CARE HOMES FOR OLDER PEOPLE
The Regency Torrs Park Ilfracombe Devon EX34 8AZ Lead Inspector
Fiona Cartlidge Unannounced Inspection 21st March 2007 11:15 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 Regency DS0000065822.V325839.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 Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Regency Address Torrs Park Ilfracombe Devon EX34 8AZ 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) 01271 862369 01271 863012 Norma Martin Care Homes Limited Ms Norma Elfreda Martin Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (20) The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The Regency is registered as a care home able to provide care accommodation for up to 20 service users in the categories OP Old Age (20), DE (E) Dementia over 65 (20) and MD (E) Mental Disorder over 65 (20). 01/11/06 Date of last inspection Brief Description of the Service: The Regency is a care home providing accommodation and personal care for 20 people over the age of 65 years, in the categories of old age, dementia and mental disorder. The Regency is an older type property providing accommodation on four floors. The building has been adapted for it’s current use by way of the provision of a passenger lift and ramps. Currently all service users are accommodated in single rooms. The Regency changed ownership in February 2006 and is now owned and managed by Norma Martin Care Homes Limited. The home is situated in the Torrs Park area of Ilfracombe, Devon, a short, steep walk from the High Street and beaches. Information about the home was found in the entrance hall, as was a copy of the latest inspection report. Information given to the Commission by the provider indicates the current range of fees is from £307 to £363 per week. Additional charges are made for chiropody and hairdressing. The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The site visit took place over 5 hours 30 minutes and was unannounced. Two inspectors made a partial tour of the home when some bedrooms and all communal areas were viewed. Two hours were spent particularly observing the care given to some service users and any the activities undertaken. After which staff were spoken with and comparisons to care records were made. Two service users had their care needs studied in detail - their records were examined in detail and both service users were spoken with in depth about the care and services they receive. Ten other Service users were spoken with during the visit, 3 members of staff and the provider. Personnel records of 4 members of staff and policies and procedures were also inspected. Written information was received via survey forms that were returned to the Commission by 5 members of staff and 6 relatives/visitors and 3 visiting health and social care professionals. What the service does well:
Prospective service users have the information they need to make an informed choice about their admission to this home. The home has a written statement of purpose, this document sets out the aims and objectives of the home and provides information about the service in the form of a booklet. This booklet was available in the entrance of the home; it has recently been reviewed and updated and now contains current information about the staff available in the home. A guide to services in the home was also seen in the bedrooms of some service users. The admissions process is safe; an assessment of care needs of prospective service users takes place prior to admission to the home. Documents provided evidence that staff use a standard pre- admission assessment form; this is used to assess prospective service users ability to undertake their activities of daily living. Other records seen included copies of assessments carried out through care management arrangements and hospital/community health care teams where applicable. Service users spoken with confirmed they receive a good level of care. Both Service users who were spoken with in detail about their experience in the The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 6 home were aware of the records held on their behalf and said they had been involved in plans to meet their needs. Most staff treat the service users with respect and promote their dignity. Some staff observed in conversation with service users were heard to be courteous and respectful. The Service users were complimentary about the staff team confirming their needs were met 24 hours a day. Comments received from clients included: ‘I am really impressed with the care and support that I am given here’, ‘the staff are kind and attentive,’ ‘Staff attitudes are perfect, they all try very hard’. The feedback about food was positive - all of the Service users spoken to said how good it was; Service users requiring assistance with their meals were given this in an appropriate manner. During a period of observation, all Service users appeared to be enjoying their meal and were in a positive mood. The people living in the home said they were happy with the visiting arrangements. What has improved since the last inspection?
A tour of the building showed that some areas of the building have been decorated since the last inspection. The provider has compiled a building and maintenance programme to ensure continual improvements are made. The rear garden has been tidied since the last inspection and dangerous decking has been removed. There is still work needed to ensure the service users will have access to a safe and pleasant garden in the summer months. The registered provider who also manages the home takes her responsibilities seriously. Environmental and fire risk assessments have been performed on all areas of the home. The registered provider has consulted with service users about their social interests and some arrangements have been made to enable them to engage in local social and community activities. The registered provider has established a system for reviewing and Improving the quality of care provided at the care home. Communication systems are in place, with regular staff shift - handover of information and regular staff meetings. A director of Norma Martin care Homes Ltd undertakes monthly audit visits. In addition to this, recent documented risk assessments have been performed about each individual service user as well as the entire environment. Records seen included regular audits of accidents/incidents in the home, the results of which have been reported on to the staff team. The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 7 What they could do better:
To ensure service users have ample recreational stimulation their plans of care, which provide the basis for the care to be delivered, need to provide more detail about their social needs and how these will be met. When nutritional assessments indicate that a service user has either lost a lot of weight, or has been admitted in a malnourished state, support and advice should be sought from specialist health personnel such as dieticians, so as to ensure all of the health needs of service users are met. The medication system needs to be safely managed. The medication storage and recording procedures, and administration practice showed that the actual practice of administration and recording was in direct breach of the documented procedure. Poor practice poses a risk to Service users because pots may get mixed up, paper name labels may be mixed up or lost; service users may refuse their medication but the records would indicate they had taken it - therefore the record would provide incorrect information. Some of the staff need to improve verbal interaction/ communication skills to ensure that service users needs and wishes are met in a sensitive and inclusive way. The registered provider needs to ensure that there is sufficient numbers of staff available to meet the health, personal and social needs of service users as well as meet the domestic duties required within the home, as at times, staffing levels were low. To ensure a pleasant and comfortable environment is available for all service users, work to improve the environment needs to continue as per plan. More attention to cleanliness of particular areas of the home is required in order to reach a more acceptable standard. Some of the bed linen and pillows seen were of poor quality and need replacing. The health and safety of service users and staff needs to be consistently protected. The registered person must ensure that all staff use safe moving and handling techniques at all times. The Regency DS0000065822.V325839.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 Regency DS0000065822.V325839.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 Regency DS0000065822.V325839.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): 1,3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about their admission to this home. The admissions process is safe. This home does not provide intermediate care. EVIDENCE: The home has a statement of purpose booklet which sets out the aims and objectives of the home and provides information about the service. This booklet was available in the entrance of the home. The document has recently been reviewed and contains current information about the staff available in the home. A guide to services in the home was also seen in the bedrooms of some Service users.
The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 11 The personal records of 2 service users were looked at in detail, these service users were then spoken with about their experience of living at The Regency; both confirmed that the home was meeting the expectations they had when they were admitted. An assessment of care needs of prospective service users takes place prior to admission to the home. Documents seen provided evidence that the home uses a standard pre- admission assessment form; this assesses prospective service users ability against all activities of daily living. Other records seen included copies of assessments carried out through care management arrangements and hospital/community health care teams where applicable. The Regency DS0000065822.V325839.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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health and personal care needs are met. The system for administering medication is not safe this poses a risk to people who use this service. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Service users spoken with confirmed they receive a good level of care. Personal records held on behalf of 2 service users were examined in detail; there were documented assessments which provided information about skin integrity, moving and handling, safety - including risk of falls, nutritional screening and social needs. The information in the assessments had been used to form the plans of care and provided the basis from which the care
The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 13 was to be delivered. Some of the other records seen lacked detailed plans on how the individual’s social needs would be met. One resident’s plan of care did not contain detail about how to meet their increased needs - the plan needed to be reviewed and updated. Both Service users who were spoken with in detail about their experience in the home were aware of the records held on their behalf and said they had been involved in plans to meet their needs. Despite nutritional assessments being performed and service users weights being regularly recorded, where they had either lost a lot of weight or had been admitted in a malnourished state support and advice had not been sought from specialist health personnel such as dieticians. Records are written about all visits to the home by social or health care professionals, and all service users are registered with a General Practitioner. Records provided evidence that as well as visits from GPs, district and specialist nurses and chiropodists also visit. Records of outpatient appointments show that visits to community and hospital health resources are enabled. Surveys were returned from one General Practitioner, one specialist nurse and a social services care worker. Comments about what the service does included: ‘ there is a focus on meeting individual needs and rights, perceptive response and appreciation of health needs’. ‘ Visits are often inappropriately requested when the patient could attend the surgery with a little help from the home’. The medication system is not well managed. Medication storage and recording and procedures were inspected and administration practice observed. The actual practice of administration and recording was in direct breach of the homes written procedure, this was watched by the provider. Medicines were seen dispensed into pots with names put on small pieces of paper in the pots, these were then transferred to a tray and carried to the service users for administration. The staff member signed the administration records before the medication had actually been given to the service users. These practices pose a risk to service users because pots may get mixed up, paper names may be mixed up or lost and service users may refuse their medication, but the records would indicate they had taken them, therefore the record would provide incorrect information. Staff were seen and heard knocking on doors before entering bedrooms and were carrying out personal care for service users in private. Some staff observed in conversation with Service users were heard to be courteous and respectful others either did not communicate or interact at all and one, on one occasion, was patronising. The Regency DS0000065822.V325839.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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle experienced in the home meets the expectations of most of the people who use this service. Service users are able to maintain contact with family, friends and representatives and the local community. Service users are enabled to make some choices and have some control over their lives. The food served in the home is appealing and provides a balanced diet. EVIDENCE: During the site visit, two hours were spent in the lounge observing service users and how staff interacted with them. This highlighted examples of excellent practice but also of very poor practice, which was explained to the Provider at the end of inspection. Some care given by staff was at the right
The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 15 speed and demonstrated genuine warmth and attention, and showing respect, whilst other interactions were based on tasks that were done quickly, or by ignoring service user’s requests. The radio was tuned to the local radio station, but there was no communication about whether this was the service users choice, but it appeared rather that an assumption had been made that service users would like the radio on, none of the service users seemed distressed by the sound of the radio. Other service users were seen spending time in their rooms, reading, listening to music, and watching television or simply sitting with no obvious stimulation or recreation. During the period of observation, one member of staff presented some service users with an art activity with no choice given about their preference or participation. Once this was happening another member of staff removed the art materials with little or no explanation. Other staff were seen to engage with service users using humour, respect and concern, which Service users appeared to respond to and enjoy. Service users spoken with confirmed social activities are arranged, they spoke of occasional trips out of the home. Service users said that activities are advertised by word of mouth, with staff telling them what’s available; a notice board was seen in the lounge/dining room but this contained out of date information- it was updated midway through the day. Records held about service users included information about their social and economic histories, this person centred approach to care allows the staff to know more about the people they care for such as their family and working history as well as their hobbies and interests. However, some examples of this person centred approach were ignored, with no explanation in the care plan why the personal social preference was not followed by staff. This meant that the service for the resident was for the benefit of the service rather than the personal preference of the resident. The feedback about food was positive, all of the Service users spoken to said how good it was. Staff said that a choice of menu is available and notices in the lounge-diner indicated the main menu only. Service users spoken to during the morning of our visit were unaware of what was for lunch or if there was any choice. We were shown documents for recording what each resident had eaten, but completed forms were unavailable at the time of our visit. The food served at lunchtime looked and smelt appealing. Service users requiring assistance with their meals were given this in an appropriate manner. During the period of observation, all Service users appeared to be enjoying their meal and were in a positive mood. The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 16 The people living in the home said they were happy with the visiting arrangements. Completed survey forms were received from 6 relatives/visitors; when asked – ‘does the care home help your friend or relative to keep in touch with you?’ three indicated ‘always’, one ‘usually’, one ‘sometimes’ and the other did not indicate. Comments included ‘ we visit every week’. ‘We speak to staff at those times and we get occasional phone calls about needs or health problems’, ‘ My relative telephones me but it seems they have to use the telephone in the reception area, there is no private place to telephone from’. The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider takes complaints seriously and acts upon them. Service users are protected from abuse. EVIDENCE: The complaints procedure was displayed in the entrance hall and complaints forms were also available. The procedure includes the address of the Commission at the top of the page, this may mislead people into thinking the Procedure is ‘owned’ by the Commission and is not the Regency’s own procedure. Two people who had their care ‘case-tracked’ said they were aware of how to make a complaint and knew who to speak to; if they were not happy they said they would talk to ‘the owner or staff’. Both said they had nothing to complain about and that they feel safe living in the home. Of the six surveys returned to the Commission from relatives/visitors, five indicated they know how to make a complaint, four of those indicated that if they had made a complaint they had ‘ always’ (indicated on three of the survey forms) or ‘usually’ (one) been responded to appropriately. A record of complaints is kept. Most recorded complaints were about loss of clothing items from the homes laundry, in response to this a member of staff now has specific responsibility for working in the laundry.
The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 18 The policies and procedures seen included information on adult protection. Staff training records show that staff have recently received training on the protection of vulnerable adults. The Commission sent surveys to all members of staff, 5 were returned, all of them confirmed they are aware of the adult protection procedures. The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is safe and improvements to some of the décor and fabric have been made, however there is still work to be done to ensure a pleasant and comfortable environment is available for all service users. EVIDENCE: A tour of the building showed that some areas of the building have been decorated since the last inspection. The provider has compiled a building and maintenance programme to ensure continual improvements are made. Evidence that improvements are on-going included walls that had been stripped of wall paper ready for redecoration. The environment was warm and largely odour free at the time of the visit. The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 20 Some ‘assisted baths’ have been fitted to enable service users to be helped safely with bathing. Mechanical sluices have been fitted on the ground and top floors of the building. The sluice room on the top floor does not currently have hand-washing facilities. Some WCs and bathing facilities were worn and stained. Some mobile commodes were seen to have rust and a build up of dirt around the wheels and legs. A new ramp has been constructed to provide access between the old part of the home and the annex, visitors to the building have commented on its steep incline and this was discussed at the time of this visit. The provider has told us that an occupational therapist has been requested to carry out an assessment of the ramp. Environmental and fire risk assessments have been performed on all areas of the home. Records show that all equipment and systems are regularly serviced. Some parts of the home were dirty, such as the skirting boards in the lounge/dining room, old food debris was seen on a cabinet, in one bedroom the carpet was also exceptionally worn and stained. Some of the bedding seen was in a poor state - one pillow case in use had a hole and the pillow was lumpy, duvet covers and sheets were extremely worn and thin. Another bedroom (in use) showed signs that a leak had taken place with water marks on the ceiling and floor, with wallpaper hanging from the ceiling. The rear garden has been tidied since our last visit and dangerous decking has been removed. There is still work needed to ensure the Service users will have access to a safe and pleasant garden in the summer months. The Regency DS0000065822.V325839.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. There are not always sufficient numbers of staff or staff with the skills required to meet all of the needs of the service users. The recruitment process offers protection to the people who use this service. Staff receive training to enable them to be competent to do their jobs. EVIDENCE: Three staff personnel files were examined, all of these records showed a commitment to safe recruitment practices, the files contained an application form, 2 written references, Criminal Record Bureaux check, health checks and main terms and conditions of employment. Individual training records (personal development plans) provided evidence that training is provided and ongoing. Staff spoken to on the day of the site visit confirmed they received sufficient training to enable them to meet the needs of those living in the home. Of the five staff who completed and returned surveys to us four indicated the home provides funding and time for them to receive training, and the other indicated they didn’t know if the home did.
The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 22 The Service users were complimentary about the staff team confirming their needs were met 24 hours a day. Comments received from clients included: ‘I am really impressed with the care and support that I am given here’, ‘the staff are kind and attentive’, ‘Staff attitudes are perfect, they all try very hard’. Comments received on returned surveys from visitors/relatives included ‘ I fully appreciate that the staff have the skills required, they are very attentive and friendly’, ‘all are willing, some are short of experience and some have problems understanding the English language’ ‘some of the girls, whilst being very kind and friendly lack language skills, I appreciate that some have nursing qualifications but this does not help greatly if they cannot understand what is being said’. Observation during the inspection showed two staff were having difficulty understanding each other, the information took time to be understood. Observation of interaction between the staff and service users was undertaken for a 2 hour period during this visit. Some staff communicated and interacted very well but some did not, ignoring requests and performing tasks with no explanation. On our arrival to the home, when asked if the owner was available, the staff spoken to did not know if she was in the home or not, another member staff told us she was not, however the duty rota indicated that she was working at the home from 08:00hrs to 20:00hrs. Staff that were on duty between 08:00hrs and 14:00hrs included 3 care assistants, one chef and one domestic. The Chef leaves at 16:00hrs. Domestic at 13:00hrs and 2 carers at 14:00hrs 1 carer started duty at 14;00hrs to 21:00hrs and another member of staff commenced at 16:15hours until 18:15hrs. At night there is one carer employed on a waking duty and another who comes on duty at 21:00hrs and sleeps from midnight until 06:00hrs, and both the sleeping carer and the provider are available to be called if necessary. Minutes of a recent staff meeting stated ‘it is difficult to do all checks and activities and keep up with the laundry and look after the Service users with only 2 members of staff’. Comments received from relatives/visitors on the returned surveys included ‘ staff levels are poor – girls are very rushed, things often get overlooked or forgotten as they have so much to do’. ‘ Need to employ more English speaking staff so balance is better i.e. always having one English speaking (confidently speaking) person on each shift’. Comments received on surveys returned by staff included ‘in my opinion we are short staffed, we are expected to answer the phone and doorbell as well as care for the service users, it is sometimes a rush to get things done’. ‘staffing levels are too low, there are not enough staff altogether to work the home to The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 23 its best, some staff do too many hours’. ‘ We need less time filling out paperwork and more time spending with the Service users’. The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 24 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider manages the home and she takes her responsibilities very seriously. The home is run in the best interests of the service users. Money that is held on the behalf of service users is secure. The health and safety of service users and staff are not consistently protected. EVIDENCE: The provider/manager is an experienced 1st level registered nurse, has limited management experience and has yet to attain the Registered Managers Award, she has recognised gaps in her management skills and has recently started to
The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 25 utilise the services of a business consultant/trainer to assist her to develop key skills. Communication systems are in place, there are regular staff handovers and regular staff meetings; minutes of these were seen and contained positive reassuring messages for the staff team. A director of Norma Martin care Homes Ltd undertakes monthly audit visits. In addition to this, recent documented risk assessments have been performed about each individual service user as well as the entire environment. Records seen included regular audits of accidents/incidents in the home, audit results have been given to the staff team. A number of policies and procedures have recently been introduced with staff now signing to say they have received them, some of the policies seen lacked specific information relating to the Regency. Improvements have been made in securing money held by the home on behalf of service users. Two signatures are required for every transaction and receipts are kept for all expenditure; the actual balances held were checked against the records and these were correct. During the period of observation the moving and handling technique of some staff showed lifts and transfers were being used, these are no longer recommended. Training records showed that moving and handling training had been given, but this was not being put into practice, which places service users and staff at risk. Maintenance and associated records provided evidence that the registered provider has a sensible approach towards maintaining the safety of the environment; the fire precautions logbook indicates that the fire alarm is tested weekly and emergency lights monthly. Records and discussion confirmed that the staff have regular training in fire safety. The Regency DS0000065822.V325839.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 X 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 The Regency DS0000065822.V325839.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. 1 Standard OP9 Regulation 13(2) Requirement The registered person must make arrangements for the safe recording, handling, storing and administration of medications in the care home to ensure that the health care needs of service users are met. Timescale for action 01/06/07 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 Refer to Standard OP7 OP15 Good Practice Recommendations The service users plans of care should set out in detail the action which needs to be taken by staff to ensure that all aspects of the social needs of the service users are met. To ensure service users are aware that there is a choice of meals, there should be a menu that offers a choice presented in written or other formats to suit the capacities of all service users, which is given, read or explained, to them. To ensure every one is able to understand the complaints procedure, the procedure needs to provide specific information about how complaints made about the regency
DS0000065822.V325839.R01.S.doc Version 5.2 Page 28 3 OP16 The Regency 4 5 6 OP19 OP26 OP27 7 8 OP31 OP38 will be dealt with by the home. Improvements to the environment need to continue to ensure service users live in a comfortable, well maintained home. The premises should be kept clean and hygienic throughout. The staffing numbers and skill mix of staff should be appropriate to meet the assessed needs of the service users as well as to take account of the size and layout of the home. The registered manager should undertake management training to ensure that she has the appropriate skills to manage this service. The registered manager should ensure compliance with manual handling operations regulations 1992 through ensuring that staff who have received training in safe moving and handling techniques have understood and consistently follow the instruction given. The Regency DS0000065822.V325839.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Regency DS0000065822.V325839.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
