Inspection on 25/03/08 for Ventress Hall Care Home

This inspection was carried out on 25th March 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

Ventress Hall Care Home 18/01/10

Ventress Hall Care Home 23/12/09

Ventress Hall Care Home 06/01/09

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Ventress Hall Care Home 22-28 Trinity Road Darlington Durham DL3 7AZ Lead Inspector Alan Baxter Unannounced Inspection 10:00 25 March 2008 th 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 Ventress Hall Care Home DS0000070546.V354532.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. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ventress Hall Care Home Address 22-28 Trinity Road Darlington Durham DL3 7AZ 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) 01325 488399 01325 480011 Southern Cross OPCO Ltd Vacant Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability (45) of places Ventress Hall Care Home DS0000070546.V354532.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 with Nursing, Code N 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, Code OP, maximum number of places 45 2. Physical Disability - Code PC, maximum number of places 45 The maximum number of service users who can be accommodated is: 45 N/A (new registration) Date of last inspection Brief Description of the Service: Ventress Hall is a care home with nursing for up to 45 older people. It was registered by its current owners, Southern Cross OPCO Ltd., in August 2007. Ventress Hall was purpose built in 1989. It is conveniently located, close to Darlington town centre and other amenities. The home is a three-storey building with passenger lifts between floors. There is a central courtyard garden with seating, pleasant floral displays and a water feature. From information provided by the home, fees range from £418 to £600 per week. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 5 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. How the inspection was carried out Before the visit: We looked at: • Information we have received since the service was registered in August 2007. • How the service dealt with any complaints & concerns since then. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 25th March 2008. During the visit we: • • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since registration. This inspection was assisted by the involvement of an Expert by Experience from Help The Aged. The expert talked to service users and staff and observed how people got on together. He was particularly interested in service users quality of life, exercising choice and control, the environment and the catering. His findings have been incorporated into this report. We told the manager/provider what we found. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Residents should be given contracts. Care plans do not cover all the assessed needs of the residents and mental health needs, in particular, are not covered. There is also a need for better recording of medicines given to residents. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 7 There is insufficient social activities and stimulation. They are, however, encouraged to keep contact with family and friends, and with their local community. They have a reasonable amount of choice and control over their daily lives. Not all complaints have been recorded and complaints records have gone missing; some staff training records have also gone missing. There are no clear, resident-focussed systems in place to check the quality of the care being given. All safety documentation must be kept up to date at all times. 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. Ventress Hall Care Home DS0000070546.V354532.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 Ventress Hall Care Home DS0000070546.V354532.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): 1, 2 and 3. People who use the service experience good quality outcomes in this area. People wishing to come to live in the home are given up to date and detailed information about the home, so that they can make an informed decision about whether it’s the right place for them to live. Not all residents have been given contracts by the company, and so may not be clear as to their rights and responsibilities. No one moves into the home until all his or her individual needs have been fully assessed and the manager is sure that the home can meet those needs. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: The home’s statement of purpose and its service user guide have both been updated, to reflect the home’s recent change of ownership. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 10 Patients receiving ‘continuing health care’ have contracts in place, but other residents did not. The new company must issue statements of terms and conditions (or contract, for those who purchase their care privately) to all the residents. A requirement is made regarding this issue in this report. The care records of four residents (three of whom had been admitted to the home in the past three months) were studied. All but one had a comprehensive assessment from the referring authority; the fourth had copies of the person’s hospital care records. The home also conducts its own assessment of the needs of each person referred for admission. This is done before the person is accepted for admission. Assessments are comprehensive and generally well completed. They include ‘body mapping’ charts, and assessments of nutritional, skin care, moving and handling, continence and dependency needs. Ventress Hall Care Home DS0000070546.V354532.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 and 10. People who use the service experience adequate quality outcomes in this area. The care plans for residents do not cover all the areas of assessed need, so not all needs are likely to be met. Most areas of health needs are being met, but mental health care needs are not being fully met, nor are some referrals for specialist input being made. The recording of the medicines given to residents is not sufficiently robust, and does not properly allow for auditing of medicines. Residents are treated with respect, and their privacy and dignity are protected by staff. We have made this judgement using available evidence, including a visit to this service. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 12 EVIDENCE: Most of the assessed needs of the four residents whose care records were studied were matched by appropriate plans of how their care in these areas was to be given by staff. These were mostly comprehensive, suitably detailed, and reviewed (and, where necessary, updated) monthly. However, there were no care plans in place for a range of identified mental health needs, including schizophrenia, depression and confusion. Two of the four also lacked any clear plan for meeting their social or spiritual care needs. A requirement is made regarding this issue in this report. The home draws up a pre-admission draft care plan, based on its assessment of needs, to make the person’s admission to the home as easy as possible. This is good practice. Care plans are not routinely being agreed and signed by the resident and/or his or her next of kin. A requirement is made regarding this issue in this report. The home has good systems in place to assess the health care needs of its residents. It also has systems for making sure that such assessments are kept up to date with, for example, monthly re-assessments of nutritional needs and of skin integrity. It has appropriate documentation on file to back up care plans to meet identified needs, in the form of documents to record elimination, dietary intake, turning records etc. It also keeps clear records of visits to or from health professionals such as doctors, district nurses, opticians and physiotherapists. However, as noted above, there were some significant omissions in meeting some areas of assessed need. In particular, metal health issues must be addressed more actively. There was also evidence, in two sets of care records, of incidents where assessments had identified the need for referral onto specialist health professionals such as Parkinson’s nurses and dieticians, but where there was no evidence that such referrals had been made. A requirement is made regarding this in this report. The home uses the ‘monitored dosage system’, and was able to demonstrate the secure storage of medicines, including that of ‘controlled drugs’. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 13 Study of the Medication Administration Records (MAR) showed that there were a number of unexplained gaps, leading to uncertainty as to whether all prescribed medicines had been administered as they should have been. There were also a number of handwritten changes or amendments to the prescribed medicines where the member of staff had not signed to take responsibility for the change. This means that any later audit of the MAR would not be able to identify who had authorised such changes. It was noted that there was a list of staff names with the initials they use in the MAR, but it was also apparent that bank staff who administered medicines did not routinely add their name and initials to this list. This, again, would hamper any future audit of the MAR. A recommendation regarding this issue is made in this report. To safeguard against medication errors, there are photographs of permanent residents attached to the relevant page in the MAR. However, this system does not operate for the many short-term residents (for whom such an identification tool would be even more useful). A recommendation regarding this issue is made in this report. The temperature in the cupboard used for storing the medicines was seen to be 26 degrees Centigrade, which is excessive for the safe storage of medicines. This must be monitored daily and remedial work carried out, if necessary, to reduce the temperature. Those residents engaged in conversation confirmed that staff treat them with respect at all times, and that their privacy is protected by the staff. Ventress Hall Care Home DS0000070546.V354532.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 and 15. People who use the service experience adequate quality outcomes in this area. The home does not fully meet the social and recreational interests and needs of the residents. Religious needs are met. Residents are encouraged to keep up contacts with their families and friends and with the local community. Residents have a reasonable degree of choice and control over their daily lives. Residents receive nutritious and appealing diet that includes a reasonable level of choice. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: The home has a few regular activities available for the residents, including weekly visits by the ‘pat-a-dog’ service, a weekly exercise class, and a church Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 15 service every two weeks. It does not otherwise have a structured activities programme. No evidence of social activities were seen on the day of this inspection, although staff on the ‘intermediate care’ unit said that they occasionally play dominoes and bingo with the residents, when they get the time. Residents spoken to confirmed that there is little social activity arranged in the home, and that they only go out when their relatives come to take them out. A full-time activities co-ordinator had just been appointed and started work on the day of this inspection. The home’s representatives stated that the aim is to tailor activities to the individual needs of the residents. However, this will require an improvement in the assessment of each person’s individual social care needs, and an improvement in the related care plans. A requirement regarding social activities is made in this report. The home has a positive visiting policy, which encourages and welcomes visitors to the home. It places no unnecessary restrictions on visiting hours, but does specify that children must be accompanied. The home has its own minibus and has a fulltime driver available for trips out with residents. The new manager is in the process of setting up a weekly ‘manager’s surgery’ in the home, making her available at set times to all who wish to see her or express an opinion. She also intends to hold regular meetings with both residents and staff. There is involvement with local churches, in the form of fortnightly church services held in the home. The rights of Catholic residents to receive weekly communion were checked: it was confirmed that those wishing this received it every week. One resident commented that she would like to have more visitors, as she had no family, and only irregular visits by friends. The manager agreed to try and arrange for a volunteer visitor for this resident. Those residents engaged in conversation said that they felt that they have a reasonable degree of autonomy and choice in the home. There was, however, a feeling that the home was rather unsettled due to the recent change of ownership, especially with a perceived increase in ‘agency staff’, and they hoped this would settle down soon. Residents said that they have choice regarding their meals, and said that they understood there was some flexibility regarding meal times (although none had tested out this choice). Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 16 Some residents have retained control of their personal finances. Advocacy services (‘Care Aware’) are advertised on the home’s notice boards. The new manager intends to involve residents and their families more fully in the planning of their care, and has sent a letter to all residents and families, asking them to sign that they agree with the content of their care plans. Menus are in the transition, with new four-week menus just about to be introduced. These appear to nutritious, well balanced, attractive, and to give a good degree of choice. Nutritionalists have been involved in drawing them up. Residents spoken with all felt they were given choice regarding meals. They said they had been informed that there was a degree of flexibility around meal times – although none had tested this out. There was some complaint that the mid-morning tea/coffee did not always arrive and not always with a biscuit. The Expert by Experience took lunch with the residents. The meal consisted of orange juice, soup, lamb stew or vegetable lasagne with vegetables and apple crumble, followed by a cup of tea. Although very tasty, he felt that the meat in the stew was quite chewy and most of the service users agreed with him. The dining tables were nicely set and the dining room was nice and bright. Cutlery was marked: it was badly water stained rather than dirty. The Expert by Experience saw that the residents all did exactly as he had done, wiping the cutlery. When he spoke with them they stated the cutlery was usually like that. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience adequate quality outcomes in this area. Not all complaints received have been recorded or responded to by the home. Residents are protected from abuse. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: There is a clear and accessible complaints policy that is displayed in the home, and is included in the home’s statement of purpose and its service user guide. The home’s new ‘complaints register’ contained only one entry. The previous complaints book was not available, some documents having gone missing during the recent changes of temporary managers in the home. The single complaint was about the responsiveness of night staff. It was taken seriously and properly addressed, to the satisfaction of the complainant. A complaint addressed to the company in early March and copied to the Commission was not recorded. A requirement is made regarding this issue in this report. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 18 The home has appropriate policies for the prevention of abuse of vulnerable adults and for the reporting of any allegations of abuse. Recent allegations made by two former members of staff about the actions of several staff members where being currently investigated by Police and Social Services officers. It was clear that the home’s management were fully cooperating with this investigation. One member of staff had been suspended from duty without prejudice pending the outcome of this investigation. The company is putting its entire staff through a 12-week day-release training course in the protection of vulnerable adults. It is planned for all qualified staff and care staff to complete this training by the end of July, and ancillary staff by the end of September. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate quality outcomes in this area. The safety of the environment is being brought up to an appropriate standard but the plan for the full refurbishment of the building has not been made clear. The home is clean, pleasant and hygienic. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: The company has plans for the refurbishment of the home. These were not, however, available on the day of inspection, and were not clearly described in the ‘action plan’ submitted to the CSCI in January this year. A requirement is made regarding this issue in this report. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 20 The home’s manager and the company’s project manager said that most of the bedrooms have been redecorated; and that major improvements (including full re-decoration) have been carried out in the kitchen. They also said that it is intended to re-carpet all corridors. On the day of this inspection, the home was having both a new ‘nurse call’ system and a new fire alarm system installed. Although this was a major disturbance to the normal routines of the home, residents appeared to have been well prepared for this disruption, and were aware of what the work was for. Those bedrooms seen had been recently redecorated and were nice, warm and clean. A number of residents pointed out that their water jugs, although clean, were old, chipped and lacked lids to keep the water fresh. The toilets and bathrooms were clean and had appropriate equipment, but presented as being institutional and clinical, with no homely touches. Toilet seats were badly chipped and marked. Paper towel dispensers were empty. A recommendation regarding these issues is made in this report. Other than in the immediate vicinity of the work being carried out by the electrical contractors, the home seemed to be and clean and tidy, and free from offensive odours. New cleaning schedules had just been introduced. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. The numbers and skill mix of the staff available to them meets the needs of the residents. Residents are protected by the home’s recruitment policy and practices. Although there is a commitment to staff training, training records do not fully demonstrate that all staff are competent and trained to do their jobs. We have made this judgement using available evidence, including a visit to this service. EVIDENCE: Study of the staff rosters and discussion with the home’s representatives indicated that the current staffing levels are meeting the needs of the resident group at the time of this inspection. This was also the general belief of those residents who spoke to the Expert by Experience. However, several commented that they don’t like the number of agency staff who come into the home, as they feel that this affects continuity and relationships. They were complimentary, however, about the regular staff. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 22 Of the 21 care staff, 13 hold National Vocational Qualification (NVQ) level 2 in care (and 2 more staff are currently studying for this qualification). At 62 , this exceeds the expected 50 of care staff with this qualification. The employment records of two recently employed staff members were studied. Both had fully completed application forms, including detailed work histories, allowing the employing persons to spot any suspicious gaps in employment. Both had had two written work references. ‘PovaFirst’ and Criminal Record Bureau (CRB) checks had been undertaken on both staff members, to make sure they are safe to work with vulnerable adults. The home has a good commitment to staff training. It was stated that all staff are up to date with all areas of mandatory training (fire safety, moving and handling, food hygiene, first aid, and health and safety). Other training currently being given to staff includes tissue viability and safe medications. There are also plans to give all staff training in ‘safeguarding of vulnerable adults’, in the form of one day a week training for twelve weeks, by the end of September this year. The home was unable to provide documentary evidence for all the above training as training records and certificates are missing. The home’s staff training matrix must be brought up to date. Ventress Hall Care Home DS0000070546.V354532.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, 36 and 38. People who use the service experience adequate quality outcomes in this area. A suitably qualified and experienced manager has recently been appointed, and is being put forward for registration. It is not clear from the few quality systems in place that the home is always being run in the best interests of the residents. Residents’ financial interests are safeguarded. There are systems in place to make sure that all staff receive regular supervision. The health, safety and welfare of residents and staff are generally protected, but safety records must be kept up to date. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 24 We have made this judgement using available evidence, including a visit to this service. EVIDENCE: The home has a new manager, Ms Jude Goode, who had been in post less than three weeks at the time of this inspection. She is a Registered General Nurse and holds the Registered Manager Award. Comments cards are available to residents and visitors, and some quality systems, such as a cleaning and care plan audits and quarterly accident summaries, have recently been introduced. However, there was no cohesive overall quality assurance system in place, and no clear focus on the views of the residents and their families. There was no annual development plan in place. Surveys sent by the CSCI to the home before this inspection, but none were returned. It was not clear why this was the case. The new manager plans to introduce a regular ‘manager’s surgery’ in the home, so as to be available to anyone who wishes to talk with her. The home’s ‘Service Users’ Guide’ clearly states the company’s policy regarding residents’ finances. This is that a ‘pooled facility’ for residents’ personal monies is offered, up to a maximum of £500. It pays no interest, but charges no bank charges. For amounts in excess of £500, a designated bank account would be opened. The accounts of money held on behalf of those residents who request this service were examined. They appeared to be accurate, but, as it is a pooled resource, it was not possible to check the account figure against a cash sum. Receipts are kept. Systems are in place for all staff to be given at least six supervision sessions each year. The home has appropriate health and safety policies and procedures in place. Problems had been reported regarding the lack of current safety certification. On the day of inspection, a recent Asbestos Contractors certificate was offered as evidence, as was a Legionellosis Audit certificate. However, no current electrical safety certificate was offered. A requirement regarding this is made in this report. Although not all training certificates are in place, the company appears to have ensured that staff have had the training necessary to ensure safe working practices. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 25 The home has a full time maintenance person who carries out and records regular checks of water temperatures, bedrails, fire safety systems and equipment etc. Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 X 2 Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No (newly registered service). 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 OP2 Regulation 5.1 Requirement The registered person must supply all service users with a statement of terms and conditions (or a contract if purchasing their care privately) at the point of moving into the home. The service user plan, drawn up from the assessments, must be holistic and must include all health, social and spiritual needs; and must be agreed and signed (wherever possible) by the service user or his or her next of kin or representative. The mental health needs of service users must be fully addressed in their care plans. Where particular health needs have been identified that require referral to specialist health professionals, such referrals must be speedily made. The Medication Administration Records (MAR) must not contain DS0000070546.V354532.R01.S.doc Timescale for action 30/06/08 2. OP7 15 30/06/08 3. OP8 15 30/06/08 4. OP8 13.1 30/06/08 5. OP9 13.2 30/06/08 Ventress Hall Care Home Version 5.2 Page 28 any unexplained gaps; and any handwritten entries must be signed and dated. 6. OP9 13.2 The temperature in the 30/06/08 medication storage room must be monitored and recorded daily, and remedial action taken, if necessary, to ensure that the temperature is no higher than 25 degrees Centigrade at any time. A structured programme of social and recreational needs must be put in place, to meet both the group needs and the individually assessed needs of each service user. A clear written record must be kept of all complaints received, including details of investigation and any action taken. A written schedule of refurbishment of the home, with timescales, must be drawn up and submitted to the Commission. Staff training records must be brought up to date, and all training certificates must be held in the home. A structured system of reviewing and improving the quality of care provided at the home, focussing on the views of the service users, must be introduced. A current electrical safety certificate must be submitted to the Commission. 30/06/08 7. OP12 16.2 8. OP16 22 30/06/08 9. OP19 23.2 30/06/08 10. OP30 18.1 30/06/08 10. OP33 24.1 30/06/08 11. OP38 23.2 30/06/08 Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 29 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 OP9 Good Practice Recommendations Bank staff who administer medicines should add their names to the list of names and initials kept to provide evidence for medication audits. Photographs of all service users should (with their individual permission) be attached to the Medication Administration Records (MAR), to aid the positive identification of service users and reduce the possibility of medication errors. Water jugs in service users’ bedrooms should be replaced. Bathrooms and toilets should be made more ‘homely’ and less ‘institutional’; chipped and marked toilet seats/commodes should be replaced; and paper towel dispensers filled. 2. OP9 3. 4. OP19 OP19 Ventress Hall Care Home DS0000070546.V354532.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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