Inspection on 30/07/08 for The Chimes

This inspection was carried out on 30th July 2008.

CSCI found this care home to be providing an Adequate 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

The Chimes 30/07/07

The Chimes 21/06/06

The Chimes 08/11/05

The Chimes 02/12/04

The Chimes 24/06/04

The Chimes 18/04/04

The Chimes 26/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/11/2008.

CARE HOMES FOR OLDER PEOPLE The Chimes 6 St Christopher Avenue Penkhull Stoke-on-trent Staffordshire ST4 5NA Lead Inspector Pam Grace Key Unannounced Inspection 30th July 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 The Chimes DS0000008211.V369168.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. The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Chimes Address 6 St Christopher Avenue Penkhull Stoke-on-trent Staffordshire ST4 5NA 01782 744944 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) Mr William Molton Mrs Marilyn Molton Mr William Molton Care Home 28 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (3) The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th July 2007 Brief Description of the Service: The Chimes is a large, extended detached property located in a residential area in Penkhull. The home provides care for a maximum of 28 service users; their needs may range from old age to dementia and/or physical disabilities. The home can accommodate 2 people with dementia and 3 with a physical disability, the staff are trained in this area, and the inspection process confirmed the home is able to meet individual needs. The exterior and interior of the property are adequately maintained and redecoration is ongoing. The service users are offered easy access throughout the home by the use of stairs or a lift. Communal areas are spacious and comfortable; there are two lounges, which can be opened into one if required. The dining room is well maintained, sizeable and sited next to the kitchen. Small, quiet sitting areas are available on all floors. There are 26 single rooms, 12 with en-suite facilities and one double room with an en-suite. Bathrooms and toilets are appropriately situated. There is a garden area for service users and their visitors to use with appropriate seating facilities; adequate parking is available to the rear of the property. Local amenities are within a short walking distance. Local towns are accessible by car or public transport. The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key unannounced inspection was carried out over one day, by one inspector. The inspection had been planned using information gathered from the Commission for Social Care (CSCI) database, the Annual Quality Assurance Assessment (AQAA) document that had been completed by the care manager, comments/surveys received from staff, people who use the service and their relatives. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, people who use the service and their visiting relatives. A tour of the environment was also undertaken. The Owner/Provider is in the process of having an extension to the service built. With a view to providing care and support for 16 people who have dementia care needs. The new build, which commenced in August 2007, is currently on hold. People who use the service are currently unable to access the rear of the building, and are unable to sit outside in the rear garden. Their view from the main lounge windows, i.e. of the garden, is also obstructed. In view of this, we advise that prospective people should visit the home, and ask relevant questions prior to making any decisions to move into the home. The previous inspection report is available to read in the main entrance hallway of the home. At the end of our inspection, feedback was given to the care manager, outlining the overall findings of the inspection, and giving information about the recommendations that we would make. People spoken with were very positive about the care they were receiving. We observed people who were unable to communicate. Our observations showed that these people were well cared for, and were happy in their surroundings. The service had received 1 complaint, and the Commission for Social Care Inspection (CSCI) had received 2 complaints since the previous inspection, one complaint had been upheld, and had already been responded to by the home, and one anonymous complaint had not been upheld. The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 6 Surveys returned to the Commission for Social Care Inspection (CSCI) totalled 17x `Have Your Say’ documents. These included 7 x surveys from staff and 10 x surveys from people who use the service. The feedback and comments we received from people about the service were generally positive, however some feedback highlighted the need for more activities and improvements to the décor of the building. These comments were highlighted and discussed with the care manager. There were no requirements, and 9 recommendations made as a result of this unannounced inspection. What the service does well: What has improved since the last inspection? Staff records showed that appropriate recruitment checks on staff had been made. We noted some improvements to the environment internally as follows – new curtains and bedcovers, new cooker and kitchen flooring, new flooring to the hobbies room and walls repainted. 3 bedrooms re-decorated, and 3 carpets replaced. The upstairs office had been refurbished and re-decorated. The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 7 What they could do better: The Owner/Provider is in the process of having an extension to the service built, with a view to providing care and support for 16 people who have dementia care needs. The new build, which commenced in August 2007, is currently on hold. People who use the service are currently unable to access the rear of the building, and are unable to sit outside in the rear garden. Their view from the main lounge windows, of the garden is also obstructed. In view of this, we advise that prospective people should visit the home, and ask relevant questions prior to making any decisions to move into the home. The previous inspection report is available to read in the main entrance hallway of the home. The Statement of Purpose and Service User Guide should also be made available in large print format. Risk assessments contained within care plans should be regularly reviewed and updated to reflect any changes in the individual’s condition. People who use the service should be consulted about the programme of activities arranged by or on behalf of the care home. People who use the service should have a forum for having their say in regard to the running of the home, and there should be feedback given in regard to quality assurance outcomes. Staff rotas should include all members of staff working at the home. Care staff should receive formal supervision 6 times per year, as per the National Minimum Standard. Staff should be updated in relation to Fire, Moving and Handling, Infection Control, Abuse and the Protection of Vulnerable Adults training. Complaint documentation and the recording of outcomes from complaints should be robustly maintained. Medication requiring safe storage in lower temperatures should be stored in a medication fridge. The Chimes DS0000008211.V369168.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. The Chimes DS0000008211.V369168.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 The Chimes DS0000008211.V369168.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): 1,2,3 and 6 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People considering using the service and their representatives are provided with up to date information, which helps them decide if the service will be suitable to meet their needs. No person moves into the service without firstly having had their needs assessed. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), which was completed by the care manager, told us: “There is a service user guide in every room, the resident is provided with this as well as receiving information about how the home is run from a senior member of staff. Each resident has a pre-admission assessment and a contract, which sets out terms and conditions of occupancy. We provide a statement of purpose that is specific to The Chimes, which sets out the objectives and philosophy of the care home. Prospective residents are invited to visit, have lunch and are given a brochure. We visit them in their own home, The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 11 other care home or hospital, to do the pre-admission assessment, this is carried out by a senior member of staff.” We were given copies of the Statement of Purpose and Service User Guide to look at. We saw that these documents had been reviewed, but that they were not available in large print. The care manager confirmed that the home also produces a quarterly newsletter. People spoken with, and feedback from surveys undertaken confirmed that they had received appropriate information prior to admission, which had included the Statement of Purpose. That they had been able to visit the home, and spend time talking with people who use the service to help them decide if the service would be suitable for them. People also confirmed that they had been provided with a contract/terms and conditions. We looked at three care plans. These showed that an assessment of needs had been undertaken for those individuals prior to and upon admission. The assessments included information about the person’s needs across all activities of daily living examples being; health, social history, risk assessment including falls, bathing, moving and handling. Intermediate care is not provided in this home. The Chimes DS0000008211.V369168.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 adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Risk assessments should be regularly reviewed and kept up to date. Medication processes need further improvement to ensure that they are safe. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), which was completed by the care manager, confirmed the following: “We encourage independence in our residents, wherever this is possible for example to manage their own healthcare and personal hygiene. As the resident’s needs change their care plan is evaluated and amended to make sure that we are providing the right level of care for each individual. We have care plans and risk assessments in place to identify those at risk of pressure damage and what action is being taken to reduce the risk for example pressure relieving equipment. Staff have been trained to administer medicines safely and understand the principles of the safe handling of medicines. End of life The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 13 care is provided to maintain the dignity of the individual and to provide a pain free death in the environment they feel at home in.” We examined three care plans. We spoke with staff, people who use the service, and their visiting relatives. Staff spoken with could tell us exactly how each of these people were to be cared for, what these staff told us reflected what was written in individuals care plans. People we spoke to told us they had been involved in their care planning processes and their review. All three care plans contained evidence of a pre-admission assessment, which had informed the care plan. There was also evidence of health professional’s involvement, for example district nurse, General Practitioner, and Optician visits. Risk assessments contained within care plans were not regularly reviewed and were not up to date. This was highlighted and discussed at the time with the care manager. People spoken with during our visit said that they were very satisfied with the care they receive, and that they were only to ask for help, and staff gave them help. One person confirmed her satisfaction with the care she was receiving, she said “ I have had many hospital appointments and Bill takes me in his car.” She said she was “pleased with her room”, and “the staff are very nice to me.” Surveys received confirmed that people who use the service always receive medical support when they need it. Staff surveys confirmed that they are kept up to date in regard to any changes in an individual’s condition. During a spot check of medication, we discovered that some medication had not been appropriately and safely stored. This was medication that needed to be safely stored at lower temperatures in a medication fridge. We recommend that a medication fridge is obtained for this purpose. This shortfall was highlighted and discussed with the care manager during our inspection. The Chimes DS0000008211.V369168.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 poor This judgement has been made using available evidence including a visit to this service. People who use the service should be enabled to make choices about their life style and should be supported to develop their life skills. Social, educational, cultural and recreational activities must meet individual’s expectations. People using the service are currently unable to access the garden and rear of the building, due to building works. EVIDENCE: People using the service are currently unable to access the garden and rear of the building, due to building works. This also means that they are not able to see the garden through the main lounge windows as their view is obstructed, or go outside, and enjoy the garden. This has resulted in a poor quality outcome for people who use the service. It is anticipated that this is a temporary shortfall, however, the new build has been on hold since October 2007. This was highlighted and discussed with the care manager. We asked that the care manager keep us informed of any changes to this arrangement. The Annual Quality Assurance Assessment (AQAA) document, which was completed by the care manager, confirmed the following: The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 15 “We have our own care home mini bus (suitable for wheelchairs) which can be used for personal or group outings. We recognise the importance of personal and social relationships that residents can have and we are respectful of their privacy. We encourage residents to become involved in activities and join in training sessions with staff if they wish to. We encourage residents to personalise their rooms with their personal possessions. We offer 3 meals, snacks and drinks each day (snacks and drinks available overnight) special diets are catered for, for example diabetic diet. We provide good food which residents enjoy.” There was little evidence that activities take place at the home. Few resources were available at the time of this visit. The care manager confirmed that he undertakes many activities, for example quizzes, skittles, crosswords, stories and reminiscence. We discussed the need for a diary to be kept in regard to what activities are undertaken and by whom. There is no activities co-ordinator employed by the home. Some activities rely upon the good will of staff members, and staff having the time to run them. People spoken with and surveys received confirmed that people are offered activities “sometimes”, one person said they “would like more to do”, and “would like some more activities”. Surveys confirmed that people like the meals provided at the home. Four weekly rotational and seasonal menus were in place. We looked at the kitchen, which was clean and tidy. The records seen confirmed that hot food temperatures are sometimes not being taken daily and recorded. There were gaps in the records. Fridge/freezer temperatures were being taken and recorded every day. We discussed the need to record the choices of meals for individuals at each mealtime. The Chimes DS0000008211.V369168.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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. People are protected from abuse, and have their rights protected. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, which was completed by the care manager, confirmed the following: “We have a clear and accessible complaints procedure illustrating timescales and how complaints are dealt with. The ethos of the home is that we welcome complaints and suggestions about the service. We use these positively and learn from them. All residents are informed of the complaints procedure and would be fully supported by staff in making their complaint. We keep a record of all complaints received and the action that was taken. We have a restraint policy, which explains how angry aggressive behaviour would be managed, and that physical intervention would occur only as a last resort. Residents and relatives can be provided with advocacy information. Procedures are in place to respond to evidence or suspicion of neglect. Staff are trained to recognise possible signs of abuse and know the correct action to take. Zero tolerance of any form of abuse towards a resident by a member of staff.” The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 17 We saw that the complaints procedure was displayed in the main entrance to the home. However, the procedure was tucked away into a corner, our address had not been updated, and the size of print was too small, making it difficult for people to see it clearly. This was highlighted and discussed with the care manager at the time. The care manager confirmed that people who use the service and or their representatives are provided with a copy of the home’s complaints procedure during the admission process. People spoken with and surveys received, confirmed that they had been given a copy of the complaints procedure, and knew who to complain to. They said that their grumbles are listened to and acted upon by staff. A new grumbles book had recently been introduced. One relative spoken with said “if there are problems I come in and have a word. Bill is always around”. The care manager confirmed that the home has an open door policy in regard to complaints. The service had received 1 complaint, and the Commission for Social Care Inspection (CSCI) had received 2 complaints since the previous inspection, one complaint had been upheld, and had already been responded to by the home, and one anonymous complaint had not been upheld. We looked at documentation held by the service in relation to complaints. This was not robust and did not contain copies of letters sent to complainants. There had been no Protection of Vulnerable Adults (POVA)/Safeguarding referrals made to Social Services since the previous inspection. We spoke with staff, they were unable to remember or confirm whether they had received update or refresher training with regard to issues of abuse, its identification and types of exploitation. It is a recommendation of this report that safeguarding/abuse training is undertaken by care staff. Staff recruitment records evidenced that appropriate Police checks had been undertaken prior to employment. The Chimes DS0000008211.V369168.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): 19,20,21,22,23,24,25 and 26 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home should enable people who use the service to live in a well-maintained and comfortable environment, which encourages independence. However, some furnishings are poor and need replacement, and some areas including the downstairs toilets need refurbishment. People using the service are currently unable to access the garden and rear of the building, due to building works EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, completed by the care manager, confirmed that all health and safety checks on equipment and fire systems had been undertaken, and confirmed the following: The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 19 “We ensure that the environment is well maintained and offers residents a homely, clean and safe place in which to live. A programme of routine maintenance works is kept within the home. The home complies with the requirements of the local fire service. All statutory checks are made including lift, bath and manual hoists. We have outdoor space that is accessible to residents with mobility problems. Communal space is available within the care home for all residents to access. We have two lounges one with a TV, and one that has a radio. Toilet and bathing facilities are available to meet the needs of the residents as set out in NMS. Adapted equipment is provided within the home for those residents with limited mobility for example grab rails. We have a call system with an accessible alarm facility in every room.” People using the service are currently unable to access the garden and rear of the building, due to building works. This also means that they are not able to see the garden through the main lounge windows as their view is obstructed, or go outside, and enjoy the garden. This has resulted in a poor quality outcome for people who use the service. It is anticipated that this is a temporary shortfall, however, the new build has been on hold since October 2007. This was highlighted and discussed with the care manager. We asked that the care manager keep us informed of any changes to this arrangement. People spoken with and surveys received expressed satisfaction with the general cleanliness of the home. We noted some improvements to the environment internally as follows – new curtains and bedcovers, new cooker and kitchen flooring, new flooring to the hobbies room and walls repainted. 3 bedrooms re-decorated, and 3 carpets replaced. The upstairs office had been refurbished and re-decorated. The home’s general standard of hygiene had improved since the previous visit, and some carpets had been cleaned and much improved. However, the main lounge and corridor carpets need replacement, and the downstairs toilets, (set of 3) appear cold and unwelcoming and institutional in nature. These need total refurbishment. Furniture in the Hobbies room needs replacing. The two freezers identified need replacement. We noted that equipment and adaptations were provided as necessary to maximise independence. For example, wheelchairs, raised toilet seat, bed rails, pressure mattress, handrails, and assisted baths. Kitchen and laundry areas were clean and tidy, we discussed the need to appropriately dispose of water in mop buckets, and drying of mops, following mopping of floors to prevent cross infection. The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 20 The Chimes DS0000008211.V369168.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): 27,28,29,30 - Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff in the home are in sufficient numbers to support the people who use the service. However, refresher and update training should be undertaken to ensure that people are in safe hands at all times. The staff rota should list all staff working at the home and their stated hours EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, completed by the care manager, confirmed the following: “ As an organisation we recruit in a fair and open way, ensuring we employ the right people. We carry out various checks on possible employees, e.g. CRB and POVA checks, references, employment history. All staff receive induction training. We display a rota, which clearly shows what staff are on duty at specific times. 52 of staff currently have NVQ 2 or above qualifications. Both the deputy care manager and care manager have NVQ4 and Registered Manager Awards. All care staff have been given a copy of the GSCC Code Of Practice. All care staff are trained to encourage residents to feel safe and secure whilst promoting independence.” The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 22 Staff spoken with confirmed that although they are supervised on a daily basis by the care manager and deputy care manager, in regard to their workload, they are not formally supervised as per the National Minimum Standard. This was highlighted and discussed with the care manager. Staff spoken with were not sure when they had last attended a staff meeting, and the staff training matrix evidenced that mandatory and update training had not been undertaken. This included fire, abuse and protection of vulnerable adults, moving and handling. Staff surveys supported the view that staff had undergone induction and training suited to their role and responsibilities. The majority of staff surveys said that they had the right support, experience and knowledge to care for the needs of the people who use the service. Three staff recruitment files were examined. They contained all the appropriate security/police checks, and evidenced a good standard of procedures from an administrative point of view. The staff rota for July 2008 confirmed that staffing levels are being maintained, however, not all staff working at the home were included in the rota. This was highlighted and discussed with the care manager during the inspection visit. The Chimes DS0000008211.V369168.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): 31,32,33,36,37 and 38 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home should further develop its quality assurance system to make sure that services are provided in the best interests of those who use them. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document completed by the care manager confirmed the following: “All staff have induction training. The manager has 7 years management experience at the Chimes, and holds the RMA. The deputy manager 7 years management experience at the Chimes and has recently obtained level 4 qualification in Management and Care as well as the RMA. The home has a clear and accountable management structure appropriate for its size. The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 24 Records are kept to safeguard everyone’s interests for at least 7 years. The care home has up to date policies and procedures which are regularly evaluated. Residents are able to read the records written about them by the care home if they wish to. When a resident does not want to manage their finances, or does not have the capacity to do so we can encourage the resident to appoint Lasting Power of Attorney. We provide a safe place for residents to keep valuables and money. A record of everything kept within this area is maintained. Residents manage their own money except where they choose not to.” A more comprehensive quality assurance system needs to be implemented which encourages and seeks feedback from people who use the service, their relatives and or representatives, and other visitors to the service. This information should be acted upon and outcomes feedback through staff and resident’s meetings. Efforts have been made to meet the recommendations made at the previous inspection. However, the AQAA confirmed that budgetary restraints have impacted upon this. For example the Hobbies room was painted and a new floor was laid, but the furniture remains shabby and of poor quality, this will not be replaced until the budget improves. We looked at the home’s system of recording complaints. Documentation seen did not contain a copy of the final letter to the complainant. We discussed the need to have a robust system of recording and documenting complaints, and that this should include complaint outcomes. The following areas were highlighted, discussed with the care manager, and recommendations made: * Staff should undertake Mental Capacity Act training. * Care staff should receive formal supervision as per the National Minimum Standard. *Staff should undertake update and refresher training in Fire, Moving and Handling, Safeguarding and the Abuse of vulnerable adults and infection control. * A wider range of activities should be provided for people using the service. * The staff rota should reflect all of the staff employed at the home. * Large print versions of the home’s complaints procedure, Service User Guide and Statement of Purpose should be made available. * The home’s Complaints procedure should be clearly displayed on the notice board. * Medication that requires safe storage at lower temperatures should be stored in a medication fridge * The two identified freezers in the kitchen need replacing. * Hot food temperatures should be undertaken and recorded each day. The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 25 *Risk assessments should be reviewed monthly. The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 26 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 3 3 X X N/A 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 1 2 3 3 3 2 3 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 3 2 X X 2 2 2 The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 27 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. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP7 OP9 OP16 OP16 OP30 OP30 OP33 Good Practice Recommendations Risk assessments contained within care plans for people who use the service should be reviewed and updated. Medication requiring storage in lower temperatures should be safely stored in a medication fridge. The home’s complaints procedure should be easily accessible and clearly visible to all people who use the service and their representatives. There should be a robust system of documenting and recording in relation to the outcome of complaints made about the service. Staff should receive training in regard to the Mental Capacity Act 2005 Staff should be updated in relation to Fire, Moving and Handling, Infection Control, Abuse and the Protection of Vulnerable Adults training. People who use the service should be consulted about the programme of activities arranged by or on behalf of the DS0000008211.V369168.R01.S.doc Version 5.2 Page 28 The Chimes 8. 9. OP36 OP38 care home. Care staff should receive formal supervision 6 times per year as per the National Minimum Standard. The two freezers identified need replacement. The Chimes DS0000008211.V369168.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 The Chimes DS0000008211.V369168.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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