Inspection on 06/11/06 for Townsend House

This inspection was carried out on 6th November 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

Townsend House 31/07/07

Townsend House 06/03/06

Townsend House 22/08/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Townsend House Court Farm Lane Mitcheldean Glos GL17 0BD Lead Inspector Mrs Ruth Wilcox Unannounced Inspection 6th November 2006 08:15 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 Townsend House DS0000064611.V318434.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. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Townsend House Address Court Farm Lane Mitcheldean Glos GL17 0BD 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) 01594 542611 01594 541449 manager.townsend@osjctglos.co.uk The Orders of St John Care Trust Mrs Dorothy Jayne Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One bed in the rehabilitation unit can be used to provide respite care for service users over the age of 55 years. 6th March 2006 Date of last inspection Brief Description of the Service: Townsend House is situated in the centre of Mitcheldean, and is in close proximity to the local shops and amenities. The home is managed by The Orders of St John Care Trust. The home is purpose built, and is registered to provide both nursing and personal care for 40 older people over the age of 65 years. Four of the registered places are used to provide rehabilitation care, with one of these four places registered for the use of a rehabilitation resident under the age of 65 years if necessary. The home is able to provide respite care if there is a vacancy. A day centre, which serves the local community, is also integral to the home. The home provides forty single rooms, six of which have en suite facilities. A passenger lift has been installed to provide easy access to the first floor. Communal areas consist of a main lounge and dining space incorporating a conservatory, a second lounge and dining room, and a separate lounge and kitchen/dining area for rehabilitation care. Adapted bathing facilities are provided. The home is surrounded by well-maintained gardens with inner courtyards of flowerbeds. A number of rooms overlook the gardens and courtyard. Information about the home is available in the Service User Guide, which is issued to prospective residents, and a copy of the most recent CSCI report is available in the home for anyone to read. The charges for Townsend House range from £337.15 to £637.00 per week. Hairdressing, Chiropody, Newspapers and Toiletries are charged at individual extra costs. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector carried out this inspection over two days in November 2006. A check was made against the requirements that were issued following the last inspection, in order to establish whether the home had ensured compliance in the relevant areas. Care records were inspected in the main home and in the rehabilitation unit, with the care of four residents being closely looked at in particular. The management of residents’ medications was inspected. A number of residents and relatives were spoken to directly in order to gauge their views and experiences of the services and care provided at Townsend House. Some of the staff were interviewed. Survey forms were also issued to a number of residents, visitors and staff to complete and return to CSCI if they wished. 100 of residents’, 50 of relatives’, and 10 of staff surveys were returned. Some of their comments feature in this report. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, training and provision of staff were inspected, as was the overall management of the home. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There has been a significant reduction in the amount of agency staff usage, with any continued use being largely on the basis of the deputy nurse manager’s prolonged and unavoidable absence. There has been a review of the deployment of staff, particularly during the morning, with slight alterations to working practices implemented. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 7 The call bell system has been replaced, a new assisted variable height bath has been fitted on the ground floor, and a new sink and wall tiling has been provided in the intermediate care unit bathroom. Following assessment by the accrediting body, the home has done well to achieve the ISO 9001 Award, for providing a ‘Quality Service for Older People in Care Homes’. 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. Townsend House DS0000064611.V318434.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 Townsend House DS0000064611.V318434.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments are carried out on all prospective residents, so that they can be assured prior to admission that the home can meet their needs. Those admitted for intermediate care are well supported to regain their independence for their return home. EVIDENCE: Copies of assessments carried out on three of the permanent residents were inspected, as was one carried out on that of a rehabilitation resident. These had either been conducted and recorded in hospital or another care home before the resident’s admission to the home was agreed. Appropriate care and health information from other health care professionals was also on file, as were copies of the placing authority assessments and care plans where applicable. Copies of Registered Nurse Care Contributions assessments were on file where relevant. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 10 The intermediate care unit is integral to the home, and comprises four places, although only two were occupied at this time. There are designated facilities for the intermediate care residents’ use, which apart from their own single room, include a pleasant sitting room, bathroom and kitchen diner. There is a multi disciplinary team approach to the care, support and rehabilitation of the residents here, with designated home staff, an occupational therapist, a physiotherapist and district nurses. The aim of the care and support delivered in the intermediate care unit is for the residents to be rehabilitated to regain their independence with daily living, in order that they could return to their own homes. Townsend House DS0000064611.V318434.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. 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’ health and personal needs were being satisfactorily met; however some improvements are needed to certain aspects of care plan documentation in order that they more accurately record the standard of care needed and actually being delivered in practice. Certain failures in the management of medications could pose risks to the residents; it is for this reason that quality in this outcome group is scored as only adequate. Residents are treated with courtesy and respect. EVIDENCE: Residents had a recorded plan of care that linked to an individual assessment of their health and personal needs; plans were regularly reviewed. Three relating to permanent residents and one relating to an intermediate resident were chosen for closer scrutiny as part of the case tracking exercise. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 12 In most cases care plans contained clear instructions for staff to follow when delivering both personal and health related care. Recording took into account residents’ choice, privacy and level of independence. Each plan contained appropriate risk assessments, such as for risk of falls, pressure sore vulnerability, nutrition and moving and handling. In most of these cases there were associated care plans documented accordingly to address any risks identified. However, in two cases a risk assessment had identified that the person was at high risk of developing a pressure sore. In each case appropriate care was being delivered, however this was not documented in the plan of care. In another case the person’s pressure areas were healthy and intact, despite a high risk factor, and it had been decided that support equipment was not necessary; in cases such as this staff should record the rationale to support such a decision not to introduce equipment. Each plan contained records of regular weight monitoring, and comprehensive nutritional assessments. In one case where a significant risk factor had been identified, an associated plan of care was recorded, with referral to and assessment by the Speech and Language Therapist for the person’s swallowing problems. Dietary supplements were prescribed in some circumstances. In another case the person was losing weight, but case tracking showed that this person was eating well and that appropriate monitoring arrangements and support was in place; however there was nothing recorded in a plan of care to support this. There was good evidence of multidisciplinary working between the home and other health care services, with residents afforded regular medical reviews and consultations, and access to a range of health care services, either in the community or in the home. Residents in the intermediate care unit were regularly assessed and monitored by an occupational therapist and physiotherapist. Residents’ survey responses, without exception, confirmed they were happy with the care and support they received from staff. Visitor responses indicated the same, with one saying ‘we have total confidence in the home’. All residents spoken to during the visit were very supportive of the home and staff, and expressed their satisfaction with the way in which they were looked after at Townsend House. Several residents said how happy they were at the home. Residents were supported to manage their own medications if they wished and were able to do so; two examples of this were seen, and each was done on the basis of a recorded risk assessment. Medications were stored safely and securely. The majority of medications were dispensed in a Monitored Dosage System, although some were boxed and bottled; such items were dated on opening so that they were not used beyond their expiry date. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 13 Items requiring cold storage were held securely in a designated refrigerator, and temperatures in here were regularly checked and recorded. Scheduled drugs were stored securely, and the associated register properly recorded. The supplying pharmacist printed the medication administration charts. Staff recorded the receipt of items on the charts, and a separate book of returned items was kept. The person responsible signed their hand written entries on medication administration charts, with a second signatory as witness. There were a number of shortfalls identified on some of the medication administration charts, as follows: • Variable dosages recorded in the main, with isolated omissions in this regard seen • External creams prescribed at specific frequencies in a number of cases, with no signatures recorded for their administration • Eye ointments with no recorded instruction for which eye specifically • A very small number of medications prescribed at specific times, with no signatures for their administration or coded reasons for their omission. • In some cases the use of external creams were linked to a plan of care, which contained instructions for its application, however in others there was no recorded instruction for usage. An audit trail was conducted on six specific medications. In four cases there was a discrepancy between the stock remaining and the amount apparently administered since the supply was opened. A reason for this was not identified during this visit, and the manager must carry out an investigation of these circumstances with the staff concerned and report to CSCI as soon as the outcomes are known. Throughout the two days of this visit, staff were only ever observed being most kind and supportive to the residents. Their approach was always sensitive, gentle and respectful. Care was delivered in the privacy of the residents’ own bedroom, or in closed bathrooms. If help was needed in one of the communal rooms, then all efforts were made to ensure that people’s dignity was maintained. Residents confirmed that staff were respectful and mindful of their privacy, with some saying that staff knocked on their door before entering. There were some who said that staff assisted them to retain their level of independence. Townsend House DS0000064611.V318434.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 good. This judgement has been made using available evidence including a visit to this service. An increased emphasis on the provision and coordination of a more regular and comprehensive activities programme will improve opportunities for residents to be more stimulated and socially active if they wish. Residents are free to exercise choice in their daily lives. Visiting arrangements are such that residents can keep close contact with their families and friends. Dietary needs are well catered for, with a selection of good food available that meets residents’ tastes and choices. EVIDENCE: There was an activities programme displayed in the home, although events on this seemed to be infrequent. Examples of recent activities were discussed, and these included a variety of games, an outing, social events and entertainments. There were regular religious services, with respect for individual religious preferences observed. There were a series of events planned for the forthcoming festive season. A resident’s birthday was being celebrated during this visit. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 15 There were times when residents were observed sitting, with no apparent stimulation. Some were watching television or reading. It was encouraging to know that a designated social activities coordinator had just been appointed to work in the home, and that greater emphasis would be placed in this area in the future. Some residents were entirely satisfied with the level of social opportunities in the home, whilst others felt that things could be better. There were no restrictions on visitors to the home and families and friends were free to visit at any time of their or their relative’s choosing. Visitor survey responses confirmed that they felt welcome here, and that they were adequately informed and consulted; however two exceptions to this felt this was not the case. Residents spoken to during the visit confirmed that their visitors are free to come in whenever they liked, and that staff made them welcome. Residents were evidently spending time how and where they wanted; some were more dependent on staff however. Individual choices and preferences were clearly respected by staff, with the manner in which they approached residents, by the personal influences noted in individual bedrooms, with the provision of different meals, and with those who were freely moving around the home. Respect was shown towards those residents who wish and were able to manage their own affairs. One resident said that she could ‘do as she liked, and that no-one interferes’. Another said she felt ‘free to choose what she did’. The service of the breakfast and lunchtime meal was observed. Each was well presented in calm surroundings, with a variety of choices served. Residents, without exception, said that the food they had was good and plentiful, and that they always enjoyed their meals; they also confirmed that there was a lot of choice. The meals appeared well balanced, nutritious and fresh. Staff were giving assistance where needed. The cook was informed about individual dietary needs and preferences, and good catering records were maintained. Storage of food was appropriate. Townsend House DS0000064611.V318434.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust complaints system enables residents and their families to feel assured that their views would be listened to and acted upon. The home’s Adult Protection policies help to provide a safe environment for the residents. EVIDENCE: The home had a robust procedure for addressing complaints; any that were received and addressed were audited each month. Residents confirmed that they were aware of how to make a complaint if they needed to, with most indicating confidence in the staff to listen and act on concerns raised, although there were a very small number that had slight reservations about staff in this regard. Residents spoken to during the visit indicated their confidence in the staff to address any concerns, with one saying that if she had ever had any, they were always quickly sorted out. Another said that if she ever got worried then staff were ‘always so helpful’. Visitors in the main were aware of the procedure should they need it, with just two unsure; a copy of the Complaints Procedure was on display and easily accessible in the home however. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 17 There had been a number of verbal complaints received since the last inspection, and there were records for each of these. The home had written policies and procedures for the protection of the vulnerable residents, and staff have received training in recognition and how to deal with abuse, although there were some for whom this specific training had yet to be updated; staff were able to confirm their awareness of such issues. Power of attorney arrangements were in place for more vulnerable residents where appropriate. Townsend House DS0000064611.V318434.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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable and safe place to live. The home is clean, with appropriate and full observations regarding the control of infection. EVIDENCE: Townsend House was very well maintained and decorated, and there was an ongoing maintenance programme to address issues as they arose. The whole environment was pleasant, homely and comfortable. The call bell system had been replaced, and there was a new sink and tiling in the rehabilitation bathroom. A variable height assisted bath had been installed on the ground floor. Repair work was scheduled for the conservatory windows. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 19 The carpet on the ‘zone 2’ ground floor corridor was discoloured and worn through general wear and tear. The smoking room carpet was badly marked, but was scheduled for replacement. The gardens and courtyard were well maintained and tidy. The home was clean and fresh, with only very transient odours detected during the morning. Residents confirmed their satisfaction with the standards of cleanliness that were maintained. The laundry room was clean and organised, and laundry was being handled in accordance with good infection control practices by the staff and designated laundry worker. Gloves, aprons, liquid soap, sanitising hand gels and paper towels were provided for staff throughout. Clinical waste was handled appropriately, with a contract in place to ensure it was collected and disposed of safely. The metal cupboard used to store chemicals in the sluice room in the rehabilitation unit was badly rusted around the base through prolonged usage. Townsend House DS0000064611.V318434.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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing provision is satisfactory to meet the needs of the residents currently living in the home. Robust recruitment procedures ensure that suitable staff are employed for the protection of residents. The arrangements for the induction and training of staff are good, with the staff able to learn the skills necessary for their role. EVIDENCE: A staff rota was maintained, which allowed for one registered nurse to be on duty at all times, with six care staff in the morning, four in the afternoon and evening, and two overnight; in addition to this there was one designated intermediate care unit worker on duty during all day time hours. There was provision for the deputy manager to have one day each fortnight when she could work in a supernumerary capacity; the manager worked totally supernumerary. An ancillary team of cleaning, laundry, catering, maintenance and administration staff ably supported the care and nursing team. There had been a significant reduction in the amount of agency staff used, with that which continued, being largely due to the long-term absence of the deputy nurse manager. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 21 Written survey responses about provision of staff were variable from residents and visitors, with a small number feeling that there could be more on duty at times. Some residents said that staff were usually available to them, but the call bell was heard ringing for a prolonged spell on at least two occasions during one particular period before being answered. During the visit, residents spoke very highly of the staff, saying that they were most attentive, caring and helpful. Staff were seen carrying out their work in a calm and methodical manner, appearing organised and hard working. They were also very friendly and approachable. There had been a review of the deployment of staff since the last inspection, with slight changes to working practices implemented; this was in an effort to provide more consistent staff cover in the home throughout the morning shift in particular. The home was making good progress with the National Vocational Qualification (NVQ) training programme for care staff. The home had not quite reached the target of 50 of care staff being qualified to NVQ level 2 standard, but there were twelve who were qualified to at least this level, with eight others currently undertaking the award, and three awaiting enrolment. Five staff files were chosen for inspection, on the basis of their recruitment to the home since the last inspection. Each record contained application forms, including a full employment history. Records of interviews were seen. Full and complete evidence of the required pre-employment checks was seen in each of the files, including medical checks, proof of identity, two written references, POVA (Protection of Vulnerable Adults) checks and CRB (Criminal Records Bureau) clearances. New workers have had a structured induction to the home, with records of their induction training maintained; they were allocated a supervisor to mentor them for this period, who tended to be one of the senior care leaders, the identity of whom could be ascertained from the rota if necessary. A staff survey confirmed that staff received induction training, and had good opportunities for ongoing training. A new worker was observed using the new electronic induction-learning package that had recently been introduced. This innovative programme was providing training in six modules, which included Principles of Care, Roles and Organisation, Health and Safety, Communication, Abuse and Neglect, and Developing as a Worker. Training records were maintained for each member of staff, and these showed a range of mandatory and optional training available and undertaken by all levels of staff. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 22 Following this inspection the manager resolved to ensure that all care staff were encouraged to maintain a professional development portfolio, and to review if all care staff had been issued with a copy of the General Social Care Council Code of Conduct. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are some good management systems in place here to ensure that the interests, health and safety of the residents are safeguarded. The home reviews aspects of its performance through a good programme of self-review and consultations, which includes seeking the views of residents and their relatives. EVIDENCE: The home manager is a first level registered nurse, who has achieved the Registered Manager’s Award, and who is registered with the CSCI for her role. The manager had attended additional training to ensure her continued professional development. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 24 Residents’ and relatives’ opinions had been sought as part of a quality monitoring process, and recently an annual quality assurance survey was distributed to them, so that they could provide feedback on their experience of the accommodation, facilities, catering, care, social activities and visiting arrangements. The manager was drafting a report on the basis of collated results, with a view to drawing up an action plan to address any issues. Comments and suggestions forms were available in the entrance hall, enabling anyone to offer their views of the service at any time if they wish; there was also a displayed notice inviting anyone to approach the manager and staff about any issues they might like to discuss. A residents’ meeting had been held. The home had a system for residents to have a six monthly review of their stay, so that they could offer their views about care, services, facilities and any concerns they might have had, however this had not been consistently undertaken. Meal monitoring forms have been regularly issued to residents, chosen on a random basis, so that they can give feedback on their experiences of the food and drink provided for them in the home. Following recent assessments the home had done well to achieve the ISO 9001 award, for providing a ‘Quality Service for Older People in Care Homes’. Some residents have placed personal money and valuables with the home for safekeeping. Clear and transparent records for each person, which include transaction details, running totals, and receipts were kept. Two case tracking audits on residents’ monies proved to be correct, with no discrepancies seen. Residents or their representative had signed to acknowledge some transactions, but where this was not possible in the majority of cases, two staff members had signed the record to witness on behalf of the resident. There were written policies, procedures and risk assessments and provision of necessary equipment to protect and promote the health and safety of those living and working at Townsend House. There was a small health and safety committee, which met at regular intervals to risk assess the home. Staff have received training in first aid, fire safety and health and safety. A full fire safety risk assessment throughout the whole building has been undertaken by an external assessor, with due regard to revised fire safety regulations; there were a number of issues which are to be addressed on this basis, and an action plan to address them was awaited. There was a positive Environmental Health inspection that coincided with this visit. Hot water temperatures are regularly checked for safe levels, and regular Legionella checks on the water supply are also carried out. All necessary safety checks and maintenance of equipment was undertaken in a timely fashion, and meticulous records were kept in these areas. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 25 Accident records were maintained where appropriate. The environment was generally secure, and there were coded door entries in a number of areas. Townsend House DS0000064611.V318434.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 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Townsend House DS0000064611.V318434.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 OP7 Regulation 15(1) 17(1a) Schedule 3(k) Requirement Timescale for action 30/11/06 2 OP9 13(2) The registered manager must ensure that staff document care plans that reflect the care needed and delivered in cases where a pressure sore vulnerability or a nutritional risk is assessed. 30/11/06 For the safe management of medications, the registered manager must ensure that: • There are clear directions for the use and application of all types of medications on administration charts • Staff sign consistently for all medications administered, including external creams, or record a reason for any omission if applicable. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 28 No. 1 2 3 4 5 Refer to Standard OP7 OP19 OP26 OP28 OP30 Good Practice Recommendations Staff should record the rationale to support decisions taken not to introduce support equipment in cases where a pressure sore risk has been identified. The home should consider replacing the carpet in the zone 2 corridor. The home should consider replacing the rusted metal storage cabinet in the sluice room. At least 50 of the care staff (excluding registered nurses) should be trained to NVQ, level 2 in care, or equivalent. The name of all new staff’s supervisors should be recorded on personal files or on rotas. Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Townsend House DS0000064611.V318434.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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