Inspection on 17/01/07 for The Dell

This inspection was carried out on 17th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Dell 11/03/09

The Dell 29/09/07

The Dell 16/02/06

The Dell 03/12/05

The Dell 03/02/05

The Dell 28/07/04

The Dell 09/03/04

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

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

CARE HOMES FOR OLDER PEOPLE The Dell The Dell Nelson Way Beccles Suffolk NR34 9PH Lead Inspector Mary Jeffries Unannounced Inspection 17th January 2007 10:30 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 Dell DS0000037196.V305617.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 Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Dell Address The Dell Nelson Way Beccles Suffolk NR34 9PH 01502 712683 01502 712683 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) Suffolk County Council Mrs June Ann Gill Care Home 38 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (27) The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named resident with Mental Disorder as detailed in the variation application dated 26/2/06. 16th February 2006 Date of last inspection Brief Description of the Service: The Dell is a purpose built home owned and managed by Suffolk County Council. Situated on the outskirts of the market town of Beccles in a residential area with shops and other facilities nearby. The home has access to a tail lift mini bus. The home has a landscaped garden with car parking and an attached day centre, which is run separately but available to residents of the home. The home is set out on two floors and divided in to four houses, Balmoral, Windsor, Homelea and Gloucester house. Each house other than Balmoral, which also has it’s own laundry, has bedroom, sitting and dinning rooms, a kitchen, bathroom and toilet facilities. There is a central main kitchen and laundry servicing the home and day centre. The Dell is registered to provide care to 38 older people, the places in Balmoral House are offered to people with a diagnosis of dementia. The home currently charges £368.00 per week. Hairdressing, private chiropody, and newspapers are not included. Residents are responsible for purchasing their own clothing. Some transport is charged for. The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place during January 2007 and took six hours. This inspection focused on the Care Standards for older people and the report has been written using accumulated evidence gained prior to and during the inspection. A pre inspection questionnaire was returned by the home. Ten residents returned “Have your Say” comments cards to the CSCI, and nine relatives returned pre inspection comments. The Registered Manager June Gill facilitated the inspection, staff gave assistance. Three of the four units were inspected, two mainstream units, Gloucester and Homelea, and the special needs unit Balmoral. Three residents were tracked. One was spoken with in a group, and the other two, one of whom was poorly in bed, were observed. Two other residents on Gloucester were spoken with together. Two relatives of a resident who were visiting the home were spoken with. At the time of the inspection there were three vacancies within the home, one on Balmoral, one on Windsor and one on Gloucester unit. What the service does well: What has improved since the last inspection? Contracts were in place on the files of recently admitted residents. The homes medication administration system including checks of the system had been improved. The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 6 A baffle lock fitted to French doors on the special needs unit had been removed. Risk assessments were in place to provide for fire doors between individual dining rooms and kitchens to be open during the period when meals were served. Policy documents were available to all staff in the office. Refresher training for staff was up to date. Staff supervision had been put on line. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have the information they need to make an informed choice about the home, and to visit prior to admission. Residents can expect to have had an assessment prior to admission to the home. EVIDENCE: Residents are asked on the pre inspection survey if they received enough information about the home before they moved in so they could decide if it was the right place for them. One advised they couldn’t remember, the others all confirmed they had. One commented, “ very impressed when I first came to inspect.” A relative who completed the form added “two daughters visiting with (them) were very impressed by this aspect of the visit, and the Dell was the home we (all) liked of the several local choices visited.” A relative The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 9 spoken with advised that they could have visited the home but did not as they already knew it, another relative having previously lived there. Two of the three residents files inspected contained a contract. The other did not, the manager advised that this would be given at the end of the trial period, this resident having been admitted one month prior to the inspection. It was not established whether they had been provided with a Service User Guide, this will be followed up at the next inspection. All of the files contained preadmission assessments and the home’s own assessment. The Registered Manager confirmed that the home does not provide intermediate care. The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents cannot be assured that their care plan will be complete within a short period of admission, or that it is thoroughly regularly reviewed to ensure that all aspects of their care are considered. Residents can expect that their health care needs be met. Residents can be assured that they are treated with dignity and respect although the environment on Balmoral did not fully support their privacy. EVIDENCE: The care plan for the resident who had been admitted four weeks prior to the inspection did not have all aspects of their care plan complete. Whilst there was a manual handling assessment and a night care arrangements, there was no nutritional screening/food preferences, and the risk assessment for having room keys had not been completed. The other two care plans inspected were complete, but had not had regular monthly reviews. One showed that it had The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 11 been reviewed monthly, but that this had not occurred in September and November 2006. The other care plan showed that there had been a major review had been held following admission in March 2006. It did not show clearly that it had been fully reviewed on a monthly basis; most recently, the night care plan had been reviewed in September 2006 and January 2007, and the day care plan in October 2006 and January 2007. Residents’ files contained details of appointments with G.P.’s, district nurses and chiropodists. The residents had the equipment they required, for example, one of those tracked had an extra wide commode. A resident who was poorly and in bed on the day of the inspection had a pressure pad mat besides their bed. This resident was not on an air mattress, but one had been delivered that morning and was to be put in place. The carer advised that a rise and fall bed had been ordered and was due to arrive in two days time. Balmoral House special care setting has limited aids to assist residents understanding, for example menu’s in alternative appropriate formats. A board listing the names of staff was present in the dinning area, with photographs. Since the last inspection, a lockable medication trolley had been purchased for each unit. The registered manager advised that the trolley for Balmoral was stored in a locked cupboard when not in use, and the other three were stored in the office. During the administration of medication these were seen to be secure. Lockable refrigerators had also been provided on each unit for medications which needed to be kept cool, such as some prescribed creams with active ingredients. In the fridge inspected, one of the tubes of a cream had not been dated when opened. Medication records were inspected and found to be in order. No missing signatures were found, there was recording of the number of tablets taken where a prescription was for one or two tablets. The Registered Manager was able to provide evidence of quality assurance taking place in respect of the administration of medicine. During a period in December this had been stepped up to daily checking, but routinely occurred weekly. A relative wrote, “ The family are very happy with the care at the home. The staff do a great job, sometimes short staffed but still have time for everybody, with a smile.” Carers were seen to have a good manner with residents, they were courteous and polite when approaching them, and addressed residents directly, ensuring that eye contact had been achieved when speaking with them. Two carers spoken with expressed some pride in this aspect of care within the home. One showed a card from the relatives of a recently deceased resident The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 12 which stated, “ It’s all down to all of you on Gloucester. Your care and kindness have not gone unnoticed, and brought about ……..’s beautiful smile. Thanks for making us so welcome….” The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to enjoy a good quality of daily life, enhanced by the quality of attention given to them by staff, and are free to move around the home as they wish. They can expect that activities will be offered on a group basis, but cannot be expect these will be frequently available. Residents can expect that well cooked and presented meals will be served in pleasing surroundings and that there is flexibility of times to meet individual requirements. Relatives can expect to fell welcome in the home. EVIDENCE: Written menus were displayed at the time of the inspection. A resident advised that they were asked what they wanted for lunch in the morning, and that they had a choice. They were unable to remember what they had ordered, but advised that they knew it would be nice and did not feel a need to be reminded of what they were going to have. A vegetarian choice was offered. One resident stated on their pre inspection comment card, “ always willing to get something else if I don’t like what they are offering.” The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 14 Lunch, which appeared well cooked and appetising, with fresh vegetables, was conveyed to the units on heated trolleys and plated in the small kitchen on the unit. Staff went about assisting in a personable manner and there was no sense of residents being rushed to finish their meal. Residents were seen to move around freely, including on Balmoral where one resident with dementia had chosen to spend some time sitting in a lobby area. Two of the residents spoken to Gloucester unit, which is upstairs confirmed that they could go downstairs and see what was going on if they wanted to, but one said that they needed to use the lift and were scared to do so alone so did not take up this option. Records confirmed that this resident had been given the choice of moving to a downstairs room. This resident advised that the view that they had form their lounge was a major source of pleasure and interest. On the one side they overlooked a small housing estate where daily life could be seen to go on, on the other a playing field where they could see children playing and observe birds, “ I watch the sea gulls”. These residents also valued the freedom of choice they enjoyed; “ We think it’s lovely, we can choose what time you get up and we have breakfast them.” They also commented, “ You are not in hospital, you are in a home.” A member of care staff spoken with confirmed that there is an activities carer is in post who works three days a week, but noted that when they are working they are not working with all residents. The activities programme showed that eight activities a week were provided, across three days. Three of these were usually one to one, four or five of the sessions were on individual units, and session one was sometimes held for all units together, e.g. Bingo. Thus residents can only expect one or two activities a week provided by the activities worker to be available to them. These include quizzes, word games, flower arranging, cooking, and skittles. Two residents advised that there was not much to do in terms of daily activities. They advised that they understood that they could join in the day centre activities down stairs, but were not inclined to do this, as they enjoyed each other’s company and their living environment. One commented, “ We are lucky, there are many people who would love to be where we are.” The Registered Manager advised that access to the day care resource was now much more limited than it used to be. Balmoral unit also has a monthly activity schedule that carers are to carry out with residents, which includes an activity each half day, including dominoes, eye spy, reminiscence box, sing a long. Later in the day a carer was seen taking this resident to a private area to work with a fumble basket. The majority of residents were in the lounge on Balmoral unit during the day, a relative was also seen to be present during the afternoon, and there was a pleasant atmosphere. None of the residents in the lounge were observed to be sleeping. Whilst one resident had an upper limb exercise programme which carers had been shown how to carry out, gentle exercise sessions were not generally The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 15 available; a carer on a mainstream unit advised that they been told not to do any exercises with residents, as they have not been trained. A visitor to a resident on Gloucester advised that their relative chose to spend a lot of time in their own room, but that if staff had five minutes to spare they sat and spoke with them. The carer on a mainstream unit confirmed that they are also expected to do activities with residents, but that this can be difficult; they recalled that they sat down to play a game with a resident recently and immediately someone else needed assistance to go to the toilet. The home does run a number of outings during the year. A relative stated on their pre inspection comment card, “The outings which my mother can be involved in are fairly frequent and I’m always asked if I’d like to go along.” A written comment received indicated that the home is welcoming to relatives, “The staff are always welcoming to me which means an awful lot.” All nine of the relatives providing comment cards confirmed they were made to feel welcome. All nine of the relatives providing comment cards confirmed they were kept informed of important matters affecting their relative. Two visitors who attended Homlea unit were observed to be welcomed and offered the choice of whether they wished to see their relative in private or in the lounge. The Dell DS0000037196.V305617.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, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be able to make complaints, for these to be taken seriously and dealt with appropriately. Residents cannot be sure staff recruitment processes will minimise any risks of abuse to them. EVIDENCE: Residents spoken to thought that they knew who to complain to, but stressed they considered this was unlikely to be required. A record of complaints was maintained. A number of complaints had been made. It was not clear from this record whether the complaints had been upheld, not upheld or were inconclusive. Eight of the nine of the relatives providing comment cards confirmed they were aware of the home’s complaints policy. The Registered Manager advised that there were no advocacy arrangements in place. They identified one resident as having no relatives, this resident however did not want to speak with the inspector. The home’s training analysis showed that all staff had received Protection of Vulnerable Adults (PoVA) training, and a carer spoken with demonstrated an The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 17 understanding of the types of abuse and how they should respond. The home was able to demonstrate that they were taking a complaint from a resident about the attitude of one carer seriously, however it was noted that a PoVA referral had not been made. The Registered Manager advised that a prosecution was to take place in respect of a PoVA that was active at the time of the previous inspection, they had kept the CSCI informed during the period that that the worker who had been subsequently dismissed and had been put onto the PoVA list. CSCI had been notified with a regulation 37 notice of an alleged theft from a resident, and the police had been informed and visited the home, but found that there was no evidence to support the allegation. Good storage facilities and arrangements for holding money are available to residents, but these had not been used by the resident on this occasion. See standard 29, for details of a breach of regulations in recruitment practices that represents a failure to fully protect residents. The Dell DS0000037196.V305617.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, 24, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in an attractive, homely, well-maintained and safe environment, however they cannot be assured that the home will always be odour free. Residents on the special needs unit will find that the environment has not been developed as well as it might be to facilitate their needs, or that the environment offers them full privacy. EVIDENCE: The home’s environment was generally good; it was clean, attractive and homely. The arrangement of the home in unit’s offers residents the opportunity to sit be in small group settings. The views over the surrounding area are particularly good for residents living on the first floor, where large windows open the home up to views of the neighbourhood and recreational ground. The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 19 All residents’ rooms visited were decorated with their own possessions and a comfortable armchair. On Balmoral, residents had their names displayed on their doors in coloured writing with pictures. The menu was on display on Balmoral but it was not in picture form. One resident, only, on Balmoral unit had a lock on their door, and had asked for this. The Registered Manager confirmed that other residents had not had the choice. On one unit, Homelea, there was an unpleasant odour in the corridor. This was brought to the attention of a carer who advised they were not aware of it. After spending some time on the unit it was not obvious, however, on entering this area it was apparent in contrast to the rest of the home which smelt fresh. Seven out of ten residents’ surveys stated that they home was always fresh and clean, three stated usually. A new emergency call system was seen to have been put into operation, replacing the two separate systems that had been in place. A copy of Suffolk County Council’s infection control policy had been forwarded to the CSCI, the home also had its own infection control policy to supplement this which addressed practices within a care home. Protective clothing was seen to be available through out the home. Communal toilets were clean and had liquid soap, paper towels and bins. A member of staff spoken with had a good knowledge and understanding of infection control. The home’s washing machine was seen to have a sluice cycle, and the laundry was in good order. Arrangements for collecting and returning laundry were discussed with a two residents, who considered this to be a very good service. An environmental health inspection had been carried out on the main kitchen and unit kitchens and had been carried out in March 2006 and had found all kitchens to be clean and well maintained, and good practices to be in evidence in the kitchens. The Dell DS0000037196.V305617.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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by a consistent group of carers who are well trained, and have a good manner, however they cannot always be assured that recruitment practices will minimise the risk of abuse. EVIDENCE: The Registered Manager advised that staffing levels were “just about ok.” Staff spoken with felt they would like more time, so as to do more with the residents. The Registered manager had evidenced that they had written to their management about staffing levels, but advised that no changes had resulted. They advised that there can be times, when staff are attending to a residents personal needs when other service users are without supervision. During the visit the inspector noted that staffing on each of the frail elderly units consisted of one member of staff, and on Balmoral two members of staff. The Registered Manager advised that two floating carers are employed during the morning until eleven or twelve o’clock, and that these work one on each floor. Also, they advised that one float is employed during the evening who works across the whole home to support the carers in units. This represents some improvement. The home has one duty team leader on duty at all times, day and night, and that sometimes there is a senior team leader of a day team The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 21 leader also on duty between 9 and 5 pm. The staffing rotas provided confirmed this. The pre inspection questionnaire provided by the home in August 2006 indicated that there is a very low staff turn over, and very limited use of agency staff. The Registered Manager advised that this was still the case, and was able to show the expenditure record on agency staffing, which totalled just £2366 for the period from April to December 2006. They also advised that two members of staff had left since then, and one other was currently not working. The PIQ indicated that over 60 of carer had NVQ 2, and noted that six carers had recently achieved level 3 NVQ. Six of the nine relatives who provided written comments stated that they did consider there were always enough staff on duty, one noting that the special needs unit, Balmoral did appear to have enough staff but the others did not. Household staff also work on units, including a domestic and the kitchen staff. Records showed that all staff had had updates on manual handling, fire safety and Protection of Vulnerable adults. Staff on the special needs unit had also received UNISAFE training in de-escalation techniques. The training analysis provided showed that training provided for carers included a three-day course on dementia and a one-day course, called “ coping with Margaret.” One of the team leaders on the special needs unit was shown to have undertaken a three-day course in special needs in 1999, but had not attended the one-day course. Records for staff recruitment showed that one carer employed during mid 2006 had been employed before a PoVA First check or CRB had been received. The Registered Manager advised that these were now being obtained by Social Care Services. The manager was given advice on the changes in regulations applying to supervising staff who are recruited on the basis of a PoVA First, but not a Criminal Record Bureau check being in place. Applications, references and personal identity documents were all in order. The Dell DS0000037196.V305617.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, 34, 35, 36, 37, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect the home to provide a safe environment, however they cannot be assured that quality control measures will be consistently in place to ensure all standards are consistently maintained. EVIDENCE: The Registered Manager was undertaking NVQ 4 in care. They already have a relevant management qualification. They had taken a break from the NVQ studies, but advised that they had resumed work on this course. They had course work to evidence this. They are aiming to complete in May 2007. The home’s policies were available in the office, and a member of staff spoken with knew where they could access these. The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 23 The home does not keep any petty cash for residents, all monies are banked, and accounts managed by Social Care services where necessary. The home keeps a small amount of petty cash that can be used for small purchases, and the resident’s account is then invoiced on the basis of the receipt. Copies of Social Care Services accounts were seen on files inspected. Individual Petty cash and records was inspected for three residents and found to tally. A carer spoken with advised that they had supervision every five or six weeks, and had had a Personal Development review with their last supervision. They confirmed they had recently had a manual handling refresher and had had PoVA training. They were clear what type of events or concerns should be reported immediately to heir manager. The Registered Manager advised of the residents who had died since the home had submitted its pre inspection questionnaire. Regulation 37 notifications had not been sent to the CSCI in respect of all of these. Two of the missing regulation 37 notices were completed, but had not been forwarded, these were handed to the inspector. Two others were not available. Regulation 26 visits had been carried out each month since June 2007, and copies of the reports were available in the home, with the exception of November 2006. A copy of a residents’ satisfaction questionnaire was provided. The Registered Manager advised that this exercise had been undertaken, but they advised that the administrator was on long term sick leave, and they were unable to locate a copy of the collation. The Registered Manager could not recall any matters arising from the exercise that had informed changes in the home. The Registered Manager advised that dementia mapping had not yet taken place on the special needs unit. Wheel chairs seen in use in the home had footplates. Risk assessments were in place to provide for fire doors between individual dining rooms and kitchens to be open during the period when meals were served. The home’s certificate of Registration was displayed and correct. The home’s public liability insurance was displayed and was in date. A letter from the fire officer on the outcome of a fire safety audit conducted in August 2006 was seen, the outcome recorded was satisfactory. Fire extinguishers were seen to have been serviced in January 2007. The Dell DS0000037196.V305617.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 3 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 17 2 18 2 3 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 3 2 3 The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(1) Requirement Care plans must be completed in a timely way. This is a repeat requirement from the previous inspection. Care plans must be regularly reviewed. This is a repeat requirement from the previous inspection. Provide aids to communication in formats appropriate to specialist needs of residents. This is a repeat requirement from the previous two inspections. Medicinal creams with active ingredients must dated when opened. This is a partial repeat of a requirement made at the previous inspection. The record of all complaints must show outcomes. Residents on Balmoral must be offered the choice of having an appropriate lock and key for their room door unless their risk assessment shows otherwise. Steps must be taken to remove the odour from the corridor of Homelea Unit. Staff must not be employed prior DS0000037196.V305617.R01.S.doc Timescale for action 28/02/07 2. OP7 15(2) 28/02/07 3. OP8 12 (4) (b) 30/04/07 4. OP9 13(2) 31/01/07 5. 6. OP16 OP24 17(2) 12(4) 28/02/07 28/02/07 7. 8. The Dell OP26 OP29 16(2)(k) 19(1) 31/01/07 31/01/07 Page 26 Version 5.2 OP18 9. OP33 Sched2 24(2) 10. OP33 26 11. OP37 37 to an acceptable PoVA first check or CRB being obtained. A copy of the collation/report of 07/02/07 the 2006 quality assurance exercise which elicited residents’ views must be forwarded to the CSCI. Regulation 26 visits must take 31/01/07 place each at least once a month and a record of the visit available in the home. CSCI must be notified of any 07/02/07 significant occurrence including the death of any resident, and missing regulation 37 notifications in respect of the deaths of two residents must be provided. 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. Refer to Standard OP12 OP17 OP18 OP30 Good Practice Recommendations The use of the activity workers time should be reviewed in the light of equity of access to activities on a regular basis for all residents. The requirements for a resident without relatives to have an advocate should be explored. There should be consultation to establish whether a PoVA referral should have been made in respect of the member of staff currently subject to disciplinary proceedings. Team leaders on Balmoral special needs unit should have recent training in dementia care, to ensure awareness of changes in theory and practice relating to dementia care. The Dell DS0000037196.V305617.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Dell DS0000037196.V305617.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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