pressure relieving equipment was in place and a discussion with a visiting professional indicated they were satisfied with the care provided. Weights were recorded with evidence of action taken when issues arose, however records appeared to indicate that people put weight on during their stay at Templecroft. The staff were proud that they looked after people well and no one had any pressure sores in the home. Service users confirmed that care was provided in a way that respected privacy and dignity. During the day the inspector observed how staff spoke to service users and how they assisted them to mobilise. Support was provided in a professional and caring way. Generally the management of medication was good. Medication was signed into the home and on administration. However it was noted that one service user had been prescribed a controlled drug to take in conjunction with other medication for breakthrough pain. It was prescribed ‘when required’ and although there was evidence to suggest that so far the home had managed this appropriately, staff must have clear instructions regarding time lapses between doses and when they needed to take advice from the GP or district nurse. One service user admitted for respite care self- administered a particular medication. They required a risk assessment and care plan for this. It was also noted that when staff transcribed medication onto the medication administration record, on two occasions they had not completed the full instructions. This was important to ensure staff administered medication correctly. Templecroft DS0000002894.V295658.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a varied and nutritious diet and appropriate social stimulation. Staff supported people to maintain contact with their relatives and to have some control over aspects of their lives. EVIDENCE: Discussions with thirteen service users and eight staff members indicated that routines were flexible and there were no set times for visitors. One visitor spoken to confirmed they were able to visit at any time and could always see their relative in private and were kept informed of issues affecting them. The inspector observed some service users coming in for breakfast at 10.15am and catering staff confirmed they provided breakfast up until about 10.30am if people chose to lie in. The meals provided were prepared and presented well and the home catered for special diets as required. The menus were on display on the door to the lounge, although this needed updating to reflect the correct meal for the day. Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 15 Those spoken to enjoyed the meals and felt they received a varied and plentiful diet. Staff spoken to stated they tried to accommodate people as much as possible and ensure they had choices about aspects of their lives and remained as independent as possible. This was confirmed in discussions with service users, ‘they come in and ask me if I want to get up’, ‘when we first came in they talked to us about what we liked to do, I’ve just got up now (10am)’, ‘you tell them if you don’t like food and they give you something else’, ‘the seniors say, do you want your tipple yet (evening drink)’, ‘they pop their heads in to see if you are awake, I had my bath this morning because I like to have it on the day I have my hair set’, ‘I don’t like puddings so I have cream crackers instead’, ‘I make my own bed, I like to do it and it helps the staff’. One staff member stated, ‘we treat people how you would want your own relative to be treated’. One service user commented, ‘it’s a happy place, you have someone to chat to all the time’ whilst another summed up saying, ‘it’s a nice place to live’. The Commission had received information that one night staff member got people up early if they needed attention rather than assisting them with personal care and supporting them back to bed. However service users spoken to did not confirm this but the proprietor is to hold a night staff meeting to ensure all staff are aware of night routines and the manager will update preference sheets and care plans with clear instructions from service users regarding the times they like to rise or bathe when this is early in the morning. Service users and staff described a range of activities provided in the home including visiting entertainers, bingo, reminiscence therapy, ‘pat the dog’, cards and dominoes, games, exercises, visits to shops and the auditorium, sing-a-longs, a country and western afternoon and seasonal parties. One staff member spoke about small group entertainment where they looked at memory cards with service users and this prompted conversations, songs and stories. Other staff spoke proudly of the show they put on in their own time and the pleasure this gave to both service users and staff. Individual logs were maintained when people participated in activities. Templecroft DS0000002894.V295658.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to complain about services and are protected from abuse by staff members’ knowledge of policies and procedures and adult protection training. EVIDENCE: The home had a complaints procedure that was displayed in the home. Staff members were aware of the procedure and the documentation used to record complaints. Service users spoken to knew who to speak to if they had any complaints and most named the manager in person, ‘I would tell anybody, theres plenty of people to complain to, I’m not worried about telling staff things’, ‘I would go to the manager, Ann she would sort things out’. Relatives spoken to were aware of the complaints process but they hadn’t needed to use it. There was evidence in a service user meeting that they had been made aware of a ‘niggles book’ to reord any minor issues. Complaints that the home had received were minor and dealt with appropriately. The complaints records indicated that people felt able to complain in the knowledge that they would be addressed. The home had a policy and procedure on the protection of vulnerable adults from abuse and the manager confirmed that all staff had completed video training in induction. Staff members spoken to were very aware of how to respond if they suspect abuse has occurred and the manager was aware of Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 17 how and to whom a referral had to be made. Service users spoken to stated they felt well looked after and surveys received from relatives and visiting professionals confirmed these statements. Templecroft DS0000002894.V295658.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): 19, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were cared for in an environment that was clean and fresh, well maintained and had appropriate communal space. EVIDENCE: During an environment check it was noted that the home was spotlessly clean, a credit to domestic staff. Surveys and discussions revealed that people were happy with the cleanliness of the home and individual bedrooms, ‘the laundry is very good’, ‘the bedrooms are spotless, 100 ’, ‘the bedrooms are always cleaned and tidied’, ‘it’s always clean and tidy, this is what my daughters made their decisions on’, ‘a true home from home’ . One relative stated, ‘the home is always clean, I’m very happy with the home’. The home was well maintained, light and airy and had three separate lounge areas and a large dining room set out with individual tables. There was also a quiet area on the first floor. Decoration and furnishings were of a good Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 19 standard. The home had an enclosed courtyard area accessed via ramps from the dining room, which was well used in the warmer weather. Those service users who wished to smoke did so in a designated area of the dining room but only when not in use. Bedrooms were personalised to varying degrees and some people had their own telephones and items of furniture and ornaments. Not all bedrooms had lockable facilities and privacy locks to the doors, but these were discussed with service users on admission and provided as required. Documentation was completed to reflect this. Templecroft DS0000002894.V295658.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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team had access to appropriate training to enable them to fulfil their role, although some mandatory training needed to be completed and in some cases updated. The home recruited new staff appropriately. EVIDENCE: Staffing rotas were examined and showed that usually five staff members were on duty throughout the morning with four in the afternoon and evening and three staff at night. Four out of nine staff surveys felt they would like to spend more time with service users and sometimes there were shortages but on the whole staffing numbers were consistent. Comments from service users, a relative, a visiting professional and surveys about staff and their attitude were good, they are excellent, the staff are very understanding, more than we are at times, ‘I can’t fault the staff they look after them very well’, ‘the staff are very good, you can have a laugh and a joke with them’, ‘they know everything about you and know what you need’. One relative stated, ‘they take care of her and look after her well, she is settled and has made friends here’. A visiting professional stated, ‘some staff are long serving members, they are always around, and there is no pressure damage in this home’. Staff were observed giving support in a friendly way, they spoke to people appropriately and there seemed a genuine warmth between them. Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 21 Many staff talked about providing activities and support on outings in their own time. The manager had completed a training log of mandatory and service specific training and the proprietor was in the process of producing a training plan for the next year to be recorded in the end of year business plan. Some staff required mandatory training and others had completed it but required updates. The company used a range of training which was a mixture of in-house, external facilitators, visiting professionals, distance learning and local colleges. Twelve of the twentyseven care staff have either completed NVQ level 2 and 3 and five more were progresing through the courses with a further four staff awaiting registration. When those progessing through the course complete it the home will have over 50 of care staff trained to NVQ level which will be a good achievement. The proprietor confirmed that the company had recently employed a training officer who was due to start shortly and would address any shortfalls in training. Staff completed induction packs, which were signed off by the manager but they did not give any evidence of competence in the induction standards, although one inductee spoke about the manager filling out the book with her and asking her how she was getting on. The manager was aware of the new Skills for Care induction standards and this will be implemented with new staff. The manager will ensure that evidence is provided as staff work through induction packs. Recruitment was robust. Four staff files were examined and all had application forms, two references, povafirst checks prior to the start of employment and criminal record bureau checks. Templecroft DS0000002894.V295658.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): 31, 33, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the way the home was managed promoted the health, welfare and safety of service users who lived there and staff who worked there. EVIDENCE: The registered manager had worked in the home for twenty years, sixteen of those as the manager and had recently completed the Registered Managers Award. The manager has kept herself up to date with various relevant training courses throughout the year and continues to be proactive in ensuring the home is a safe environment for service users and staff. Maintenance records were examined and fire systems and equipment checked regularly. Staff completed health and safety training and posters were displayed in the home. Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 23 Staff supervision records were examined and detailed care staff members were on target to receive up to six supervision sessions per year. The manager provided formal supervision to senior care staff and they in turn supervised care staff. Surveys and staff spoken to confirmed they received supervision, support and direction from the manager. The proprietor documented supervision discussions with the manager, attended meetings in the home as required and completed monthly visits. Comments from staff were, ‘we maintain a family feeling in a professional manner’, ‘Templecroft is a nice place to work, the staff all get along with each other, therefore a good atmosphere makes a happy home’, ‘the manager is approachable and very supportive’ and ‘we have an excellent manager’. Staff surveys commented on the importance of teamwork. The home used a recognised quality assurance system that consisted of checks and questionnaires to service users, relatives, and professionals. There was evidence of the home continually obtaining service users views throughout the year. To date the home had surveyed service users on housekeeping in January, food in February, laundry in March, privacy and dignity in April and a generic questionnaire about the home in August. Surveys to relatives had been sent out between August and October and to district nurses and staff in October. Returned surveys were analysed and action plans produced to address any shortfalls. A service user meeting had been held in May to discuss entertainment, fundraising, activities, meals and complaints and niggles. The management of finances was not assessed at the inspection but previous inspections had indicated that these were managed appropriately. Templecroft DS0000002894.V295658.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 X X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X X X 3 X 4 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The registered person must ensure that the service users or their representatives receive formal confirmation that, having regard for the assessment, their needs can be met in the home. The registered person must ensure that service users who are self-funding have care plan reviews with appropriate people present to discuss the ongoing effectiveness of the plan. 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. 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 DS0000002894.V295658.R01.S.doc Timescale for action 30/11/06 2 OP7 15 31/01/07 3 OP9 13(2) 30/11/06 4 OP9 13(2) 30/11/06 5 OP30 18 31/01/07 Templecroft Version 5.2 Page 26 having completed the specific sections. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations The home should continue to work towards 50 of staff trained to NVQ Level 2. Templecroft DS0000002894.V295658.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor 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.V295658.R01.S.doc Version 5.2 Page 28 - 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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