Inspection on 28/02/08 for Walldene Court

This inspection was carried out on 28th February 2008.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Walldene Court 07/02/07

Walldene Court 14/02/06

Walldene Court 13/06/05

Walldene Court 25/02/05

Walldene Court 16/07/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Walldene Court Threap Gardens off Simonside Avenue Howdon Wallsend NE28 7HT Lead Inspector Elaine Charlton Unannounced Inspection 28 February and 11 March 2008 08:45 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 Walldene Court DS0000028822.V357123.R02.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. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Walldene Court Address Threap Gardens off Simonside Avenue Howdon Wallsend NE28 7HT 0191 263 3791 0191 234 3313 tracey.clayton@anchor.org.uk Anchor.org.uk Anchor Trust 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) Miss Tracey Armstrong Clayton Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (1) of places Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2007 Brief Description of the Service: Walldene Court is a purpose built care home in Howden. The home is divided into four units arranged over two floors. Some local amenities are within walking distance and access in and out of the home is good. There are forty-two single rooms, all with en-suite facilities. There are communal sitting rooms and dining areas on each floor. Assisted bathing and toilet facilities are located around the home. There is a passenger lift in the centre of the building. Walldene Court provides nursing and residential care. The costs of the service are £400.99 per week for funded residents, and £440 to £497 per week for self-funding residents. All fees are subject to an additional nursing fee element where appropriate. Information, including inspection reports, is provided for people who live in the home, people interested in moving to Walldene Court, their relatives and friends, to help them decide if their care and nursing needs can be met. Walldene Court DS0000028822.V357123.R02.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 2 star, this means that the people who use this service experience good quality outcomes. An unannounced visit was made on 28 February 2008, with a further follow up visit on the 11 March 2008. The manager was present on both days. Before the visit we looked at: Information we have received since the last visit on 7 and 8 February 2007; Annual Quality Assurance Assessment (AQAA). The AQAA gives CSCI evidence to support what the agency says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are; How the service dealt with any complaints and concerns since the last visit; 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 and other professionals who visit the service. During the visit we: Talked with eight people who use the service, seven staff, the manager and visitors; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building/parts of the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit; Sent “Have your say” questionnaires for residents to complete. A Pharmacy Inspector carried out a full audit of the home’s medication procedures, records and all medicines held in the home. His comments are included in this report. An ‘Expert by Experience’ also took part in the inspection. Experts are an important part of the inspection team. They help inspectors get a picture of what it is like to live in or use a social care service. The `Experts’ comments and observations are included in this report in bold writing. “Expert by experience’ means a person who knows about social care services from using them. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 6 We told the manager what we found. What the service does well: What has improved since the last inspection? Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 7 New documentation is being introduced into the home, which is improving access to information. New residents are given a “Welcome to Your Home” card as part of their introduction into the home. They also get “Change of Address” cards to send out to their relatives and friends. Eight staff achieved a distinction on completion of their City and Guilds Safeguarding Adults course. 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. Walldene Court DS0000028822.V357123.R02.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 Walldene Court DS0000028822.V357123.R02.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 and 6. People who use the service experience good quality outcomes in this area. People are given good information to help them decide about moving into the home. Assessments are carried out so that everyone knows their needs can be met. Before moving in people can visit, look around, enjoy a meal or have a short stay. This all helps someone wanting to move in to make his or her decision. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at the process and records completed for a new person moving into Walldene Court. All nurses have had training to use the new documentation that Anchor is introducing. The newest resident was admitted to the home on the 27 February 2008. A full, professional assessment had been obtained from the Local Authority concerned. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 10 Although the person had only been admitted to the home the day before the inspection staff and we were able to see what this person’s needs were. Including how they communicated, dietary issues, equipment that was needed and what signs staff should look out for that might indicate the resident was in pain. The information was of an excellent quality. We saw that all the records for people living on the ground floor had been changed over to the new system. Staff on the first floor were in the process of completing the changeover. The documentation has been Crystal Mark approved which means it complies with plain English best practice. We saw that each resident’s record is kept in a standard way and is comprehensive covering all areas of daily living, health/medical and nursing needs, equipment, and areas of risk. The home’s administrator talked us through the process for welcoming a new resident to the home. Anchor have recently introduced a “Welcome to your new home card” and change of address cards for people to send out. We heard staff talking to relatives with sensitivity and reassuring the family of a resident recently admitted when they telephoned to see how their relative was. Twelve residents sent back questionnaires. Eight of them told us they had a contract of terms and conditions, one person was not sure and three did not answer this question. Eleven people said they had been given enough information to decide if this was the right home for them. People also said: “The home was our first choice, mainly through good reports that we heard from friends who had relatives staying at the home.” “I was glad to get a place here for Mum,” The home does not provide intermediate care. Walldene Court DS0000028822.V357123.R02.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 and 10. People who use the service experience good quality outcomes in this area. People living in the home are asked how they wish their personal care to be provided, and by whom. They are supported and helped to be independent with medication and can see health care professionals as their health needs dictate. Staff are trained in the safe handling of medication and new audit systems have been introduced to promote good practice in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Eight of the twelve people who sent back questionnaires said they always got the care and support they needed. Four said they sometimes did. They also said: “The staff have been very good both with my mother and the family.” “Staff are always very helpful.” Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 12 We saw the records for five other people who live in the home Personal care needs were fully detailed including appointments for Physiotherapy and with Ophthalmology. We saw good evidence of the advice and support of a wide range of health care professionals being sought. Speech and Language Therapists have been, and continue to be, involved with residents who have swallow problems. The cook told us how they had given support and advice for a resident who had previously needed a pureed diet to move onto soft foods. Staff are given excellent information about all a persons needs including personal care, mobility, nutrition, communication (that may include the use of “Yes/No” cards or a personal communication book) and monitoring of medical conditions. We saw printed stickers being used to identify areas of risk - “warning triangle style”. The format used identifies all areas of risk at a glance, giving a written description of the action that needs to be taken for safe working. Risk assessments are in place covering falls from bed, moving and handling, and diabetes care. All documents seen were fully complete, well detailed and up to date. We saw records of equipment that people needed to help with their daily life and to help them eat. The home is well equipped and adapted to meet the needs of people who live there. The manager told us that most residents use The Green Surgery at Wallsend. But during the inspection we heard staff negotiating, on behalf of a new resident, to keep her own GP at a different surgery following admission to the home from hospital. Unannounced Pharmacy Inspectors Visit – 28 February 2008 Medicine storage facilities are good. Monitoring of the fridge temperature was inconsistent which means that medicines may not be stored under optimum conditions and this could affect their use and the health of people in the home. A maximum/minimum thermometer is not in use so there is no record of the fluctuation of temperature within the fridge. The controlled drugs cupboard appears to meet safe custody requirements and is of an adequate size. The controlled drug register is suitable for use and entries are legible and complete. We saw no signature list of staff authorised to administer medicines. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 13 A number of Medication Administration Records (MAR) were loose in the folder and could easily fall out and there is a risk that all medication a person needs may not be administered as prescribed. The quantity of medicine from one monthly cycle to another is not always recorded on the MAR chart. This means that it is difficult to have a complete record of medicines within the home and to check if a medicine is being administered correctly. There were a small number of gaps on the MAR charts and no explanation as to why the prescribed medicines had not been administered. We found an out of date bottle of cyclizine mixture, although no longer being administered, located in one of the medicines trolleys. This was given to the nurse in charge for disposal. Out of date medicines and medicines no longer in use must be kept separate from medicines in use. They should be disposed of safely to reduce the risk of people receiving medicine that may be unsafe or no longer appropriate for their medical condition. We saw inconsistencies in the recording of the date of first opening on medicines with limited use once opened. Handwritten entries for two medicines, on one MAR chart, which had not been signed. Two care plans incorporating an assessment of medicines needs provided good detailed information on how to use medication, test results and hospital visits. All care plans need to be updated to provide detailed information on the person’s medication, medical condition and visits from healthcare professionals. An appropriate record is made of the disposal of all medication. Residents were asked if they received the medical support they needed. Ten out of 12 said they always did and one person said usually. Ten out of twelve residents said that staff listened to and acted upon what they said. Two people did not answer this question. Residents also said: “Nurses are available 24 hours a day.” Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 14 “Medical support from bank staff leaves a lot to be desired. Nurses from the home are alright when dealing with medical problems.” “Although staff listen they sometimes don’t act until further requests are made.” “I find sometimes some staff don’t listen, some say that have not the time to listen or act on my behalf.” Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 15 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 and 15. People who use the service experience good quality outcomes in this area. People living in the home are encouraged to be as independent as they wish. They access social opportunities within the home and the wider community. Choice and rights are promoted as well as healthy living. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: One resident had told staff that they wanted to join in the multidenominational service held in the home. We met the hairdresser who visits the home twice each week. She has been doing so for a number of years and knows the residents well. There are four dining rooms in the home, two on each floor, or we saw people making choices to eat in their own bedroom. The cook told us that she prepares the menus. The dietician checks these for nutritional value. To help people who live in the home make choices about Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 16 what they want to eat there is a folder of “meal pictures” that they can use. This was nicely set out and very colourful. Two residents need a pureed diet and one person was just coming off this type of diet onto soft food. A speech and language therapist had supported cook and the resident with this process. We saw evidence on the menu and in the kitchen of home baking and freshly cooked meals. On the day of the inspection cook made soup, fresh bread (red onion and tomato, fresh cream and strawberry buns, brac (a popular type of fruit loaf) and a range of pureed foods for freezing in moulds. Cook uses moulds for liquefied food. We saw some excellent examples being frozen – meat into the shape of chops was an example. We were told that staff can also do puree effects that look like sandwiches and cakes. It was evident that a great deal of effort goes into ensuring people who need a pureed diet receive this in a way that looks just like the menu choice. Juice machines are located in each dining room where residents or their visitors can help themselves. There is a different flavour juice each day. Each day, usually in the afternoon, there is a ‘fruit run’ when residents can choose finger style, peeled and sliced fruit for a snack. Cook told us that she also does a ‘chocolate run’ and an ‘ice cream run’. One lady did not want to go out in the afternoon “in case she missed her ice cream”. Five out of the 12 residents who sent back questionnaires said they always enjoyed the food, six said they usually did. One person said, “Meals are not hot enough, menu very boring, not enough to eat, not enough variety of vegetables – sick of broccoli and cabbage”. We talked to cook about this and looked at the menus. There was a choice of several vegetables each day. The Expert by Experience said: I was shown around a clean, well-appointed home. The feeling of space was everywhere. Every room was big enough to take a wheelchair and hoist with ease and a lot of resident’s personal things even in some cases a small fridge. Every room was well decorated, clean and tidy but very homely – photographs or dolls decorated every one. The residents themselves were extra clean and tidy and all took good advantage of the hairdresser. Everyone I spoke to was happy, content and felt safe. One lady tried to get her brother into Walldene “so that Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 17 she could look after him” but his needs were so great that this was not possible but the staff have promised to take her down to see him to check for herself and set her mind at rest when he gets settled into his new accommodation. I thought this was great. The kitchen was clean and well equipped. The lunch menu was varied with plenty of choice. I just had to try it of course. I shared lunch with two other ladies in a comfortable dining room with plenty of room for wheelchair access. Each one of us had a different first course, which was well cooked, well served and followed by an unforgettable almond tart with custard and a cup of tea. After lunch I spoke to a visiting relative who was more than happy about her mother’s care. She said Mum was really happy and content, loved her bingo and had won that morning. The overall impression of this home was happy, contented residents, staff and management totally committed to care first and always. I will repeat a story I was told which says better than I can possibly do what this home is like. A resident passed away recently and the notice in the paper read………….”cortege to leave her home, Walldene Court”. All relatives had met in her room to discuss the arrangements and felt “it was Mum’s home”. Residents expressed different views about whether there were activities they could take part in. They told us: “There is not a replacement for activities due to sickness.” “Activities take place – not very interested – I prefer one to one.” Walldene Court DS0000028822.V357123.R02.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 and 18. People who use the service experience good quality outcomes in this area. The views of people who live in the home are listened to. They are protected from harm through policies, procedures and staff training. People are encouraged to talk about their concerns and know they will be listened to. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Eleven of the twelve people who sent back questionnaires said they knew how to make a complaint and who to speak to if they were unhappy. One person also said “The family know who to contact if there is a problem”. The home has a comprehensive complaints policy and copies of the Compliments, Concerns and Complaints leaflet were on display in the home. We saw the complaints register that is well kept giving details of the name of the complainant, date of complaint, who accepted the complaint, the action taken and the outcome. This is good practice. Complaints made since the last inspection were seen. There was evidence of people being listened to, their concerns being well recorded as well as the feedback they were given. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 19 One concern involved the new Smoking Legislation. The manager had provided the residents family with copies of this so they could see exactly what this meant for people living in the home. Locked facilities are provided in residents’ bedrooms so that they can keep their money and any personal items they wish safe. The manager told us that approximately 20 staff have completed a 12-day course on Safeguarding Adults. Eight of them had achieved a distinction. Anchor has also introduced a one-day mandatory training course on safeguarding adults. Ten staff still needs to complete this. The manager said they were waiting to receive dates for training in April 2008. Care staff are employed in accordance with the General Social Care Council Code of Conduct. Regular checks are carried out and recorded to show that nurse registrations are up to date and are valid. The manager was seen to have worked well with a range of professionals when a concern had been raised through the safeguarding procedures. Walldene Court DS0000028822.V357123.R02.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 and 26. People who use the service experience good quality outcomes in this area. People live in a homely environment that promotes their independence and the chance to spend time privately. Everywhere is clean and tidy and hygiene routines are good. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager showed us around the home. Accommodation is divided into four units, two on the ground floor and two on the first floor. There is a central lift to help people access the first floor. Bedrooms have toilet and hand washing en-suite facilities. There is a dining room, lounge, bathrooms/showers, linen stores and sluices on each wing. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 21 We saw one bathroom that had been re-decorated last year. It is now completely tiled and has new flooring making it easy to keep clean and hygienic. The water temperature to the baths was checked and found to be within the recommended levels of 37 – 43 degrees centigrade. Water and heating temperatures throughout the home are computerised and centrally controlled from Bradford. The sluice areas were all clean, tidy and odour free. We were told that the “bedpan washers” were all due to be replaced. One lady who has a downstairs room has had bird feeders put up outside her bedroom as she enjoys feeding and watching the birds. During the tour of the premises we spoke to one lady who had just been out for the first time in two years. She said she had really enjoyed her outing but had come back because it was cold. She said she was looking forward to going out again. We spoke to residents and their relatives who were spending time in their bedrooms. They all said they were made comfortable and had everything they needed. All areas of the home were clean, tidy and odour free on both days of the inspection. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 22 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, 28 and 30. People who use the service experience good quality outcomes in this area. People living in the home are protected by recruitment and selection procedures that are properly followed. Staff are supported through training and supervision to provide care to people in a way that meets their individual needs. Supervision targets are not always met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manger told us that one nurse and three carers work on each floor, with the additional of an extra carer between 08:00 and 12:00. Two nurses and three carers are on duty throughout the night. In addition, the staff team comprises of a cook, assistant cook, kitchen assistants, domestic staff, laundry assistants, a gardener/handyman, administrator, the manager and her deputy. Throughout both days of the inspection sufficient staff were seen to be on duty to meet the needs of everyone living in the home. Four residents who sent back questionnaires commented that they did not always feel there were sufficient staff on duty when they needed them. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 23 The uniform they wear can identify staff. Nurses wear navy blue, carers are in turquoise and the domestic staff wear polo shirts. Agency staff working in the home wear white uniforms. Everyone was seen looking smart, clean and tidy. We looked at the files for three new and three long-term members of staff. There is an excellent format for staff files that is consistently used and is easy to use. We saw evidence that recruitment and selection procedures and consistent and properly followed. Checks are carried out with the Criminal Records Bureau (CRB) and the Nursing and Midwifery Council. Everyone receives a contract of employment. This includes a statement that staff are responsible for reporting any new cautions or convictions they may receive to the manager. There is an Anchor Care Services Induction Workbook; this is supported by an Induction Tracking Document that monitors progress through three days of induction and shadowing. The documents are signed and dated by the staff member and their supervisor. Staff induction is comprehensive and covers equal opportunities, diversity, elder abuse, the Race Relations and Sex Discriminations Acts and Disability Rights. There is also a section that covers the areas of medication, health and safety, fire safety, moving and transferring and infection control. We saw good input and evidence of work being checked/“marked”. And the use of a practical checklist for shadow shifts. There is a final section where a person’s performance is reviewed and any actions needed are recorded. A date is also set for a review. A Skills for Care certificate is issued for the completion of the Common Induction Standards. From training records we saw that staff have taken part in medication training, syringe driver and health and safety updates. End of life care, moving and handling and food hygiene. Records of training include an individual sheet for each staff member and one for each area of training. This is not the easiest system to follow. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 24 The deputy manager checks and records the outcome of checks with the Nursing and Midwifery Council. Her summary includes the staff member’s name/PIN/date of birth and expiry date. All checks were up to date on the day of the inspection. We saw good evidence of follow up through health care professionals of a colleague’s illness and ability to return to work. All staff were sent a letter to their home address about the new smoking legislation. Staff relations with each other, health care professionals and residents were seen to be warm, friendly and professional. Walldene Court DS0000028822.V357123.R02.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, 33, 35, 36 and 38. People who use the service experience good quality outcomes in this area. The home is well run which benefits the people who live there. They are consulted about what goes on in the home through surveys and meetings. Both people living in the home and staff are protected through good health and safety procedures, systems and training. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home is purpose built and meets the needs of the people who live there. The manager is experienced and qualified to carry out her job and receives support from a regional manager. Both the manager and her staff were open, honest and co-operative throughout the inspection. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 26 We saw relatives, professionals and contractors being dealt with in an efficient and pleasant way. Health and safety policies and procedures are comprehensive and easily accessible by staff. An asbestos survey has been carried out and was on display for contractors or other visits to see. Contractors were seen being asked to sign in and out of the building and to state what work they were carrying out. We saw evidence that contracts were in place and checks had been carried out on electrical systems and equipment, fire alarms, emergency lights, gas systems, moving and transferring equipment and the lift. Any remedial work requested had been carried out. Complaints leaflet on display also welcomes compliments. We saw a compliment from a relative thanking staff for “being so kind and helpful and for making the last four years of their relatives life so happy”. We were told that quality assurance questionnaires are available but are not being used at the moment. We carried out a random check on monies held on behalf of four residents. Records were up to date and correct and we were told that an internal financial audit was due the next week. Monies are held in a Lloyds Bank account that is non-interest attracting. All residents who want monies looked after sign a residents’ agreement form to “Open an Individual Residents Personal Monies Account”. Anchor Bulletin 21 – Residents Personal Monies is given to residents or their relatives as a guide. The fire log and accidents records were also seen. Fire checks and tests were seen to be regularly carried out and recorded. Accidents are recorded on an accidents/incident form and also on the in-house computer system AIM. A monitor form is also completed for each “event”. A new fire risk assessment for the home has been carried out. Records of some staff meetings and supervisions were seen. Staff supervision levels do not yet reach the minimum standard required of six sessions per year. Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Best practice guidance and the provider’s current procedures must be followed when receiving, storing and recording all medicines. This will help to make sure that people’s health and welfare are protected from the risk of medication errors or omissions. Medication with limited use once opened must only be used in line with the manufacturers recommendations. This makes sure that medicines are always safe to give when needed. 2. OP36 18(2) The staff supervision programme must be undertaken as planned. This will support staff to do their job and keep people who live in the home safe. Previous timescales of 14 February 2006 and 30 April 2007, not met. 3. OP33 24 A system for monitoring and reporting on the quality of care provided in the home must be DS0000028822.V357123.R02.S.doc Timescale for action 30/04/08 30/03/09 30/03/09 Walldene Court Version 5.2 Page 29 fully operational. This will help people to know that they are listened to and their comments are acted on. 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 A system should be in place to record all medication kept in the home and carried over from the previous month. This helps to confirm that medication is being given as prescribed and assists in checking stock levels. Staff should sign and date handwritten entries they make on the MAR charts. Each entry should be checked and countersigned by a second person to reduce the risk of error when copying information. 2. OP30 Consideration should be given to introducing a training matrix that is easy to use and keep up to date. This will make it easier to see what training staff have undertaken and need keeping people who live in the home safe. Compliments should be dated so that it is easy to see how many have been received in a specific period of time. This will make the process of monitoring quality in the home easier. 3. OP33 Walldene Court DS0000028822.V357123.R02.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. Extracts may not be used or reproduced without the express permission of CSCI Walldene Court DS0000028822.V357123.R02.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!