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Inspection on 03/01/07 for Winifred Kettle Community Care Centre

Also see our care home review for Winifred Kettle Community Care Centre for more information

This inspection was carried out on 3rd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is well run and has a good manager and a willing staff group who get on with the residents and with each other. The residents said that the staff treated them "with respect and dignity" and that "nothing was too much trouble" for the staff. The home gives good care to the residents and the staff knew a lot about the residents and the care they needed. Those residents having rehabilitative care have fully trained staff to look after them and equipment is on hand to help them with their recovery. The information recorded in the care files is clear and it gives good guidance about how the residents are to be cared for. The residents enjoy the meals, special food is provided for those people who need it and those residents who cannot eat by themselves are given help. Visitors are welcome at all times. The building is well looked after and clean, and it is safe.

What has improved since the last inspection?

Good progress has been made by the manager and the staff to make sure that the things, which needed improving from the last inspection, have been done. As previously required the home`s Statement of Purpose and Service User Guide (Residents Information Guide) have now been put together in a final version. These documents are well laid out, properly written and easy to follow and they contain useful and valuable information about the home for new and existing residents and their relatives.

CARE HOMES FOR OLDER PEOPLE Winifred Kettle Community Care Centre Winifred Kettle Community Care Centre Leigh Road Westhoughton Bolton Lancashire BL5 2NE Lead Inspector Stuart Horrocks Unannounced Inspection 3rd January 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Winifred Kettle Community Care Centre DS0000031365.V312821.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. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Winifred Kettle Community Care Centre Address Winifred Kettle Community Care Centre Leigh Road Westhoughton Bolton Lancashire BL5 2NE 01942 634566 01942 634564 alison.leaver@bolton.gov.uk 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) Bolton Metropolitan Borough Council Ms Alison Irene Leaver Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 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. The service must, at all times, employ suitably qualified and experienced staff to meet the assessed needs of the service users. Within the maximum of 23 places, there is provision for up to 17 intermediate care places. 24th February 2006 Date of last inspection 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 - 3 permanent, 3 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. Care staff looks after the 3 ‘permanent’ and 3 respite residents 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 ensuite 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. A Service User Guide that describes the home’s services is readily available in the home and the staff gives other information about the home to new and prospective residents and their families verbally. A copy of the latest inspection report, the home’s Statement of Purpose and a copy of the latest quality assurance survey are also displayed in the home. The intermediate care service is provided without charge whilst charges for Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 5 other services range from £92:55 to £394:00 per week with these figures being subject to negotiation to allow for individual circumstances. Additional charges are made for hairdressing services. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which included a site visit that was started at 9.00am on the 3rd January 2007. It took place over one day and it lasted for about seven hours. The time was split between talking to the Manager and checking records, looking around the home, watching what was happening and talking to residents and other staff. Three residents and four staff were spoken with. A completed pre-inspection questionnaire was received along with feedback surveys from residents and relatives. Of the surveys sent out six were returned by residents, four by relatives and two by GP’s. The care services (case tracking) provided to three specific residents were used a basis for the process of the inspection. What the service does well: What has improved since the last inspection? Good progress has been made by the manager and the staff to make sure that the things, which needed improving from the last inspection, have been done. As previously required the home’s Statement of Purpose and Service User Guide (Residents Information Guide) have now been put together in a final version. These documents are well laid out, properly written and easy to follow Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 7 and they contain useful and valuable information about the home for new and existing residents and their relatives. 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. Winifred Kettle Community Care Centre DS0000031365.V312821.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 Winifred Kettle Community Care Centre DS0000031365.V312821.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, 3 & 6. Quality in this outcome area is good. Residents’ needs are properly assessed before admission so that all parties are assured that that identified needs can be met by the home. The home’s intermediate care service helps people to regain their independence so that they can return to live at home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement of the previous inspection was that the draft copies of the home’s Statement of Purpose and Service User Guide (Residents Information Guide) must be finalised with completed documents produced and made available to residents and their families. This work has now been done and both of these documents contain the required information, they are well laid out, properly written and easy to follow and they contain useful and valuable information for new and existing residents and their relatives. All of the case tracked residents had copies of this paperwork in their bedrooms although some of them had not read them. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 10 The care files of the three case tracked residents were checked for the required pre-admission needs assessment information. The home is no longer admitting resident for long term care. Therefore preadmission assessments are aimed at assessing potential residents suitability for admission to either the home’s Intermediate (rehabilitative) Care or respite care services. Such assessments were seen to be in place that demonstrated that the admission procedure was thorough and checking of the above records showed that a full assessment of these residents care needs had been completed prior to their admission to the home. From this information the home is then able to assess whether these people’s needs can be met and a care plan and a range of other care delivery information is then put together. The home’s Intermediate Care Service can accommodate up to 17 older people who need help to get back on their feet after they have been ill so that they can then return to their homes and live independently. This service is jointly provided by Social Services staff employed at Winifred Kettle Community Care Centre, and by employees of the local Primary Care Trust. A specialist team of workers is available including doctors, physiotherapists, occupational therapists, nurses, therapy assistants and care staff and managerial and ancillary staff. A range of needs assessments are undertaken and programmes of care are normally set up shortly following the resident’s admission to the service. The rehabilitation programme usually covers for up to a six-week period with the residents’ progress being regularly reviewed at weekly intervals. Equipment and space was available for the provision of this service and those residents receiving this care live in identified areas of the home. Residents spoken to who were receiving this service were aware of the purpose of their stay at the home and they were also fully aware that a programme of care was in place, which they knew was intended to help them to return to live in their own homes. These people said that they felt that the support that they were being given was “beneficial”, that they had been helped “to get their confidence back” and that they had been assisted “to get going again”. Where practical new residents and their families are welcome to visit the home where they can spend some time and meet the residents and the staff. Some of the residents that are referred for Intermediate Care services have previous experience of the home from attending for day care or from having been in the home when receiving respite care. Winifred Kettle Community Care Centre DS0000031365.V312821.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 & 10. Quality in this outcome area is good. Individual care plans and care programmes are in place, which were up to date, regularly reviewed and provided the staff with the information they needed to give a good standard of care. The home’s medication systems are satisfactory in ensuring that residents received medication as prescribed and care practices in the home ensure that the residents are treated with respect and their privacy and dignity is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care files of two residents receiving intermediate care, one person receiving short-term respite care and one permanent resident were checked. These were found to contain the required information that dealt with each person’s health; personal and social care needs. The files of those residents receiving intermediate care contained a wide range of information including comprehensive needs assessments, a care plan, skills and goals plans, all of which are designed to assist the resident in regaining their independence. These are reviewed frequently and a full review of each resident’s progress is held weekly. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 12 The required risk assessments were found to be in place in the above files and they were up to date. Joint daily care notes completed by all PCT and local authority staff have now been introduced that provide a good and complete picture of these residents’ progress. The short-term and the permanent resident’s care files also contained up to date risk assessments and a current care plan. All of the above examined records also showed that the residents weight is checked regularly. The staff said that they knew each residents needs by reading the readily available care files and also the skills plans (care plans) for those residents receiving Intermediate Care that are kept in these people’s bedrooms. Discussions with the staff and looking at records showed that the permanent residents health care needs are taken care of and that when necessary health workers such as doctors, nurses and opticians are called. The health care needs of intermediate care residents are well met, as previously mentioned they have access to the team of doctors, nurses, physiotherapist and occupational therapist attached to the home. All residents spoken with felt they were being well cared for by the staff team and relative feedback received from comment cards, indicated they were satisfied with the overall care provided by the home. Two systems of giving medicines to the residents were used at the home. The system used for the permanent residents is one where the medicines are kept in individual packs whilst those for the residents receiving Intermediate Care are provided on an individual basis. All medicines were safely stored and the medicine administration records were correctly filled in and were up to date. Lockable Controlled Drugs storage is available and the checking of the one Controlled Drug in use found the quantity kept corresponded as required with the amount recorded in the Register. Identification photographs of each resident are kept with the medication administration records and those staff that give out medicines have been given the necessary training for this task. The home has a satisfactory medicines policy and procedure that includes guidance for the self-administration of medicines and the use of homely remedies. Those resident receiving rehabilitative care are encouraged and assisted to administer their own medicines. This process is risk assessed and monitored with advice being provided by a visiting pharmacist. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 13 The home’s Statement of Purpose and the Service User Guide reinforced the importance of staff treating residents with respect and dignity. Residents spoken with were all complimentary about how staff assisted them with personal care tasks and felt their privacy and dignity was respected at all times. This was also observed during the inspection. Residents were asked quietly if they needed the toilet, they were taken without having to wait, toilet doors were closed and staff knocked on bedroom doors before entering. Those residents spoken with said that the staff were “courteous”, “caring”, “lovely” and that “they (the staff) talk to us properly”. The staff were seen to have a good relationship with the residents, speaking to them in a natural, thoughtful and warm manner. Winifred Kettle Community Care Centre DS0000031365.V312821.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): Quality in this outcome area is good. Residents have choice about their daily routines (e.g. getting up and going to bed times, when to eat) thus they are able to spend their time as they wish. Visitors are welcomed and the meals provided are good, offering choice and variety, and catering for special dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The day centre staff at Winifred Kettle organise and run a varied programme of recreational and social activities for those people attending this service. In practice those residents receiving the Intermediate Care Service are largely kept occupied by the therapeutic nature of their care and they said that they tended to mostly watch television, listen to music, or read. These people can however if they wish, join the day centre activities providing that at any given time there is space in this part of the home to accommodate them safely. Virtually all of the permanent stay residents have now lived at the home for a considerable length of time and they have now become very elderly and some of them rather infirm. These residents showed little interest in joining activities, with the manager and the staff being well aware of the difficulties in finding stimulating activities for them and they said that these residents enjoyed an individual chat and that the staff is now providing individual (one to one) time with these residents. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 15 The residents said that they had enjoyed the entertainments that had been put on over the Christmas period, which included musical entertainment, a pantomime and a mind reading act that was done by the manager. From talking with residents and staff the inspector confirmed that visitors are welcome at any time, although preferably not at meal times. Those residents spoken with said that they “were free to see their visitors wherever they wanted to”. They described taking visitors to their bedrooms for privacy or seeing them in the main lounge. The residents said that visitors are made welcome and that they (the visitor) can have a warm drink if they so wish. Residents felt their routines were flexible and that they had choices in where to sit in lounges and dining room, whether or not to take part in activities, what to wear and times of rising and retiring. For those residents who may have a limited ability to make decisions and choices about their day-to-day living arrangements the staff said that they try to assist the them with this by offering choices about such things as what clothing to wear, when to rise and retire and helping to choose from the menu. The staff were seen to treat residents in a dignified,respectful and curteous manner and to deal with them in a friendly and caring way. The residents are able to, and do bring personal items in to the home such as radios, photographs, pictures and ornaments. The home has a four weekly menu that offers a choice of good nourishing food with the main meal served at lunchtime and a lighter meal at teatime. Warm food is always offered at midday and a warm choice is also available at most teatimes. The cook speaks to all residents at the time of their admission to the home when she asks them about their food likes and dislikes with this information being recorded. The residents praised the food served generously saying that the food was “good”, “appetising”, that “you get enough to eat” and that “you can have something else” if you don’t want what is on the main menu. The residents also said that drinks and snacks were available at most times of the day. The inspector had a meal at lunchtime with the food found to be well presented and to be to an excellent standard. Meals were seen to be presented in an appealing manner with good portions offered. They are eaten in a number of small dining rooms that are nicely furnished that provide a comfortable and homely setting for the residents to dine. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home has a clear complaints system that ensures that concerns are speedily dealt with and good protection of vulnerable adults guidance and staff training in this topic makes sure that residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has copies of both the Bolton Social Services and Bolton NHS Primary Care Trust comments, complements and complaints procedures that are available in leaflet form in the reception area. Further information regarding the making of complaints is also included in the Service user Guide. Both of the above leaflets state how a complaint can be made, who to and that an initial and final response will be provided within a given period of time. The facility of contacting the local CSCI office is also included in the Bolton Social Services leaflet and the Service User Guide. The home has a record for documenting complaints. No complaints have been made either to the home or to the CSCI since the last inspection in February 2006. Discussion with residents and information obtained from the survey questionnaires showed that these people would feel comfortable about raising concerns and that they would “talk to the staff” if they had any worries. It was clear in discussion with staff that they knew what steps to take should a resident make a complaint. A number of staff said that if “they couldn’t sort things out at the time” then they would inform the manager about the problem. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 17 There are written procedures and policies covering adult protection, whistle blowing, the none acceptance of gifts, borrowing money and legacies and the home has a full copy of the Bolton Inter-Agency Safeguarding Policy. Looking at records showed that the staff had been given training in adult protection procedures. In discussion the staff confirmed that they had received such training and they were aware of the different sorts of abuse and they also understood what they should do if they suspected that someone was being abused. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. Winifred Kettle provides clean, safe, comfortable, homely and friendly surroundings for the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Winifred Kettle is well maintained both to the inside and to the outside. The home is bright and welcoming. Decoration, furnishing and lighting is to a high standard and is domestic in style. A lounge and a bedroom have recently been redecorated and the flooring has been replaced in two other bedrooms and in the reception area. The three case-tracked resident’s bedrooms and a number of others were checked. All were found to be generally properly decorated, furnished and equipped and these residents were satisfied with the standard of the accommodation provided. However, in one of these bedrooms the mid-height wallpaper border was seen to be damaged. The manager advised she had already identified this and other work as a part of a future programme of maintenance that the Local Authority intends to undertake. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 19 There is good accessibility around the building with ramps, assisted baths and other equpment provided. Aids and adaptation are provided in bedrooms, bathroom and toilets. The home has an attractive garden area with level access, seating, raised flowerbeds, planted tubs and a water feature. The laundry is properly equipped and information regarding the control of infection is available. The building was clean and tidy throughout and was free from any offensive odours therefore providing a pleasant place to live. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. The residents are well cared for by sufficient numbers of staff that are safely recruited and properly trained This judgement has been made using available evidence including a visit to this service. EVIDENCE: Looking at rotas showed that as well as employing care staff, the home also employs domestic and catering staff. Other staff that are employed by the PCT also work within the home’s Intermediate Care Service. Staff rotas for the period 1st to the 28th January 2007 were examined. These showed that 4 carers and a care supervisor are on duty in the morning, 3 carers and a care supervisor in the afternoon and 4 carers and a care supervisor are available in the evening. Two staff covers the night time period with on call support being provided. The manager who is also present from 8.45am to 5.0pm from Monday to Friday also provides on call support. Although this is a busy home where due to the nature of the service resident numbers fluctuate, the general feeling amongst the staff was that the abovedescribed staffing levels are in the main sufficient to meet the needs of the residents although some of the staff did point out that at times when dependency levels increase that they are “a bit pushed” to meet everyone’s needs. Staff morale was good with staff saying, “we enjoy our work”, they also said “there is a good atmosphere here”. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 21 The residents said that the staff were “excellent”, “cheerful” and “supportive ” and a letter from a family said “thank you for taking such good care of my mum” and the “thank you for all the care and kindness shown”. A further letter said “couldn’t have asked for better care from such a wonderful group of people”. Of the 26 care staff employed at the home 20 have got a National Vocational Qualification at Level 2 or above with three other staff presently undertaking NVQ assessment at the same Level 2. This meets the requirement for the home to have 50 of the care staff with NVQ level 2 qualifications or above by the end of 2005. Recruitment records are held in Bolton Social Services personnel department. Periodically inspectors from the CSCI examine the records held centrally. The records examined during the last visit demonstrated that thorough preemployment checks had been carried out. All contained 2 satisfactory references, completed application forms, Criminal Records Bureau Check, verification of identity, and a signed declaration of physical and mental fitness. Discussion with the staff and looking at records showed that there is a strong commitment to staff training within Bolton Local Authority. The staff gave examples of the wide range of training that they had done. This included induction to the job training, NVQ assessment, the giving out of medicines, safe moving and handling, fire safety, food hygiene and first aid. The provision of this training was confirmed when looking at computerised staff training records. Good practice was noted in that the manager has developed a number of charts that are used to record staff training needs that are identified at individual personal development meetings. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 22 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 and 38. Quality in this outcome area is good. The manager is able and experienced and she manages the home well, therefore ensuring that the residents receive a good standard of care and residents’ views are listened to and acted upon, ensuring the home is run in their best interests. Procedures and practices within the home promote and safeguard the health, safety and welfare of the people living and working in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager is a qualified social worker (CSQW) and has extensive experience of running care homes for older people. She has also completed NVQ (National Vocational Qualification) level 4 registered managers award. The home is well run and discussion showed that the manager knows the residents and the staff well. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 23 The residents and the staff said that the manager operates the home in an open and inclusive way and that she is fair-minded, approachable and easy to get along with. A requirement of Standard 33 is that care homes must use quality assurance systems that are largely based on seeking the views of residents to measure their success in meeting the home’s aims and objectives. The home presently asks residents about what their experience is of using the home’s Intermediate Care Service. This information can then be used if necessary to bring about changes or improvements to the service. These people are therefore given a questionnaire at the time of leaving the home, which they are asked to complete and to return to the home by post. The answers are then regularly brought together and analysed and displayed in the home in the form of a report with good points noted and action being taken to deal with any issues raised. The report for October 2006 showed largely positive responses with the people surveyed being on the whole very satisfied with the care and services provided. A number of survey questionnaires were sent out to the residents, relatives and health workers (GP’s, district nurses etc) before the inspection. These questionnaires give these people the opportunity to comment upon various aspects of the services provided by a care home. At the time of writing this report 12 questionnaires had been returned; all of these were complimentary about the accommodation, the services and the care provided at Winifred Kettle. One person said “My stay this time has been very good, I thank all concerned for all their help” and another person said, “Meals are good (and) staff are friendly, its been 100 for me”. The home holds money for a number of residents for safekeeping. This system was checked with the details found to be properly written down and with the correct amounts of money kept. Secure storage is available for the safekeeping of money and of any valuable items. Information obtained from the pre-inspection questionnaire and from random checking of servicing records showed that the homes fixtures, fitting and equipment is properly maintained and regularly serviced. Looking at records and conversations with staff also showed that the necessary training had been provided so that they can work safely. The home is safely maintained with fire precautions tests done weekly and the details of accidents are properly recorded. Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 24 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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Winifred Kettle Community Care Centre DS0000031365.V312821.R01.S.doc Version 5.2 Page 27 - 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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