Inspection on 09/11/07 for Upalong

This inspection was carried out on 9th November 2007.

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

Upalong 10/01/07

Upalong 21/11/05

Upalong 01/10/04

Upalong 20/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Upalong Upalong 16 Castle Road Camberley Surrey GU15 2DS Lead Inspector Christine Bowman Unannounced Inspection 9th November 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000013817.V353036.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. DS0000013817.V353036.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Upalong Address Upalong 16 Castle Road Camberley Surrey GU15 2DS 01276 682132 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) diana@atkinsonshomes.com Mrs M McTeggart Mrs M McTeggart Care Home 9 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (9), of places Physical disability over 65 years of age (2) DS0000013817.V353036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2007 Brief Description of the Service: The home has been established since 1988 and has benefited from regular modernisation. The home enjoys a location that is close to the centre of busy Camberley and yet situated in a peaceful location. The accommodation is arranged over two floors and contains nine mainly single rooms, one double; all rooms are en-suite. Rooms are fitted with individual alarms and the home has recently installed a basic surveillance system for added security. The home is registered for nine residents over the age of sixty-five, three of whom may have dementia and two who may have a physical disability. Fees range from £500 to £700 per week. DS0000013817.V353036.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a key inspection using the Commission’s ‘Inspecting for Better Lives’ (IBL) process. The site visit took place over six hours commencing at 10.30am and ending at 16.30pm and was undertaken by Ms Christine Bowman, regulation inspector. The registered manager, Mrs McTeggart was available throughout the day and assisted with the inspection process. The activities co-ordinator, the chef and two carers were interviewed and the staff were observed throughout the day as they interacted with the residents. Three residents were interviewed as they socialised over lunch, a tour of the premises was undertaken and two residents permitted their bedrooms to be viewed. The home had a calm but purposeful ambiance; the staff were friendly, cheerful and enthusiastic about their work and the residents happily spoke about their interests, their social activities, their earlier lives and trips they had made to other continents. Staff and residents alike were very appreciative of the management and the compliment was returned by the owner/manager, who was totally committed to empowering the staff and ensuring the residents retained their independence, their dignity and interest in life. Resident’s files, including initial assessments care plans and risk assessments, were sampled and the personnel files of two staff including their recruitment, induction and individual development plans were also inspected. The complaints and compliments log, photograph albums, person-centred activity plans, medication records and maintenance records were viewed. Four residents completed surveys and comments from these sources have been included in the report. Relatives/ representatives of the clients and health care professionals involved in their care had very recently completed surveys for the home’s own quality assurance process and comments from these sources have also been included in the report. The Annual Quality Assurance Assessment completed by the home and sent to the Commission for Social Care Inspection and other information received since the previous site visit and recorded in the Inspection record have been included in this report. Thanks are offered to the management, the staff and the residents of Upalong for their assistance and hospitality on the day of the site visit and to all those who completed surveys for their contribution to this report. What the service does well: DS0000013817.V353036.R01.S.doc Version 5.2 Page 6 Prior to admission to the home each prospective resident has the opportunity to decide how much of their own furniture they would like to bring with them to make their bedroom as much their own as possible, to reflect their personality and taste and have a sense of identity and belonging, which could so easily be lost in otherwise impersonal settings. 100 of the residents always liked the meals at the home and relatives and representatives commented, ‘Superb choices and well cooked, delicious too,’ ‘I am very happy with the variety of choices,’ ‘good variety,’ and ‘ the home provides good food. The residents benefit from living in a comfortable, safe, pleasant, wellmaintained environment, which is clean and hygienic. The home retained many of its original features, was equipped with good quality furnishings and fittings and all the rooms were pleasantly decorated. Comments from relatives/representatives of residents included, ‘the home environment is very good and it is run and laid out like a normal home that my mother would have lived in –excellent,’ and ‘the home is warm, welcoming, clean and cheerful.’ There was a team of dedicated and loyal carers most of whom had worked at the home for some considerable time. Carers spoken with stated, they were extremely happy in their posts, really enjoyed working at the home and, ‘couldn’t have a better manager.’ The relative of a resident commented, ‘I think all the staff do an amazing job. They are very kind, caring with a good sense of humour.’ What has improved since the last inspection? Improvements had been made with respect to medication processes in that residents’ medication administration records included a photograph of the resident for identification and the pharmacist as confirmation of receipt had signed the ‘drugs-return book’. A carer had taken the role of activities co-ordinator, had attended training to support her role and this had resulted in many and varied creative ideas designed to bring colour, enjoyment and lots of fun into the lives of the residents. Over the year events included a ‘Ladies Day at Upalong Ascot’, ‘Wimbledon at Upalong’, an Hawaiian night, seasonal and birthday celebrations. Each resident had a lifestyle profile covering their interests and preferences with respect to creative activities, learning and intellectual activities, relaxation and entertainment, cultural, physical, spiritual and social activities in order that the home could make an individual response to the resident’s preferences with respect to how they wished to spend their time and the support they might require to achieve this. DS0000013817.V353036.R01.S.doc Version 5.2 Page 7 A current copy of the local authority Safeguarding Adults policy and procedure was available at the home to inform the staff in dealing with disclosures and referrals in order to protect the residents. New carpets had been purchased creating a comfortable, luxurious but homely and warm feel to the environment. A health and safety audit of the kitchen area had been conducted and the chef had attended a health and safety refresher course to ensure he is up to date with current practice and that the procedures in the kitchen are safe. 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. DS0000013817.V353036.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 DS0000013817.V353036.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): Standards 3,6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A full assessment of the prospective resident’s needs is carried out prior to the offer of a placement to ensure the home is able to meet their individual needs and requirements. The home does not provide intermediate care. EVIDENCE: One new client had been admitted to the home since the previous site visit and a comprehensive assessment of the client’s needs was viewed on their file. This included the client’s needs with respect to daily living, communication, mobility, medical and health history and medication needs, dietary requirements and preferences and religious, cultural and social needs. Sufficient information with respect to the diverse needs of the individual had been recorded to ensure a person- centred approach to their care was possible. The manager stated that she always goes out to do the assessments and that prospective residents and/or their relatives/representatives visit the home. At this point residents are made aware of the fact that they can bring as much of their own furniture as they wish according to the dimensions of the DS0000013817.V353036.R01.S.doc Version 5.2 Page 10 bedroom. Although the home provided good quality furnishings, they were prepared to put these items into storage to ensure the prospective clients had the opportunity to make their bedroom as much their own as possible, to reflect their personality and taste and have a sense of identity and belonging, which can so easily be lost in otherwise impersonal settings. One of the residents, whose bedroom was viewed, had requested a double bed and her wish had been granted. Three of the four clients, who completed surveys confirmed they had received enough information about the home before moving in to decide if it was the right place for them one stated their family had dealt with that. DS0000013817.V353036.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): Standards 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A person-centred approach to care promotes the fulfilment of individual needs with respect to health, personal and social care. Medication is handled safely, the residents are treated with respect and their right to privacy is upheld. EVIDENCE: Two client files were sampled and each contained a care plan and details of monthly reviews, which had been signed and dated to confirm the involvement of the clients in the process. Care plans covered all aspects of daily living and contained details of the client’s ability to self-care and how this independence could be promoted and maintained. The levels of intervention were recorded to inform the carers and there was a clear description of how the client preferred the support to be given. All sections of the care plan, which covered the personal, health and social care needs of the client had objectives recorded with positive outcomes for the client with respect to maintaining their independence, health, social contact and interests. Risk assessments were included with respect to falls, nutrition and the development of pressure areas DS0000013817.V353036.R01.S.doc Version 5.2 Page 12 and each file contained an audit of the activities the client had been involved in and a record of intervention by healthcare professionals. Access to a General Practitioner, a chiropodist, optician, a dentist and the district nurse was evidenced and the manager recorded in the Annual Quality Assurance Assessment that advice and support was also valued from tissue viability nurses and the McMillan nursing team. The manager noted that the home had improved by the purchase of more pressure-relieving equipment over the last twelve months. Three of the four residents, who completed surveys, thought they always received the care and support they needed and one thought they usually did. 100 of the relatives, who completed surveys thought the residents were well cared for and commented, ‘ It is lots of attention to detail that makes all the difference,’ ‘the residents are cared for very well and individual needs are catered for,’ and, ‘ the residents are very well cared for.’ The Annual Quality Assurance Assessment confirmed that the policy for the storage, disposal, recording and administration of medicines had been reviewed since the previous site visit. Medication was appropriately stored in a secure metal cabinet, the drugs returns book had been signed by the pharmacist, and the medication administration records contained photographs of the residents to ensure correct identification. Staff training records contained certificates for ‘Handling Medication’ and ‘Diabetic Insulin Administration’ and ‘Good practise guidelines’ were available to the staff. There were no gaps in the medication administration records and clear, regular blood/sugar readings were recorded for a diabetic resident. During the site visit the staff observed treated the residents very respectfully, knocking on bedroom doors and waiting to be invited in, and paying close attention when communicating with the residents. There was a good rapport between the staff and the residents. The Common Induction Standards were used, the manager stated, to ensure new staff were aware of how to support individuals with respect to privacy and dignity, to promote equal opportunities and to give support respecting diversity, different cultures and values. DS0000013817.V353036.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents enjoy individual lifestyles, maintain social contacts, access the community according to their needs and wishes and receive a wholesome, appealing balanced diet in pleasing surroundings. EVIDENCE: The home employed a carer in the role of activities co-ordinator, who was interviewed in connection with her role. The manager had encouraged this member of staff to attend training to support her role including ‘Reminiscence and Activities for People with Dementia’ and ‘The Provision of activities within a Care Setting,’ and the result was many and varied creative ideas designed to bring colour, enjoyment and lots of fun into the lives of the residents. Each resident had a lifestyle profile covering their interests and preferences with respect to creative activities, learning and intellectual activities, relaxation and entertainment, cultural, physical, spiritual and social activities in order that the home could make an individual response to the resident’s preferences with respect to how they wished to spend their time and the support they might require in order for this to be achieved. She was also in the process of collating DS0000013817.V353036.R01.S.doc Version 5.2 Page 14 life profiles of the residents including details of their social history in connection with reminiscence. A photograph album contained images of memorable times arranged for the residents over the year including a ‘Ladies Day at Upalong Ascot’, Wimbledon at Upalong, seasonal and birthday celebrations. Photographs showed a horseracing game set up and residents wearing suitable ‘Ascot’ hats and enjoying tea in the garden. Horses had been chosen and there was a silver cup and certificate for the winner. Wimbledon was celebrated with tiddily-winks tennis in the garden accompanied by cucumber sandwiches, cake, and strawberries and cream. For Halloween a communal meal had been enjoyed from a table covered in a spider’s web tablecloth surrounded by staff, which were suitably dressed for the occasion. A Hawaiian night showed a staff member playing a ukulele as residents sang and enjoyed cocktails whilst wearing colourful garlands around their necks. A ninetieth birthday celebration of a resident showed them being reunited with their brother and his family they had not seen for a long time. The room was decorated with balloons and enlarged photographs of the resident throughout their life up to the present time and musical entertainment was provided. Photographs showed happy, smiling residents and equally happy staff looking just like ‘the big happy family’ a staff member had described the home. At the time of the site visit, preparations were in progress for Christmas and some residents had been attending the Christmas workshop and been re-discovering their creative talents by making Christmas decorations. Three of the residents, who returned surveys, confirmed there were usually activities arranged in the home that they can take part in and one stated there always was. 100 of the relatives/representatives, who completed surveys, confirmed they were always welcomed when they visited the home. One relative commented, ‘ they always seem pleased to see us,’ another that they were, ‘Always made very welcome.’ Others confirmed, ‘Very much so,’ and, ‘Very welcoming.’ During the site visit a relative called in to see her grandmother, bringing the resident’s grandchild with her and it was clear that relatives were free to call at any time. A priest, who completed a survey stated he brought Holy Communion to three Roman Catholic residents. 100 of the residents always liked the meals at the home and relatives and representatives commented, ‘Superb choices and well cooked, delicious too,’ ‘I am very happy with the variety of choices,’ ‘Good variety,’ and ‘ The home provides good food.’ Lunch on the day of the site visit was soup with croutons, poached salmon with fresh vegetables and roast potatoes followed by rice pudding, one resident chose to have a salad and the chef stated that the menu is frequently changed in consultation with the residents. Residents spoken with over lunch stated they enjoyed shopping trips, walks and visits to local garden centres in the home’s minibus. DS0000013817.V353036.R01.S.doc Version 5.2 Page 15 After lunch some of the residents enjoyed taking items back to the kitchen, helping the chef and engaging in some friendly banter with him. The chef had a very caring attitude, responded accordingly and felt it was important for the residents to access the kitchen, when he was not actually cooking and risks were at a minimum, because it made those residents feel useful and valued and it was their home. DS0000013817.V353036.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): Standards 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and training ensure the staff are informed and the residents are confident that their complaints will be listened to and that they will be protected from abuse. EVIDENCE: Three of the four residents who completed surveys always knew who to speak to if they were not happy and one usually did. They all confirmed they knew how to make a complaint and that the staff always listen and act on what they said. All the relatives, who completed surveys thought they could discuss any presenting issues with the staff and comments included, ‘The staff are very easy to talk to,’ and, ‘I have never needed to make a complaint, although I know the procedure.’ The complaints procedure was displayed and accessible to the residents but no complaints had been recorded in the complaints file. The Commission for Social Care Inspection (CSCI) had not received any complaints with respect to this home. Staff personnel files inspected included certificates to confirm the Protection of Vulnerable Adults training was kept up-to date and a current copy of the local authority Safeguarding Adults policy and procedure was available at the home to inform the staff in dealing with disclosures and referrals. No Safeguarding referrals had been made since the previous site visit. DS0000013817.V353036.R01.S.doc Version 5.2 Page 17 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 19,24,26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a comfortable, safe, pleasant, well-maintained environment, which is clean and hygienic. EVIDENCE: The home was located in a slightly elevated position overlooking the garden and the car park. The grounds contained mature trees and shrubs and the exterior of the attractive, detached house matched those in the surrounding area. The house retained its original features with high ceilings and wooden moulding forming patterns on and around the ceilings and around the doorways. The effect was very attractive and the owner had added to this by providing good quality furnishings and fittings and retaining the original fireplaces. The shared spaces were of a generous size and comfortable, with new carpeting throughout. All the rooms were pleasantly decorated, fresh and clean. DS0000013817.V353036.R01.S.doc Version 5.2 Page 18 To the rear of the home was an enclosed garden equipped with benches, tables and chairs for taking meals outside, and pots of plants, which, the manager stated some of the residents enjoyed planting. The garden extended around the front of the house where an aviary was located. The home also had a shared cat, which enjoyed the attention of the residents. Some of the resident’s bedrooms were located on the ground floor and some were on the first floor. The staircase was wide, light and airy and a stair lift was available to assist those for whom the staircase was too challenging. The resident’s bedrooms inspected were equipped with good quality furnishings and were exceptionally clean and fresh. Most of the bedrooms had en-suite bathrooms equipped with bath, wash hand basin and toilet. Equipment was provided to support the residents to retain their independence, but call bells were within easy reach. A downstairs-shared bathroom was equipped with a Jacuzzi, which was designed to enable the residents to sit and enjoy the gentle massage of the water. The residents were encouraged to bring with them their own furniture should they wish to do so, the manager stated, there was sufficient storage space to store the home’s furniture to enable this to happen. This policy was fundamental to the promotion of the resident’s individuality, the retention of their self-esteem and their rights and choice to make the home ‘their’ home. Rarely had the personalities of the residents in homes for older people shown through as they did here. The bedrooms were not just personalised with a few photographs, they were the residents’ own domain. The laundry room had an impermeable floor and was equipped with up to date industrial washing machine with sluicing facility. Hand washing facilities were provided to facilitate infection control. 100 of the residents who completed comment cards thought the home was always clean and fresh and 100 of the residents’ relatives/representatives thought the home provided a good quality environment. Comments included, ‘the home environment is very good and it is run and laid out like a normal home that my mother would have lived in – excellent,’ and ‘the home is warm, welcoming, clean and cheerful.’ DS0000013817.V353036.R01.S.doc Version 5.2 Page 19 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 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A stable, well-trained staff team meet the needs of the residents and ensure they are in safe hands at all times. Recruitment procedures are in the process of review to promote safe practices to protect the residents. EVIDENCE: Two care staff were on duty when the site visit commenced and the manager also arrived soon afterwards. A chef was employed full time covering the weekdays meals and the manager stated that she assumed cooking duties at the weekend. ‘Waking night-staff check the residents every hour and this is recorded’, the manager stated. ‘Residents might be awake and want a drink and if anyone did have a fall the risk of remaining on the floor undiscovered is minimised.’ Domestic staff were available for cleaning and laundry duties and maintenance staff were employed to cover issues arising in the group of homes the manager/provider was involved in. The home was well maintained, very clean and hygienic and free from unpleasant odours. The home benefited from having a team of dedicated and loyal carers, most of whom had worked at the home for some considerable time and no new staff had been recruited since the previous site visit. Discussions with the staff revealed they were extremely happy in their posts, really enjoyed working at the home and, ‘couldn’t have a better manager.’ All confirmed they received DS0000013817.V353036.R01.S.doc Version 5.2 Page 20 regular training and supervision and this was confirmed when the staff personnel files were sampled. The Annual Quality Assurance Assessment showed that 50 of the staff had achieved a National Vocational Award at level 2 or above and that another 20 were working towards this qualification. A retrospective sample of staff recruitment revealed, as it had at the previous site visit, that the old application form did not require a full employment history, that gaps in employment should be explained or that reasons should be given when leaving posts which had involved the care of children or vulnerable adults to ensure only suitable people are considered for caring positions at the home. The manager stated, ‘the application form for completion by prospective new staff was in the process of review and there had been no newly recruited staff since the previous site visit’. A photograph was missing from one file and although the files had been organised, Criminal Record Bureau check numbers had not been recorded but the documents were stored in sealed envelopes on the individual files. Advice should be sought from the Criminal Record Bureau website with respect to the recording, storage and destruction of this sensitive material. It is also recommended that the information in the staff personnel files be bound to safeguard it and that an audit sheet recording the request for and receipt of all the pre-employment checks be added to clarify the process. All the residents, who completed surveys confirmed the staff always listen and act on what they say, and a relative commented, ‘I think all the staff do an amazing job. They are very kind, caring with a good sense of humour.’ DS0000013817.V353036.R01.S.doc Version 5.2 Page 21 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 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good leadership and systems in place ensure the home is run safely and in the best interests of the residents. EVIDENCE: The manager was qualified and had many years of management experience. The deputy manager had also achieved a National Vocational Qualification at level four and the Registered Manager’s Award and, during the site visit, the service manager called the manager to say she had been booked to go on a management course to keep herself up-to-date with current practise. Her management style was open and transparent and the staff commented that they, ‘couldn’t have a better boss,’ and that they, ‘loved their job and were well supported and encouraged to go on training courses to develop their skills.’ DS0000013817.V353036.R01.S.doc Version 5.2 Page 22 Systems were in place to ensure the views of the residents, their relatives and representatives and the staff contributed to the running of the home and the manager stated, ‘she was committed to working in a person-centred way to empower both the residents and the staff’. Records were kept of staff and residents’ meetings, care plans were reviewed regularly and staff supervision and appraisal records were kept. A relative wrote on the survey they completed, ‘the home pays lots of attention to detail and that makes all the difference,’ and, ‘the residents are cared for very well and their individual needs are catered for.’ The home’s quality assurance system included seeking the views of visiting social and health care professionals, in addition to the residents, their relatives and representatives, on how well they were achieving their aims. The home did not manage the residents’ financial affairs. Residents, their relatives and representatives retained this responsibility. The health, safety and welfare of the residents was promoted by regular staff training in moving and handling, fire safety, first aid, food hygiene and infection control. Certificates were viewed on staff personnel files and dates for future up-dates for training were posted on the staff notice board. Since the previous site visit a health and safety audit of the kitchen area had been conducted and the chef had attended a health and safety refresher course. The Annual Quality Assurance Assessment, completed by the manager confirmed that policies and procedures with respect to health and safety had been reviewed since the previous site visit, and that essential maintenance of equipment had been carried out according to manufacturers’ recommendations. Certificates were sampled confirming maintenance checks had been carried out in a timely fashion. DS0000013817.V353036.R01.S.doc Version 5.2 Page 23 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 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X 4 X 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 X 3 X 3 X X 3 DS0000013817.V353036.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action 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 OP29 Good Practice Recommendations It is recommended that the Criminal Record Bureau (CRB) web site be accessed for information with respect to the recording, storage and destruction of CRB checks to ensure this sensitive information is protected. It is recommended that the information in the staff personnel files be bound to safeguard it and that an audit sheet to show when the information has been requested and received be added so the process is clear. It is recommended that the reviewed application form requires a full employment history with an explanation of any gaps in employment and that reasons for leaving employment which included the care of vulnerable adults or children are recorded so that only suitable candidates will be considered for employment at the home. 2. OP29 3. OP29 DS0000013817.V353036.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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