Inspection on 01/12/08 for Tudor Rose Rest Home

This inspection was carried out on 1st December 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Tudor Rose Rest Home 30/11/09

Tudor Rose Rest Home 19/12/07

Tudor Rose Rest Home 23/05/07

Tudor Rose Rest Home 26/10/06

Tudor Rose Rest Home 20/06/06

Tudor Rose Rest Home 03/11/05

Tudor Rose Rest Home 09/08/05

Tudor Rose Rest Home 07/12/04

Tudor Rose Rest Home 13/07/04

Tudor Rose Rest Home 24/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Tudor Rose Rest Home 671 Chester Road Erdington Birmingham West Midlands B23 5TH Lead Inspector Peter Dawson Unannounced Inspection 1st December 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000059825.V373316.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. DS0000059825.V373316.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tudor Rose Rest Home Address 671 Chester Road Erdington Birmingham West Midlands B23 5TH 0121 384 8922 0121 350 4040 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) Careplex Ms Jackie Barrett Care Home 27 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (5), Old age, of places not falling within any other category (27) DS0000059825.V373316.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 27 Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 5 The maximum number of service users who can be accommodated is: 27 19th December 2007 2. Date of last inspection Brief Description of the Service: Tudor Rose is registered to provide residential care for up to 27 people for reason of old age with a maximum of five who may have mental health needs. The property is a converted and extended domestic residence and the frontage blends well with the adjacent residential properties in the area. The premises are situated on a busy main road close to local shops and amenities. It is very conveniently situated for bus and rail services to Sutton Coldfield and Birmingham city centre. There is sufficient off road parking at the front of the building to accommodate three vehicles and further parking is available in nearby side roads. The majority of the accommodation is located on the ground and first floors; a shared room is situated on the second floor that has its own adjacent bathroom. There is a shaft lift that gives access to all floors and permits a maximum of two persons. This restriction in conjunction with the narrow corridors prohibits the home from caring for presidents who are wheelchair users. Communal toilets and bathrooms are strategically located throughout the home. There are five double bedrooms and seventeen single bedrooms; all DS0000059825.V373316.R01.S.doc Version 5.2 Page 5 have wash hand basins and a call system. Communal rooms are situated on the ground floor and consist of two lounges and two dining rooms. There is an extensive rear garden with out houses and a paved area with seating that residents and visitors can sit in the good weather. Meals and a laundry service are supplied on site. The weekly fees at Tudor Rose are £349 - £368. There is no top-up charge. DS0000059825.V373316.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out on one day by one inspector. An AQAA (Annual Quality Assurance Assessment) was requested from the service but not received prior to the inspection. This is a document of selfassessment by the service and is required by law but was not requested in time for the inspection so can not be included in the information given in this report. There were 26 people in residence at the time of this inspection, the majority were seen and approximately 12 spoken with together or separately. People made positive comments about the home and the care they received from staff. Comments included “they really look after you here” and “I am happy here, the food is excellent”. Observations and discussions with staff evidenced good interactions with people in residence. There was an inspection of the environment including all communal areas and a sample of bedrooms. Records relating to the inspection process were readily available and included care plans, risk assessments, medication records, complaints and accident records. All required documents were available for inspection. There was a positive dialogue throughout the day with the Manager and Deputy Manager who provided detailed information as required and they were receptive to advice and comments about the service. The four requirements and 23 recommendations of the last inspection report were all checked and had been addressed satisfactorily. One new requirement and 5 good practice recommendations are made as a result of this inspection. DS0000059825.V373316.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? The 4 requirements and 23 recommendations made in the last report have all been addressed. Improvements have therefore been made in many areas: The homes pre-admission assessment tool has been replaced with a more detailed assessment of needs. A letter is now sent to the person confirming in writing that assessed needs can be met. Assessments are also now always obtained from Social Workers prior to any admission to the home. A new care planning format has been introduced giving considerably more detail about the health, social and recreational needs of people. Changes to the medication system have been implemented, including staff countersigning handwritten notes on medication records, photographs provided for reference when administering medication, all short-life medicines, for example eye drops are dated when opened ensuring they are used within 28 days, medication records had all been signed correctly as proof of medication given. All staff have had training in relation to the Mental Capacity Act and assessments were seen on personal records. The Independent Advocacy Service is used to assist people making decisions where family or friends are not available or appropriate. DS0000059825.V373316.R01.S.doc Version 5.2 Page 8 Staff have received training from specialist nurses in continence care and tissue viability needs. Recruitment and selection procedures for staff have improved with a new format and checklist more easily identifying checks or documents obtained prior to employment. New staff appointed on POVA checks are supervised until a CRB is obtained. There is a new staff induction programme which meets the Social Skills Council requirements. The safekeeping of residents monies has been reviewed and changed to provide a more robust system to protect them. 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 DS0000059825.V373316.R01.S.doc Version 5.2 Page 9 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000059825.V373316.R01.S.doc Version 5.2 Page 10 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 DS0000059825.V373316.R01.S.doc Version 5.2 Page 11 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): Standards 1 – 5 were inspected on this visit. Quality in this outcome area is good. Pre admission procedures have improved and this ensures the needs of people can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A recommendation in the last report indicated that the Statement of Purpose and Service Users Guide required updating. This has been done and a statement of the rooms sizes still needs to be included. A requirement of the last report to complete comprehensive pre-admission assessments and provided written confirmation of the homes ability to meet needs, has been met. Records relating to 3 people were seen and good preDS0000059825.V373316.R01.S.doc Version 5.2 Page 12 admission assessments had been recorded and standard confirmation letters sent stating that needs can be met. A new and improved format for recording pre-admission assessments has been introduced since the last inspection and this provides more detailed necessary information and is good. A Community Care Assessment had also been obtained from the Social Worker in each instance prior to admission. At the last inspection this had not been done in one instance and a recommendation made. DS0000059825.V373316.R01.S.doc Version 5.2 Page 13 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): Standards 7 – 10 were inspected on this visit. Quality in this outcome area is adequate . Improved care planning information and healthcare records ensure the health and personal care needs of people are known and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two requirements were made at the time of the last inspection relating to care plans and medication – both have been met. Nine recommendations were also made and have been satisfactorily addressed. These related to: training in continence care, auditing of accidents, countersigning written medication records, dating short-life medications, and providing a privacy/dignity policy. DS0000059825.V373316.R01.S.doc Version 5.2 Page 14 A new care planning format has been introduced and provides comprehensive information about the health, personal and social care needs of people. A sample of care plans were seen and contained detailed information including: social history, pre-existing medical conditions, nutritional risk assessments, falls risk assessment, room risk assessment, preferred activities, general risk assessment including transfers and moving and handling needs, night care plan and detailed instructions for staff to meet the individual personal care needs of each person. Plans seen had been signed by the person - recorded in one instance why unable to sign (visual impairment) and a review system has been put into place for all plans to be reviewed on a monthly basis. This is a vast improvement upon the previous care planning format and the information provided. The last report stated that healthcare and personal needs were generally met, but the poor recording system meant that needs may not be known. This has been addressed with the introduction of the new care planning information outlined above. A review of healthcare needs was inspected. There is no one with pressure damage in the home at this time. District Nurses are involved where there are any concerns and pressure relieving equipment provided as a preventive measure. Nursing notes were seen relating to one person with a leg wound who was receiving care from the District Nurse, there was knowledge of and clear co-operation with the treatment of this person. All people are weighed monthly or weekly if there are concerns about weight loss. Care plans seen contained evidence of regular weighing and referrals to the GP made where there were nutritional deficits. Early referrals to healthcare professionals are made. An example being a person with early symptoms referred to the GP and requiring major surgery. The person has no relatives and was supported by the key-worker in the hospital admission, treatment and the regular outpatient checks which are ongoing. All injuries following accidents are now seen by the GP. Arising from recommendations of the last report - staff have received input training from specialist nurses in relation to continence care and nutrition/tissue viability A care plan stated that footplates were not used on a wheelchair. This related to someone who had had a stroke and not able to control the use of her leg. It is recommended that a further risk assessment is carried out and a disclaimer signed by the person if she wishes to use the chair without footplates. Only one person is reported to have dementia care needs due to deterioration. The home does not have registration to admit new people with dementia care needs, although all staff have had training in dementia care. Daily notes completed by each staff shift were seen and were satisfactory. Night checks are at least hourly and were adequately recorded. DS0000059825.V373316.R01.S.doc Version 5.2 Page 15 A person went missing from the home and this was not immediately evident. He was reported missing to the police and returned unharmed 2 hours later by the police having been found near his former home. Most external doors are alarmed with the exception of the rear door, which is not and was his route for leaving. It is a requirement of this report that all external doors are alarmed to alert staff to people leaving the building. It is also necessary to carry out a risk assessment in relation to this person and ensure his future safety. The medication system was inspected and the shortfalls identified in the last report have all been addressed. The medication system clearly recorded medication to be given, was all signed for at the point of administration and an ongoing count of medication recorded to allow audit of the system. There is no self-medication in place at this time. The GP reviews medication on a regular basis. If additions to medication during the monthly cycle are prescribed, they are entered on MAR (Medication Administration Records) sheets and countersigned by another member of staff. Medication (diazepam) not available on the day of this inspection had been requested and expected delivery from the Pharmacist was within 24 hours. Boots Pharmacy provide the blister-packed medication system and carry out 6 monthly audits in the home (reports not seen). It is important to date when opened short-life medication. A sample of 4 eyedrops in current use had all been dated when opened to monitor disposal after 28 days. Shortfalls in medication administration identified in the last report have all been addressed satisfactory. A detailed privacy and dignity policy was seen and covered all required aspects of these important principles of care. This was not seen on the last inspection, although stated to be present in the home. DS0000059825.V373316.R01.S.doc Version 5.2 Page 16 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): Standards 12 – 15 were inspected on this visit. Quality in this outcome area is adequate. Chosen lifestyles are respected and some additional activities and occupation would further improve quality of life for some of the people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an outlined activities programme that provides a guide that is not always followed. People said that they have “bingo and make cards and have a service (religious) ” and “we mostly watch TV” A member of staff previously lead activities but this is now shared between all staff. Bingo was played during the inspection and it was reported that a group were due to visit the next day to provide a Christmas Pantomime. The TV’s in both lounge areas were on during the inspection, there was no quiet lounge/area where people could sit, although some were in their bedrooms. DS0000059825.V373316.R01.S.doc Version 5.2 Page 17 Chosen lifestyles were exampled by two residents who share a bedroom, are old friends and prefer to spend the day in their room, coming to the dining room for meals. Another resident does not wish to socialise, does not like TV stays in her bedroom and comes to the dining room for all meals. She said this was her chosen daily routine and she was entirely happy with it. Another person went out to the pub with a friend for half the day, this is a regular weekly event that he enjoys. He said that the staff were “good and always helpful” to him and he was “very happy” at Tudor Rose. A person who has always slept in a chair refuses to sleep in a bed – records showed a negative response when encouraged to use the bed. The Manager was advised that as this was her long-established preferred routine, if she was safe and comfortable, it was not necessary to pressurise her to conform to sleeping in a bed. External activities are occasional. There is a very pleasant, large, private garden at the rear with good seating that is apparently used during the summer months. A sensory garden with good seating has been established in a part of the garden area An example of diversity given was in relation to a Polish person, when an interpreter was used prior to admission to ensure his knowledge and needs of the home were sufficient. An interpreter was not found to be subsequently necessary. He is visited weekly by 2 people from the local Polish Church and has no special food needs. When taken out to a Polish restaurant he was not particularly impressed with the food. All attempts had been made to assess and meet his cultural needs. Clergy were reported to visit regularly, including Roman Catholic priest and pastoral needs appeared to be met. Following a recommendation of the last report all staff have had training in the Mental Capacity Act, with assessments in place to show the levels of capacity of the individual person. A large proportion of people do not have contacts with relatives/visitors and where appropriate the Independent Advocacy Service is used. Food choices have been improved since the last inspection and include more choices. There is always a choice of hot dish for the mid-day meal and always a hot alternative at teatime. New menus on tables in the dining area showed the daily choices available. People asked about food commented that it was “good and I eat too much” and “they provide really good food here”. Catering staff had a list of likes/dislikes, preferred portion size, special diets etc. The kitchen was inspected recently by the Environmental Health Officer and 4 stars awarded. DS0000059825.V373316.R01.S.doc Version 5.2 Page 18 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): Standards 16 – 18 were inspected on this visit. Quality in this outcome area is good. The complaints procedure is available and known to all. Staff have had training and have clear instructions and procedures to ensure the safety of people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the complaints procedure is posted in the home for residents and visitors. This complies with Regulation 22. A record of complaints is kept including domestic-type “grumbles”. The home have not received any complaints directly since the last inspection. One complaint was received by us and referred to the providers. It related to information that people sometimes were short of money and financial records not appropriately logged. The home undertook an audit of all finances held for people at the time of the complaint and have a robust procedure for handling peoples finances including receipts for all expenditure, 2 staff signatures for all transactions and regular checks of balances of monies held. The financial records of 4 people were randomly selected during this inspection – balances of cash correctly reflected ongoing balances of individual accounts. Income DS0000059825.V373316.R01.S.doc Version 5.2 Page 19 and expenditure was recorded accurately and records regularly checked. In relation to a substantial balance for one person the Manager was advised to transfer this amount to the persons bank account. Records seen indicated good recording and monitoring of peoples finances. The home has a copy of the Local Authority Safeguarding procedures and all staff had training in the protection of vulnerable adults. Staff spoken with had a clear understanding of the action to taken in the event of concerns about possible abuse. DS0000059825.V373316.R01.S.doc Version 5.2 Page 20 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): Standards 19 – 26 were inspected on this visit. Quality in this outcome area is adequate. The home is safe, comfortable and homely meeting the needs of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The building is a large Victorian House in its own grounds which has a large singe storey extension. Most of the bedrooms are therefore on the ground floor. There is a shaft lift the first and second floors but this is not suitable for wheelchair users. DS0000059825.V373316.R01.S.doc Version 5.2 Page 21 The home is bright, comfortable and welcoming. Some improvements have been made following previous inspections. Since the last inspection there has been ongoing redecoration and replacement of some carpets with vinyl flooring in the communal and some bedroom areas. A worn carpet in a dining area identified as a potential risk in the last inspection report has been replaced with vinyl flooring. The communal areas are bright and spacious with the exception only of the large lounge where lighting in the rear part of the lounge was poor with only light from the central area of the room. It was not possible, for instance, to read in that area and it is recommended that this should be reviewed. There is only one en-suite facility that is in the shared bedroom on the second floor and has adjoining bathroom for its sole use. Other rooms all have washhand basins and there is one assisted bathroom and two separate walk-in shower areas. It was noted in these areas that the sealing around the floor areas were poor. In one there was a large gap which exposed the brickwork between the floor and wall area. New sealant would improve the presentation and improve infection control. Bedrooms were generally bright, many well personalised, others not so well personalised. The reason given was lack of response from relatives to provide photographs and memorabilia. An example was a person with one relative who visits only occasionally and did not even have a photograph of his deceased wife. It is important to pursue these matters individually with people and their relatives. It was noted in one bedroom that a drawer pack had been repaired but still one drawer was broken and needed repair/replacement. All bedrooms doors are “front doors” with knockers and letterboxes and can be locked. All are painted different colours for easy identification by people living there. The home generally presented well. The areas mentioned above need action. Replacements and redecoration have taken place in the past 2 years and many areas upgraded, some following requirements being made. A Handyperson is employed 20 hours per week and ensures a level of ongoing maintenance. It was noted in the lounge area that small tables were placed between some chairs but not all. Some people given hot drinks had to hold them until finished and/or place cups on the floor if they were able to. The home should consider placing tables next to all chairs in the lounge areas. There is an excellent large private garden area to the rear of the building, including sensory garden and good seating for use in the summer months. In relation to a recommendation of the last report all commode pots have been replaced with procedures to ensure they are not stored in bathroom/toilet areas. DS0000059825.V373316.R01.S.doc Version 5.2 Page 22 Standards of hygiene throughout the home were seen to be satisfactory on this visit and there were no mal-odours. Reference is made earlier in this report concerning the safety of the building and a requirement made to ensure that all external doors are alarmed to ensure the safety of all people using the service. DS0000059825.V373316.R01.S.doc Version 5.2 Page 23 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): Standards 27 – 30 were inspected on this visit. There are sufficient staff on duty to meet the needs of people in the home and recruitment procedures have been strengthened to ensure their safety. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels at the time of the last inspection were satisfactory and remain so. There are 3 staff on duty throughout the day and additional person from 10am – 4pm. There are 2 waking night staff. These numbers are adequate for the present dependency levels of the people using the service. Several staff have been at the home for many years, all spoken with showed a detailed knowledge of the people they cared for and engaged well with the people in the home. Staff training is satisfactory, apart from statutory training all have received training in dementia care, challenging behaviours, person centred care and safeguarding. 65 of staff have completed NVQ2 or above. Induction training DS0000059825.V373316.R01.S.doc Version 5.2 Page 24 has been changed since the last report to meet the requirements of the Social Skills Council. There were concerns and requirement made at the time of the last inspection relating to Recruitment and Selection procedures for staff. Full employment histories were required and staff employed on POVA (Protection of Vulnerable Adults) checks were to be supervised at all times. A sample of 3 staff files were seen. The home have introduced new Recruitment and Staffing records, giving clearer evidence of checks and information sought prior to appointment. Two had commenced employment after CRB (Criminal Records Bureau) checks the other had started work following POVA check but in the interim period of 3 weeks prior to the CRB result, had been adequately supervised. References and other documentary evidence required was present on the staff records seen, these included evidence of qualifications, photographs, birth certificates, 2 written references, health declaration and copies of passports Recruitment procedures, documentation and recording have improved since the last inspection. DS0000059825.V373316.R01.S.doc Version 5.2 Page 25 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): Standards 31 – 38 were inspected on this visit. Quality in this outcome area is adequate. The home is well managed. Suggestions for improvement are acted upon to further improve the quality of life for people in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has been at the home for several years. She has completed the RMA (Registered Managers Award) - the recognised qualification. The Deputy Manager has also worked at the home for several years and the home benefits from experience and continuity of management. DS0000059825.V373316.R01.S.doc Version 5.2 Page 26 The Provider visits the home each Monday (seen during this inspection) and the Manager feels able to raise or discuss any issues or concerns with him and seek advice as necessary. Whilst there have been many requirements and recommendations following recent inspections, these have been ultimately acted upon. The Manager takes advice from CSCI Inspectors and is keen to improve the service where possible. The manager carries out checks and audits in the home and where there are shortfalls will introduce new methods of working. Examples of this are the introduction of the new care planning format and staff recruitment format both introduced since the last inspection. The home sends out questionnaires to people in the home and other stakeholders but there is generally a poor response. We were unable to send out CSCI questionnaires prior to this inspection due to internal delays, but many residents were spoken with individually and together to ascertain their views of the service. Feedback was positive about the quality of care and commitment of staff. Comments included “I am happy here they will do anything for me” and “I have no complaints but we could do with more to keep us busy during the day”. A review of procedures for keeping residents finances has been carried. Checks are carried out regularly and the method of keeping finances is more secure. A recommendation to record all staff attending fire drills has not been actioned. Records showed either drills not completed or names not accurately recorded. It was noted that there are 2 fire drills per year and the homes policy and the preferred practice, is to provide fire drills for night staff 4 times per year. There could be improvements in this area. It was drawn to the attention of the Manager during the inspection that there were gaps under some bedroom doors of around 25mm. All had intumescent (smoke) seals around doors but the gaps at the bottom would not protect from smoke in the event of fire. The Manager was asked to seek advice from the Fire Officer on this matter. Inspection reports are not readily available in the home. Information displayed stated “ask at the office”. It is important to readily provide a copy of the last inspection report in the home for residents, visitors and staff. Relationships between Managers and Staff were observed to be good. Staff confirmed that they are well supported by Managers. Supervision is provided for all staff on a regular basis confirmed in records seen. DS0000059825.V373316.R01.S.doc Version 5.2 Page 27 DS0000059825.V373316.R01.S.doc Version 5.2 Page 28 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 2 DS0000059825.V373316.R01.S.doc Version 5.2 Page 29 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 13(4) Requirement All areas of the home must be secure. External doors should all be alarmed to alert staff in the event of residents leaving the building. This will ensure the safety of all residents. Timescale for action 22/12/08 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 Refer to Standard OP19 Good Practice Recommendations Sealant in bathroom and toilet areas between floor and wall areas should be filled/re-sealed to improve infection control and presentation. Marks on woodwork on the ground floor should be repainted. Review lighting in the rear of main lounge area to provide adequate lighting. Copies of the last inspection report should be available in the home for residents, visitors and staff. Seek advice from the Fire Officer about gaps under bedroom doors. This will ensure safety of people in the DS0000059825.V373316.R01.S.doc Version 5.2 Page 30 2 3 4 OP25 OP33 OP38 event of a fire. 5 OP38 Names of staff involved in fire drills must be recorded. Ensure all staff and particularly night staff have more regular fire drills. DS0000059825.V373316.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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