Inspection on 12/08/05 for Winifred Kettle Community Care Centre

This inspection was carried out on 12th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Winifred Kettle Community Care... 03/02/09

Winifred Kettle Community Care... 03/01/07

Winifred Kettle Community Care... 24/02/06

Winifred Kettle Community Care... 21/01/05

Winifred Kettle Community Care... 13/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Winifred Kettle Community Care Centre Leigh Road Westhoughton Bolton BL5 2NE Lead Inspector Sarah Tomlinson Announced 11 & 12 August 2005 : 09:30 am 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 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. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Winifred Kettle Community Care Centre Address Leigh Road Westhoughton Bolton BL5 2NE 01942 634566 01942 634564 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bolton Metropolitan Borough Council Ms Alison Irene Leaver CRH Care Home 23 Category(ies) of OP Old Age : 23 Places registration, with number of places Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for a maximum of 23 service users, to include: Up to 23 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing levels are to be calculated in accordance with the Residential Forum Staffing Guidance (Older People) by 1 April 2004. Date of last inspection 21 January 2005 Brief Description of the Service: Winifred Kettle Community Care Centre provides personal (residential’) care for older people. It is a local authority home, owned and run by Bolton Metropolitan Borough Council. The home is a detached, purpose built building, on two floors (with a lift). There are 23 places - 4 ‘permanent’, 2 respite’ and 17 intermediate care. The intermediate care places are provided on a specialised, rehabilitation basis as a joint arrangement with the health authority (PCT), with a length of stay up to 6 weeks. Care is provided to these 17 residents by an on-site team of nursing, physiotherapy, occupational therapy and care staff. The 4 ‘permanent’ and 2 ‘respite’ residents are looked after by care staff only. These six residents share one lounge/dining area and live on the ground floor (no more permanent residents are being accepted by the home). The 17 intermediate care’ residents live on the first floor and share 3 lounge/dining areas. All bedrooms are singles, with wash hand basins (no en-suite facilities are available). The home has an enclosed garden to the rear and car parking to the front and side. It is in a residential area of Westhoughton, with a bus stop directly outside and shops and local amenities nearby. The home is also a busy community centre for older people, with a separate day centre (Monday to Sunday) and evening groups taking place. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over two days (eleven and three quarter hours in total). Time was spent talking with residents (8), visitors (3) and staff (manager, care supervisors (2), carers (6), cook and health authority (PCT) staff). Time was also spent looking at paperwork and around the building (including bedrooms, bathrooms and toilets on both floors). Before the inspection, satisfaction surveys had been posted to community workers who visit the home (e.g. GPs – 1 returned) and to the home itself, for them to give out to residents (1 returned) and visitors (3 returned). What the service does well: What has improved since the last inspection? The home had worked with hospital staff to improve the information they were getting about new ‘intermediate care’ residents transferring from hospital. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 6 Social activities had been developed for the four ‘permanent’ residents, helping them get social stimulation that suits their interests and abilities. New flooring had been put in the ‘blue’ dining area, improving the appearance and practicality of the area. Senior staffing levels had increased, providing more time to attend reviews and meetings, and work with staff and residents. The management team had started supervision meetings with staff, providing them with the chance to talk about their work and get individual support and guidance. 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. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4 Written information about the home was generally clear and informative, enabling new ‘intermediate care’ residents to understand the service they would be receiving and prospective ‘respite’ residents to make a choice about staying at the home. Making the required minor amendments and finalising the documents concerned will further improve clarity regarding the services residents can expect. Comprehensive assessment information was received, allowing prospective residents’ care needs to be known and prepared for. The limiting of admissions to a maximum of one a day, promoted the safety and well being of all the home’s residents. Residents received a high quality standard of care, with their varied and specialised needs being met. EVIDENCE: Written information about the home was still being updated. At the last inspection, the home had a combined Statement of Purpose and Service Users’ Guide. Three separate documents were now being developed. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 9 Regarding the Statement of Purpose, both the home and Bolton MBC had developed draft versions. The inspector understood the home’s version was an interim document, whilst the Bolton MBC version was to be the formal, ‘corporate’ replacement (which would be individualised). Once these two were combined, the final document should provide all the required information. The home’s version needs to clarify the social activities available to each of its three groups of residents (‘permanent’/’respite’/’intermediate care’), including access (if any) to the day centre (page 4); and that monthly reviews of the care provided to ‘permanent’ residents take place (page 8)). The final, combined document would also benefit from being dated. Regarding the Service Users’ Guide, this was well presented and easy to read, with a copy kept in each bedroom. Good practice was noted, as it was issued in a large font size as standard. As it was now a separate document, several minor amendments and additions are required. A brief description of the services needs to be included (regarding the provision of ‘intermediate’, ‘respite’ and ‘permanent’ care, including the number of places); clarification about available social activities/access to the day centre for each of the three resident groups; also a brief summary of the relevant qualifications of the registered provider, manager and staff (see standard 1.2). The reference to the latest inspection report could also note that a copy is available in reception, which residents/visitors are welcome to read. Regarding information about making a complaint, a copy of the more detailed complaints procedure (with timescales etc.), should be kept with the Service Users’ Guide in each bedroom. Information about the allocation and role of key workers would also be helpful. Information about fees was now within a new ‘statement of terms’ document, which was given to ‘respite’ and ‘permanent’ residents. A brief reference in the Service Users’ Guide to explain that intermediate care was free would be helpful. The new statement of terms needs to include further brief details of the overall care and services provided (including food/meals and social activities) and any period of notice required (see standard 2.2). The final documents would also benefit from being dated. Once completed, care staff should also receive brief training about the Service Users’ Guide, so they can better help residents understand and use it. At the last inspection, the home had had concerns about the adequacy of referral information sometimes received for ‘intermediate care’ residents. Good practice was noted, as the home had since directly liaised with hospital staff, so they had a better understanding of where patients were being discharged to and the associated information requirements of the home. In addition, reflecting seasonal demands, the pressure of admissions had slowed over the summer (good practice was noted, so not to overload staff and ensure resident safety, the home was accepting only one admission a day, with new residents with complex needs only being admitted within office hours, Monday Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 10 to Friday, when the PCT team were available). The home had also been actively involved in the forthcoming ‘single assessment process’ in Bolton, which would bring new assessment paperwork. With regard to current assessment documentation, appropriate information (received prior to admission) was seen for both ‘respite’ and ‘intermediate care’ residents. Due to the intermediate and respite care services provided, the home was always very busy; with a frequently changing resident population. From observing staff and residents together and from speaking with visitors, residents and with staff about their work, the needs of these residents were being met. The needs of the four ‘permanent’ residents were also looked at. To keep disruption to a minimum, these residents lived on the ground floor (sharing a lounge/dining area with the two ‘respite’ residents). These residents had lived at the home for a long time (5 to 14 years) and they and their families wished them to continue doing so (despite the home now mainly providing short term care). The inspection found that these four residents received a good standard of care; with the manager actively working to ensure their quality of life was maintained. Further ways of ensuring these residents continued to receive as much stability and continuity of care as possible was discussed. For example, ensuring they kept the same key worker, who could be rotaed to work more closely with ‘their’ resident; additional reviews with the remaining residents’ families if a ‘permanent’ resident moved or (very sadly) died (including a review of the physical living space available for the remaining ‘permanent’ residents). Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Care planning and risk assessment systems were in place, providing staff with the information they needed to meet residents’ needs and reduce the risk of accidents or harm. Staff had a good understanding of clients’ individual needs, working hard to meet these in a busy and frequently changing environment. The result was very positive relationships between residents and staff, with residents feeling they received a high standard of care from a friendly, caring and helpful staff team. Developing ways of helping residents identify staff would further enhance these relationships. Good physical health was promoted and maintained through regular health care checks and appointments. A review of how this information was recorded for ‘permanent’ residents would enable staff to better monitor any changes. Medication was excellently managed, promoting good health and independent living skills. EVIDENCE: Six care files were examined (4 ‘permanent’, 1 ‘respite’ and 1 ‘intermediate care’). Care plans and risk assessments were in place and updated at appropriate intervals. Regarding ‘permanent’ residents, their weight was Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 12 monitored on a regular basis and there was evidence of regular health care checks. However, the current method of recording these checks in the daily notes made long term monitoring of any improvement/deterioration difficult (e.g. reoccurrence/treatment of skin breaks; the outcome of six monthly medication reviews). With regard to intermediate care, after an initial local authority care plan was completed, all staff were now using the ‘skills plan’, which was the overall summary of the resident’s abilities and care needs produced by the PCT staff. This was reviewed weekly at a multi-disciplinary team meeting, with an up to date copy displayed in the resident’s bedroom. The need to ensure the language used was understood by all staff and the resident concerned (e.g. ‘hip precautions’), and that all relevant information was contained within this one document (e.g. whether pain was being experienced and how to reduce/manage it) was discussed. Joint daily care notes (between all PCT and local authority staff) were also due to be introduced. Again, the use of appropriate language was discussed. Due to the content of care/skills plans and reviews, there was evidence of residents (and/or their relatives) being involved in their care. Ways of continuing to document this was discussed. Senior care staff were responsible for administering medication. Medicines (including Controlled Drugs) were being stored safely. At the last inspection, gaps had been found in administration records. These were now well kept, with no omissions. There was a clear record of medicines received and returned, and a record of staff signatures and initials. Stock levels of two controlled drugs were checked at random and found to be correct. The home was advised to obtain a recognised controlled drugs record book (that was bound, with numbered pages). Good practice was noted with regard to a range of medication practices – staff carried out regular ‘administration rounds’ to ensure medicines were given at the best time for maximum effectiveness (e.g. before/after meals); the administration of ‘homely remedies’ was closely monitored, with more than one or two doses prompting possible inclusion as a regular prescription; the PCT pharmacist met with all ‘intermediate care’ residents to assess and support their self-administration abilities. One resident was currently responsible for their medication, which was kept in a locked drawer in their bedroom. To improve the service it received, the home was due to change pharmacists. As a result, it would no longer receive quarterly monitoring visits (provided by the previous pharmacist). It was agreed that as the home already carried out a range of good practice, with regard to monitoring stock levels etc., it should not experience any difficulty with the loss of these visits. Residents said that staff were “lovely”; “very nice and cheerful”; “champion”; “very friendly”. Residents confirmed that staff knocked on doors before entering. The home employed one male carer and ensured that when he Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 13 provided personal care to female residents, they had given their consent and he worked with a female carer. Good practice was noted, as the home continued to allocate a ‘key worker’ to each resident, who was responsible for assisting ‘their’ resident to bathe (helping to maintain a resident’s privacy and dignity). As noted at the last inspection, some residents were again unsure of who their key worker was. Care staff were due to start wearing identity cards, with photographs, which should help residents (and visitors) identify them. The possibility of having ‘uniform boards’ to help residents distinguish between the different staff groups and having key workers’ names and photographs in residents’ bedrooms were also discussed. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The provision of social and recreational activities to each of the three groups of residents (‘permanent’, ‘respite’ and ‘intermediate care’) was unclear, with the needs of some of these residents at risk of not being met. Residents maintained frequent contact with family and friends, with visitors feeling the home provided an excellent service. Food and meal times were well managed and to a good standard, with residents enjoying a choice of good food, in relaxed and pleasant settings. EVIDENCE: At the last inspection, the home had been asked to develop a range of appropriate social activities for the four ‘permanent’ residents. This had been done, with an activities timetable now in place. This detailed a range of one to one weekly activities for care staff to undertake (approximately three per week for each resident). However, there was generally no recording to indicate that these activities were actually being carried out. The inspector was also concerned these activities might get missed when care staff were busy (e.g. with respite or intermediate care admissions). If social activities are to be the responsibility of care staff, they must see these as an integral part of their role and not an ‘extra’, to be provided if they have time. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 15 With regard to social activities provided to ‘respite’ and ‘intermediate care’ residents, as detailed earlier in the report, the home needs to clarify and explain whether (and how often) these residents can access the day centre. These residents had mixed views about the need for social activities to be provided. Some said they were happy doing their rehabilitation exercises and then resting/seeing visitors. Others said they were “left to their own devices and would like more to do”. Some visitors also said they felt ‘their’ relative sat around for long periods and would appreciate joining in with some activities. The manager explained that PCT therapy assistants had run rehabilitation groups, although these had not taken place recently. The need to specifically ask ‘respite’ and ‘intermediate care’ residents for their views about offering social activities (and what they would like) was discussed. The manager also felt these residents could be invited to the evening social groups held in the home (by outside groups). There were a high number of visitors, particularly for ‘intermediate care’ residents. They were welcome to come at any time, although preferably not at meal times. Visitors said the home was “very, very good” and that they were very pleased with the care ‘their’ relative was receiving. They were made to feel welcome and were kept informed of ‘their’ relative’s health and welfare. The home received an extensive number of ‘thank you’ letters and cards, complimenting the staff on the care they provided. One visitor said they were so impressed they had written to their MP, the director of social services and the chief executive of the local hospital, as well as donating £200.00 to the home. Residents ate in one of four lounge/dining areas, with a hot trolley serving each. These dining areas provided a pleasant setting and were appropriately furnished (e.g. with ‘glide’ chairs). The carpet in the ‘blue’ dining area had recently been replaced with hard flooring to enable cleanliness to be better maintained. The flooring remained domestic and attractive in appearance, and was of a high standard. Residents said the food was “good”, the majority of which was freshly prepared. Residents were asked the day before what they would like for their main meals the following day, with a hot choice provided for lunch (the main meal) and tea. New residents were asked about any particular likes or dislikes, with a record kept in the kitchen. Good practice was noted, as the kitchen was about to extend a weekly ‘healthy eating’/tasting session which had been introduced to the day centre, to residents (including ‘permanent’ and ‘respite’ residents). Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Policies, procedures and training were in place to safeguard residents from abuse or harm, and for taking any concerns seriously. EVIDENCE: Since the last inspection, Bolton MBC had updated its complaint procedure, which was now available in leaflet form in the reception area. Good practice was noted, as the right to complain is detailed within a clear and simple format in the new Service Users’ Guide. However, as stages and timescales are not included, (as detailed earlier in the report), a copy of the new Bolton MBC procedure should also be kept in each resident’s bedroom (with the Service Users’ Guide). A detailed record was kept of any complaint made. Since the last inspection, the numerous ‘thank you’ cards and letters received by the home were now being put on display in the reception. Staff received abuse awareness training during their induction and when undertaking the NVQ award. Good practice was noted; as ten staff had gone on to receive further additional training in this area. The manager confirmed that all existing staff had now received CRB disclosures (apart from one, that was with the CRB and which the manager had been actively pursing (its subsequent receipt was confirmed 6 days after this inspection visit)). Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home provided residents with an attractive, comfortable, safe and homely place to live. EVIDENCE: Winifred Kettle was bright and welcoming. There was a high standard of décor and furnishings, which were domestic in style. Good practice was noted, as wallpaper continued to be used in corridors, lounge/dining areas and bedrooms, helping the building appear homely and comfortable. The garden was very attractive, with level access, raised flowerbeds, planted tubs and a water feature. Care staff had worked hard to achieve a lovely display of plants and flowers. A range of seating and umbrellas was available. Storage space had been improved with the provision of a second shed. The home was found to be clean and tidy. Residents and visitors said the home was always “very, very clean” (including toilets and bathrooms). Six general assistants were employed to carry out cleaning, bed making and laundry duties. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 Acceptable staffing levels meant there were sufficient staff to meet residents’ needs. Whilst the cessation of agency staff should further enhance the continuity and stability of care received by residents. Residents benefited from an experienced and competent care team. The introduction of internal training sessions will further ensure that the care provided is from a knowledgeable and skilled staff team. EVIDENCE: A random examination of rotas showed that staffing levels were acceptable. One carer was on maternity leave and three carers remained on long-term sick leave. Their hours had been filled by a combination of over time and agency staff. However, agency staff would no longer be needed as approximately eight staff from Bolton MBC home care scheme were in the process of joining the home through redeployment. There was a low staff turnover, with no vacancies apart from the assistant cook, which was due to be filled (through redeployment) next month. Staffing remained at 4 carers and a care supervisor in the morning; 3 carers and a care supervisor in the afternoon and evening; and two waking care staff at night. The manager’s hours were supernumerary. The manager confirmed that these levels had increased in the past to meet specific resident need. Good practice was noted, as to ensure adequate staffing for review meetings and individual support, a new rota for the four care supervisors had recently been introduced, providing periods of ‘double cover’. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 19 The home had 21 (actively working) care staff. Good practice was noted, as 11 of these staff members had now achieved the NVQ level II award. The remaining staff were all registered to undertake the award (apart from two nearing retirement). The manager was aware that whilst agency staff would no longer be used, the new ‘redeployed’ staff would need to be included within the staffing numbers. Good practice was also noted; as two kitchen assistants were due to undertake NVQ level II in catering. Training records for existing staff were examined. Staff had received annual/mandatory moving and handling and fire safety training. First aid training was provided three yearly. Cultural diversity and infection control training was due to be introduced as additional annual courses. Good practice was noted, as to make use of skills within the PCT staff team, internal fortnightly training sessions were being introduced (e.g. orthopaedic care, catheter care, oedema, acupuncture). The need to record attendance on staff training records was discussed (plus the length of any training attended (e.g. half day; 1 hour etc)). As a specialised care provider, the home also needs to ensure that any service specific training/knowledge (e.g. ‘hip precautions’) is formally documented on induction records. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35, 36 and 38 Residents and staff benefited from a well organised and well managed home (with residents receiving care from a supported, supervised and motivated staff team). Residents’ views were listened to and acted upon, ensuring the home was being run in their best interests. Regular maintenance and fire safety checks were carried out, promoting the health and safety of both residents and staff. EVIDENCE: Staff spoke about the open and inclusive atmosphere within the home. Staff said “communication was good”, they got to know “what was going on” and they felt they worked well as a team. Visitors also commented upon teamwork; who said staff “work as a real team”. Regular staff meetings were Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 21 held (which staff were paid to attend), with additional meetings for night and domestic staff. Good practice was noted, as since the last inspection, individual supervision had now been introduced (taking place every two months). Written notes were kept and signed by both parties, with a copy given to the supervisee. Staff confirmed that the care supervisors and the manager were supportive, helpful and approachable. New and prospective residents were provided with feedback from the home’s ongoing quality assurance programme, whereby views of previous residents were displayed in the entrance. The manager had acted on recent comments received regarding meal times, putting back lunchtime by a quarter of an hour. As detailed earlier in the report, the views of ‘respite’ and ‘intermediate care’ residents need to be sought regarding the provision of social activities. Money kept on residents’ behalf was being stored safely and securely. Two balances were checked at random and found to be correct. Appropriate written records were kept of all transactions, with monies for ‘permanent’ residents transferred to an interest bearing account as they accrued. No valuables were currently held. Records showed that gas, fire alarm and lift safety checks had been carried out. The fire alarm was sounded and fire escapes checked weekly. Two fire drills had taken place since the last inspection. Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 4 3 x 3 3 x 3 Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 23 Yes 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. 1. Standard 1 Regulation 4, 5 Requirement The draft Statement of Purpose, Service Users Guide and statement of terms must be completed to include all the required information, with copies forwarded to CSCI (previous timescale of 31 July 2005 not met). a - a range of varied social activities, that meet the specialised needs of the four permanent residents must be provided on a regular basis (with records kept) b - respite and intermediate care residents must be consulted about the provision of a programme of social activities, with action taken if appropriate. Timescale for action 30 November 2005 2. 12, 33 12, 16, 18, 24 a - 30 September 2005 b - 28 February 2006 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 8 Good Practice Recommendations How health care checks are recorded for permanent residents should be reveiwed, with a view to developing a F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 24 Winifred Kettle Community Care Centre 2. 10 3. 1, 16 single health appointment record sheet (for ease of monitoring). As planned, staff identity cards should be introduced. Further ways of helping residents know their key worker and the different staff groups working in the home should also be considered. Information about the stages and timescales for making a complaint should be kept with the Service Users Guide (in each residents bedroom). Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Turton Suite, Paragon Business Park Chorley New Road Horwich Bolton BL6 6HG National Enquiry Line: 0845 015 0120 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 Winifred Kettle Community Care Centre F56 F06 S31365 Winifred Kettle V230285 110805 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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