Inspection on 29/06/06 for Thomas House Care Home

This inspection was carried out on 29th June 2006.

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

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

Other inspections for this house

Thomas House Care Home 24/07/07

Thomas House Care Home 02/02/06

Thomas House Care Home 28/09/05

Thomas House Care Home 28/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Thomas House 168 Prescot Road West Park St Helens Merseyside WA10 3TS Lead Inspector Daniel Hamilton Unannounced Inspection 29th June 2006 09:30 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 Thomas House DS0000022411.V295747.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. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thomas House Address 168 Prescot Road West Park St Helens Merseyside WA10 3TS 01744 608800 01744 670701 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) Thomas House (St Helens) Limited Mrs Barbara Thornber Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to Include up to 28 (OP) Date of last inspection 2nd February 2006 Brief Description of the Service: Thomas House is a privately run care home situated on Prescot Road in the West Park area of St. Helens. The home is close to local amenities and has good links to public transport and shops. St Helens town centre is approximately one mile away. Thomas House opened in 1997 and is registered for 28 elderly persons. It is a ‘no smoking’ environment. The home is within a large house built in the 1870’s, which has had extensive renovation work done to extend the facilities. Accommodation is on two floors. The home offers three lounges, a library, dining room, treatment room and hairdressing salon. The premises has 24 single rooms with en-suites and 2 double rooms. Toilets and bathroom facilities are located throughout the home. The first floor rooms are accessible via a passenger lift and a call bell system is in place. There are extensive gardens surrounding the home and a small patio area at the rear, which is accessible from the side entrance. Car parking space is available at the front and rear of the home. The Care Home Fee is set at £359.00 per week. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted a total of 10 hours. 28 residents were being accommodated at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Owner, Registered Manager, 4 staff members, 4 relatives, 7 residents and a health care professional were also spoken to during the visit. Furthermore, satisfaction survey forms “Have Your Say About….” were distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional views / feedback about the home. All the core standards were reviewed and previous requirements and recommendations from the last inspection in February 2006 were discussed. What the service does well: Thomas House had a pleasant atmosphere and the people living in the home appeared relaxed, well cared for and comfortable. The home was decorated and furnished to a good standard and residents’ rooms were homely and personalised. A range of information on the service provided was available in the reception area of the home. The home had developed an assessment and care planning system in order to identify and respond to the health, personal and social care needs of residents. Overall, residents spoken with complimented the care provided and confirmed they were encouraged to make choices and to remain in control of their daily lives. Comments from two residents included; “The staff are very nice people and will give you as much support and privacy as you want” and “In my opinion I have choice and control of my life. I am able to choose my own bedtimes and what I do each day.” Staff were observed to be respectful and sensitive to the needs of residents and were available in sufficient numbers to offer support to residents as required. A monthly programme of activities was produced which was based upon the recreational interests and needs of residents. One resident reported; “We are never short of things to do. Activities are available most days.” Arrangements were in place for representatives from local churches to provide services for residents in accordance with their individual beliefs / wishes and visitors were welcome at any time. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 6 The people living in the home were provided with a choice of balanced and nutritious meals and residents confirmed they were generally satisfied with the meals provided. Comments from two residents included; “The food is always nice and hot” and “The meals are fine and we get alternative choices if we don’t like anything.” The home had developed a complaints procedure and feedback from residents confirmed they were aware of who to talk to if they had a concern. Procedures were available to protect residents from abuse and training records showed that all the staff had completed training in the Protection of Vulnerable Adults. Systems were in place to consult residents and their representatives on the quality of the care provided and systems had been developed to safeguard the financial interests of residents. What has improved since the last inspection? What they could do better: The home had developed a detailed Care Plan system. Some information had been duplicated. In order to address this issue and ensure that the information in care files is easily accessible, the manager should undertake an audit of care plans and remove duplicated information as previously recommended. Medication administration records viewed had not always been signed to confirm service users had received their medication. This practice is not safe and must stop. On the day of the site visit, medication had been administered to residents before they had received their lunch. Each resident’s medication should be checked to ensure it is administered in accordance with prescribed instructions i.e. before, during or after food. The manager should also provide written guidance for medication prescribed as “when required” or “as directed” as recommended at the last inspection. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 7 Some recruitment and induction records could not be checked for new employees during the site visit, as the manager did not have access or know the whereabouts of some records. Arrangements must be made to ensure the records are available for inspection in accordance with the Care Home Regulations 2001. Training records showed that some staff had not completed infection control and others required refresher training for fire awareness. Furthermore, some service / inspection records could not be located for the fire alarm system, extinguishers and electrical wiring. These matters must be addressed to confirm staff are appropriately trained and systems are in place to safeguard health and safety in the home. The manager should also instruct staff not to store clean towels on open shelves in the laundry area, to protect against the risk of cross infection as previously recommended. The Complaints Policy should be updated to provide details of the Commission for Social Care Inspection. 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. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of need had been undertaken prior to admission, to ensure the needs of prospective residents were identified. Prospective residents had access to a range of information on the home to enable them to make an informed decision about whether to move in. EVIDENCE: Policies and procedures were in place for referral and admission. Three files were viewed for residents who had moved into the home since the last visit. Each file contained a ‘Daily Living and Needs Assessment’ that had been completed by the Registered Manager before each resident had moved in. The assessment document was well constructed and enabled the manager to undertake a detailed assessment of prospective residents’ needs. Overall, assessments viewed had been completed to a satisfactory standard however the sections on medication had not been completed. The manager was advised to obtain this information (where practicable) and to also consider additional issues for example cultural needs and ethnicity, to ensure equality and diversity issues are addressed as part of the assessment process. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 10 Assessments/ Care Plans completed by Social Workers were also available on two files viewed. Residents were offered a 4-week trial period. The home had developed a range of information for residents and their representatives, which was stored in a cabinet in the reception area. The documents included; a copy of the Statement of Purpose, Service User Guide, previous inspection reports, satisfaction questionnaires and information on comments, compliments and complaints. Examination of admission records and feedback from residents through discussion and via Care Home Survey forms confirmed that residents had received a Contract and information on the home prior to admission. Signed copies of contracts had been passed to the home’s accountant for safekeeping. Each resident’s file contained a ‘Service User Admission Checklist’, which residents had signed to confirm they were aware of where to find a copy of the documents and that they had been provided with and returned a copy of the terms and conditions of residency. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. 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. Care plans were in place that outlined how the care needs of residents were to be met. Some Medication Administration Records were not being appropriately maintained to account for medication. This has the potential to place the health and welfare of residents at risk. Residents were satisfied with the quality of care provided and felt their individual rights were valued and respected. EVIDENCE: Three files were viewed for residents who had moved into the home since the last key inspection. Each file contained an individualised plan of care which provided detailed information on the support each resident required in order to ensure the health, personal and social care needs of the people living in the home were identified and planned for. Care plan files were detailed and contained a range of additional information including; access to file declarations, personal profiles, preferred routines, review notes, daily report sheets, records of visits to health care professionals, risk assessments, functional / dependency assessments, details of personal property, general correspondence / legal paperwork and incident / accident records. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 12 Plans viewed had been kept under monthly review and had been signed by residents or their representatives. Staff spoken with during the inspection demonstrated a good awareness of the needs of residents and their individual support requirements. As noted at the previous inspection, there appeared to be duplication of some records. Records of visits to health care professionals and feedback received from residents via Care Home Survey forms and through individual discussion confirmed that the people living in the home had access to a wide range of health care professionals as required. Records inspected showed that residents had attended appointments with doctors, continence nurses, chiropodists, opticians, district nurses, and hospitals. Feedback from two residents included: “I have my own doctor who I have seen recently” and “The staff are very good and will call the doctor if anyone is poorly.” The home had a Medication Policy and procedure in place, which included procedures for residents who wished to self-administer their medication. The manager reported that none of the residents were self-administering medication at the time of the visit. A copy of the Royal Pharmaceutical Guidelines and reference information on drugs used in the home was also available for staff. Staff designated with responsibility for the administration of medication had completed appropriate training and this was verified by checking certificates. The home used a blister pack system that was dispensed by a local pharmacist. On the day of the inspection the lunch-time medication had been administered prior to residents having lunch. Advice was given that the details of each resident’s medication should be checked, to ensure medication is administered in accordance with prescribed instructions i.e. before, during or after food. Suitable storage facilities were available for medication and controlled drugs and a resident identification system had been established to ensure safeguards were in place when administering medication. Examination of Medication Administration Records highlighted that some prescribed medication was not accounted / signed for and incorrect codes had been used. Since the last inspection, the manager had labelled all supplies of prescribed dressings. The manager was advised to also review the competency of staff to safely administer medication periodically and to develop guidelines for medication prescribed as when required or as directed as recommended at the last inspection. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 13 Discussion with staff, the manager and examination of team meeting minutes confirmed the owner and manager had spoken to staff following a previous requirement, in order to raise staff awareness of how to safeguard and promote the privacy and dignity of residents. Residents spoken with during the inspection complimented the quality of the care provided and confirmed they were treated with privacy and dignity. Residents appeared well cared for and staff interviewed demonstrated a sound knowledge of how to promote the values of privacy, dignity, choice, rights and independence. Staff were observed to be respectful and sensitive to the needs of residents during the visit. Comments from two residents included; “The staff are very nice people and will give you as much support and privacy as you want” and “I am quite happy living here. I am treated OK by everyone.” Thomas House DS0000022411.V295747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of recreational activities was provided in accordance with the needs and preferences of the residents. Visiting times were flexible and residents were supported to make choices and retain control of their everyday lives. The dietary needs of residents were catered for and a balanced selection of food was served in pleasant surroundings. EVIDENCE: The home had developed a monthly programme of activities that was displayed in the hallway for residents to view. The manager reported that the programme had been designed around the recreational needs and interests of residents. Details of each resident’s preferences regarding social activities had been recorded in care plans and the home maintained a record of activities provided including the participants. This showed that a range of activities was provided on a regular basis. Some residents did not wish to participate in activities and this choice was respected. Activities for June included; outside entertainers, individual time, tai chi, board and card games, sherry and reminiscence, hairdressing, ball games, walks to Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 15 the park, relaxation to music, bingo, manicure and pamper afternoons, community presence time and sing-a-longs. Feedback received from residents via discussion and care home survey forms confirmed the majority of residents were satisfied with the range and frequency of activities provided. Comments included; “We are never short of things to do. Activities are available most days”; “The activities are well organised. I particularly enjoy the tai chi sessions” and “I am not very interested in activities but I do like to play dominoes.” The manager reported that the home would support residents to follow their religious beliefs. At the time of the visit, representatives from local Roman Catholic and Church of England churches visited residents to provide services subject to individual religious beliefs / wishes. One resident who was using the home for respite care said “My Methodist minister has visited me today.” The home’s Statement of Purpose and Service User Guide detailed that within reason, visitors were welcome at any time. Residents were observed to be meeting with friends and relatives during the visit and were able to meet visitors in the communal areas of the home or in the privacy of their own bedrooms. A resident said; “My family are able to visit me everyday” and a relative stated; “I can come anytime. The staff are very friendly and welcome visitors.” The home had developed a policy on the philosophy of care, which covered choice and rights. Staff interviewed during the visit confirmed they had received training on the values of social care and demonstrated a good understanding of the need to empower residents to maintain control of their lives. Residents interviewed during the visit confirmed their wishes were respected and that they were able to choose their own routines and lifestyle. Rooms had been personalised with pictures, ornaments and personal belongings, which many residents had brought from their own homes. One resident spoken with said; “In my opinion I have choice and control of my life. I am able to choose my own bedtimes and what I do each day.” The home had a four-week rolling menu. Details of the menu were listed on a large notice board and alternative choices were available for residents. Meals were served in the home’s dining room, which was pleasantly decorated and furnished. The dietary needs of residents were assessed as part of the home’s preadmission process and the cook confirmed that the home was able to provide special diets subject to assessed needs. At the time of the visit the home was providing diabetic meals for four residents. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 16 kitchen areas viewed were clean and hygienic and the kitchen was well stocked. The cook maintained records of fridge and freezer temperatures and of meals served. The inspector observed residents eating their lunch during the inspection. Meals were well presented and staff were available to provide support as required. Overall, residents reported that they enjoyed the meals in the home and confirmed that mealtimes were unhurried and enjoyable. Comments included: “The meals are lovely”; “The food is good and there is a choice of meals” and “You can’t fault the food provided. It’s always hot and well presented.” Thomas House DS0000022411.V295747.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints procedure in place and residents understood how to complain. Safeguards were in place to protect residents from abuse. EVIDENCE: Thomas House had a Complaints Policy in place, which was displayed around the home. The policy outlined the process to follow and timescales involved. The manager was advised to update the policy to include the details of the Commission for Social Care Inspection. The complaints log showed that no complaints had been received by the home since the last visit. Feedback from residents via Care Home Survey forms confirmed that residents were aware of who they could talk to if they were not happy and how to complain if a problem arose. Comments from two residents included; “I am quite happy and I have no complaints. I feel listened to” and “I have always found the home to be OK. I have no need to complain but I could always speak to the manager. She is very approachable.” Policies and procedures were in place to ensure an appropriate response to suspicion or evidence of abuse. Training records showed that all staff had completed training in adult protection. Staff interviewed during the inspection demonstrated a good awareness of the different categories of abuse and their individual responsibility to protect vulnerable people. There had been no Protection of Vulnerable Adult referrals since the last visit. Thomas House DS0000022411.V295747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was pleasantly decorated, safe and well maintained. This provided residents with a comfortable and homely place to live. Areas of possible cross infection identified at the last visit have not been addressed. EVIDENCE: The home employed a part-time handyman to look after the garden and minor maintenance work when required. Contractors were used for all other work. A programme for the maintenance and renewal of the home was not in place as the home received continual investment. Pre-inspection records detailed that redecoration work was ongoing. The owner maintained records of all expenditure on the home and monthly audits were undertaken, to monitor the condition of the premises and to minimise hazards / risks. All areas viewed during the inspection appeared to be well-maintained and free from hazards. The home was decorated and furnished in a style that created a homely environment and residents appeared relaxed, warm and comfortable. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 19 Since the last inspection the manager had made arrangements to place hot water signs over all wash hand basins, to warn of hot water. Hot water temperature was monitored on a monthly basis. Pre-set valves were in place to regulate the hot water outlet temperature in bedrooms and the manager reported that bedrooms were fitted with low surface temperature radiators. The home employed two domestics and areas seen were clean and tidy on the day of the inspection. Policies were in place to control infection and for the Control of Substances Hazardous to Health. Supplies of disposable gloves and aprons were available for staff. The laundry was stored away from food preparation areas and was equipped with two driers and washers. The washing machines had programmable sluice washes and closed containers were in place for soiled washing. Individual baskets were available to store each resident’s laundry. Stocks of clean towels were being stored on the open shelves in the laundry area. Advice was given to store the towels elsewhere to prevent cross infection as recommended at the last visit. Thomas House DS0000022411.V295747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were deployed in sufficient numbers to meet the needs of residents. Some records were not accessible for inspection, to evidence that staff were correctly recruited and inducted. The home had made good progress in supporting staff to achieve a National Vocational Qualifications. Some staff were in need of refresher training for mandatory subjects, to ensure Safe Working practices. EVIDENCE: Inspection of rotas and direct observation confirmed that four care staff were on duty each day from 8.00 am to 9.00 pm. Two waking night staff were on duty through the night. The manager worked Monday to Friday each week from 8.00 am to 3.00 pm. Feedback received from residents via care home survey forms and discussion confirmed they felt the staff listened to them, acted upon their needs and were available when needed. Comments included; “The staff don’t keep you waiting long when you need help” and “The staff are willing to help in any way they can. I could not fault them.” The home had developed Recruitment and Equal Opportunities policies. The pre-inspection questionnaire showed that two staff had commenced employment since the last inspection. Only one file was available for inspection. The file viewed contained an application form, a health declaration, two references (one of which was dated two days after the employee’s start date), recruitment information, a Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 21 photograph, proof of identity, training record and induction checklist. A record of supervision was also on file. The manager did not have direct access to Protection of Vulnerable Adult (POVA) or Criminal Record Bureau (CRB) checks, as the records were stored in the home’s safe. At the time of the visit, one of the owners was on site and reported that only the Responsible Individual had access to the records. No issues of concern were noted regarding recruitment practice at the last inspection. The home employed seventeen care staff. Records / certificates showed that twelve of the seventeen staff had completed a National Vocational Qualification (NVQ) at level 2 or above in Care (70.58 ). The manager reported that a further five staff (29.41 ) had completed the training and were awaiting certificates. Once the certificates have been received, (94.11 ) of the staff will have attained the qualification. The remaining one member of staff was working towards the award. Induction records could only be checked for one of the two new members of staff, as the manager did not have access to the other record. Staff spoken with during the visit advised that they had received a comprehensive induction that covered; the principles of care, safe working practices, the organisation and worker role, the experiences and needs of the residents and the influences and requirements of the service setting. The home’s training matrix and discussion with staff confirmed that staff had access to a good range of training and development opportunities. Records showed that some staff required training in infection control and refresher training for Fire awareness. Thomas House DS0000022411.V295747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their representatives were consulted about the service periodically, to ensure their views were obtained. Systems had been developed to protect the financial interests of residents who require support with personal allowances. Some maintenance / safety certificates could not be located to confirm the health and safety of residents was protected. EVIDENCE: The manager of the home (Mrs Barbara Thornber) was registered with the Commission for Social Care Inspection. Previous inspection records detailed that the manager had acquired over 4 years management experience. The manager was able to provide documentary evidence that she had attained the National Vocational Qualification (NVQ) level 4 Registered Managers Award at level 4 and was advised to obtain a qualification equivalent to the National Vocational Qualification level 4 in Health and Social Care. Training records Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 23 highlighted that the manager had completed a range of training that was relevant to her role and responsibilities. Staff and residents spoken with confirmed that they were satisfied with the leadership and management approach of the home. The home commissioned an external quality assurance assessment and operated its own quality assurance system. Records highlighted that the most recent quality assurance questionnaires were distributed to residents and /or their representatives during October 2005. Feedback had been assessed and a summary report of the findings had been produced, a copy of which was available in the reception area. Monthly reports had been completed by the owners in accordance with Regulation 26 of the Care Home Regulations 2001 and discussion with residents and examination of minutes confirmed that residents meetings were coordinated on a regular basis. A staff meeting was observed to take place during the site visit. Pre-inspection records detailed that the manager did not act as an appointee for any of the residents. At the time of the visit none of the residents looked after their financial affairs independently. Residents were supported by family members / personal representatives. The home’s accountant was responsible for the management of fees and for issuing invoices. Systems were in place to enable residents to pay by standing order or cheque / cash on a weekly or monthly basis. The manager looked after the personal spending money for four residents. Records were checked for three residents. Transactions had been recorded, receipts were available for expenditure and balances were correct. Pre inspection records provided by the manager detailed that maintenance and associated records were in place for all key areas. Fire records were viewed. The fire alarm system had been tested on a weekly basis and the emergency lighting on a monthly basis. There was no record of the fire extinguishers being visually inspected on a monthly basis. Details of fire instruction and drills were recorded. Records could not be located to confirm the fire alarm system, extinguishers and electrical wiring had been serviced / tested. Records showed that some staff required training in infection control and refresher training for fire awareness as identified in standard 30. Thomas House DS0000022411.V295747.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement Medication Administration Records must be signed to confirm the administration of medication and the correct codes must be used to account for medication not given. All records in relation to the employment of staff must at all times be available for inspection in the care home. Safe Working Practice training must be completed by all staff and refresher training must be completed periodically. The home must forward to the Commission an up-to-date copy of the service / inspection certificates for fire alarm system, extinguishers and electrical wiring. Timescale for action 15/08/06 2 OP29 17 (3) 15/08/06 3 OP30 18 31/10/06 4 OP38 23 (2) C 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 26 No. 1 2 3 4 5 Refer to Standard OP7 OP9 OP9 OP16 OP26 Good Practice Recommendations The manager should audit care plans to remove all duplicated information. (Repeated recommendation from last inspection). Each resident’s medication should be checked to ensure it is administered in accordance with prescribed instructions i.e. before, during or after food. The manager should provide written guidelines for medication prescribed as when required or as directed (Repeated recommendation from last inspection). The Complaints policy should be updated to include the details of the Commission for Social Care Inspection. The manager should instruct staff not to store clean towels on open shelves in the laundry area and ensure that the instruction is followed. (Repeated recommendation from last inspection). The Registered Manager should complete an award equivalent to the National Vocational Qualification level 4 in Care. 5 OP31 Thomas House DS0000022411.V295747.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 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 Thomas House DS0000022411.V295747.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. 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!