Inspection on 08/08/07 for Withy Grove Care Home

This inspection was carried out on 8th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Withy Grove Care Home 29/09/08

Withy Grove Care Home 29/07/08

Withy Grove Care Home 28/11/06

Withy Grove Care Home 26/05/06

Withy Grove Care Home 22/11/05

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

CARE HOMES FOR OLDER PEOPLE Withy Grove Care Home Withy Grove House Off Poplar Grove Bamber Bridge Preston Lancashire PR5 6RE Lead Inspector Mrs Marie Dickinson Unannounced Inspection 10:00 8 & 9 August 2007 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000065186.V343246.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. DS0000065186.V343246.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Withy Grove Care Home Address Withy Grove House Off Poplar Grove Bamber Bridge Preston Lancashire PR5 6RE 01772 337105 01772 620158 withy.grove@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited 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) Mrs Janet Elaine Plummer Care Home 54 Category(ies) of Dementia (24), Old age, not falling within any registration, with number other category (30) of places DS0000065186.V343246.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 54 service users to include: Up to 24 service users in the category of DE - (Dementia). Up to 30 service users in the category of OP - (Old Age, not falling within any other category). Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 15th May 2007 2. Date of last inspection Brief Description of the Service: Withy Grove House is a residential care home providing 24-hour personal care and accommodation for 30 older people who have care needs and 24 older people who have care needs associated with dementia. Withy Grove House is a converted Manor House, which is set in its own landscaped gardens adjacent to parkland. The home is in a predominantly residential area, but within easy walking distance of Bamber Bridge centre. Bus and train services can be accessed to larger towns, such as Preston, Chorley, and Blackburn. Bedroom accommodation is on the ground and first floors. All bedrooms are used for single accommodation and 29 have en-suite facilities. There is a passenger lift. Accessible toilets and bathrooms are located on both floors near to bedroom and living rooms. There are sitting and dining areas sited on both floors and across the car park from the home is a private lawn area where residents are able to enjoy activities, weather permitting. Information about the service is available from the home. Weekly charges range from £326 minimum to £386; privately funded £445. DS0000065186.V343246.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place on the 8th & 9th August 2007. The inspection involved getting information from an Annual Quality Assurance Assessment provided by the manager, staff records, care records and policies and procedures. It also involved talking to residents, staff on duty, the manager, and an inspection of the premises including resident’s bedrooms. Seven relatives and six residents provided written comments direct to the Commission giving their view of the services provided. The home was assessed against the National Minimum Standards for Older People. One additional visit had been made to the home since the last inspection. This visit was to monitor progress made to improve the quality of life experience in health and personal care, activities provided, complaints and protection issues, staffing levels, and environment for the people living at Withy Grove. What the service does well: Before people are admitted to the home their needs were assessed. They were consulted about the level and type of care they required and could visit the home to look for themselves at the facilities offered. Important information needed to support them in every day living was recorded and used to decide if Withy Grove could provide the right care and support by staff for them. Good care planning meant residents had their assessed and changing needs met in a way that was suitable to them. Residents benefited the support of a named worker, referred to as a Key worker who took responsibility to make sure care needs for individuals was personalised. Assessments linked well to care plans. These included health, personal and social care needs. The standard of recording was good giving staff clear instructions on how to support people in their daily lives. Staff caring for people with dementia had training in this specialist area of work. Medication practice, policies and procedures, and staff training, reduced the risk of errors being made. There were no rules in the home and routine was personal to each resident. Arrangements were made for representatives from different religious beliefs to visit residents as they wished. One relative described staff as ‘all very caring.’ Staff were described by residents as ‘very good’ and ‘work hard’. Residents DS0000065186.V343246.R01.S.doc Version 5.2 Page 6 were supported to keep in contact with relatives and friends. They had meetings to discuss what they would like to do and find out what was going on in the home. The complaints procedure was given to resident/relatives, and complaints were dealt with within agreed time scales. Adult protection was given a high profile with staff training and contractual arrangements to protect residents. Recruitment practices were thorough and protected residents. Residents generally had a good opinion of staff.’ Gender issues were considered by having male carers. The training provided for staff was very good. Systems were in place to approach residents/relatives to give their view on the quality of services and facilities in the home. Small amounts of money held on behalf of residents were managed well. What has improved since the last inspection? What they could do better: More accountability is required to make sure care is provided as outlined in residents care plans. This should reduce the risk of complaints being made of poor care practice. Those residents who are under the care of Nurse Practitioners should be made fully aware of their doctor’s practice in using this service. However residents DS0000065186.V343246.R01.S.doc Version 5.2 Page 7 request for a Doctor visit should be followed through, and a full explanation given if this is not possible Residents should be assured their doctor would visit if it were found to be necessary. This would help them to feel less anxious. The overall supervision and assistance given to residents at meal times must increase in order for residents to receive a balanced nutritious diet. The weight loss of residents must be more effectively monitored and managed. Activities for residents must improve and take into account their wishes and prevent people from being ‘bored’ and promote their wellbeing. The residential unit requires some up grading to improve the general appearance of lounge areas, corridors, and some bedrooms. Lighting in bedrooms must be improved to enable people to see things more clearly. To make sure staff are at hand at all times when needed, emergency pull cords must be made available for residents. Sluice rooms must be kept clean. This will help prevent cross infection in the home. Sufficient staff must be employed to make sure the safety and welfare of residents is considered at all times and their needs are properly met. A positive attitude should be taken when reviewing terms and conditions of employment to help keep a stable workforce. Requirements made to comply with regulation must be dealt with in a satisfactory manner. Systems should be in place to monitor practice and compliance with plans, policies, and procedures and make sure the home is run in the interest of residents. Those residents who have money deposited in Southern Cross Residents account have interest accrued paid to them. Consideration should be given to improving the homes monthly risk management audit sent to the area office of Southern Cross, that provides a more accurate account of risk management, particularly in relation to diet. 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. DS0000065186.V343246.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 DS0000065186.V343246.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information and opportunities to visit the home were given to people that helped them decide if the facilities and services could meet needs and preferences. Contracts issued, protected residents rights by informing them about the terms and conditions of living at the home. Assessments were completed properly which helped plan personalised care. EVIDENCE: Since the last inspection there had been a number of admissions. Records made during the admission process showed how the home managed this. The pre-admission assessment format was thorough and covered all aspects of personal, health and social care needs. In most instances both social care assessment and a homes assessment was completed. These contained sufficient details essential to plan the right care for individuals. DS0000065186.V343246.R01.S.doc Version 5.2 Page 10 It was the homes policy that before anyone is admitted they are given an opportunity to visit and look at the home and meet the staff. Sometimes this is not possible and a representative of the resident is invited to look around on their behalf. Information recorded on the pre inspection assessment completed by the manager showed all residents had been issued with a contract. Residents placed in the home by the local authority were given a contract for financial arrangements for payment. This was in addition to the service user guide, that outlined the terms and conditions of residency in the home. Those residents who were interviewed were unaware of the charges they paid to stay at the home. The general feeling was, residents did not want ‘to bother with things like that’, as their family dealt with this. Residents are informed of any increase in costs. How costs were paid was sorted out when people were admitted The range of needs of residents had been considered. Staff training programme-included full induction and essential training for example, moving and handling, and protecting vulnerable adults. Training staff was ongoing as part of staffs development in providing care. Specialist dementia care training was provided. Records kept, showed staff consulted other professionals such as visiting district nurses and consultant psychiatrist to support resident care. DS0000065186.V343246.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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans written for residents helped staff to provide the right personal care for residents, however care provided must be monitored to make sure residents are being cared for properly. Healthcare was monitored and residents were satisfied their care needs were met, and considered staff were respectful to them. Medication was managed safely. EVIDENCE: A brief record was made of residents past history. This helped staff to understand people as individuals, their likes, and dislikes. Each resident had a plan of care based on an assessment of needs. The new format for care planning was good, outlining identified need, action to be taken to meet needs, frequency, and person responsible. Resident’s wishes for daily living was recorded and provided sufficient detail for staff to follow and the assistance each resident required with personal care. For example ‘prefers a shower to a bath. Staff to ensure this is done at least once a week. Family will keep her DS0000065186.V343246.R01.S.doc Version 5.2 Page 12 supplied with toiletries’. Staff were also instructed to be mindful of peoples privacy. Staff worked to a key worker system, having responsibility to make sure care needs are personalised for residents. How care was provided needs to be monitored as a number of complaints had been received at the Commission about poor care practice. Resident’s benefited additional specialist support where needed. This included healthcare and mental health care need. Staff were directed to follow best practice when managing residents with dementia who for example became agitated. Pressure care was promoted and pressure-relieving aids were used on medical advice. Sustained weight loss must be managed better, as risk assessment by the manager did not provide appropriate action to be taken. Risk assessments had been completed for moving and handling and were used as guidance for staff to help care for residents safely. Some residents were not happy with the arrangements for doctor’s visits. The rights of residents to be treated with dignity and respect was included in staff training. Rresidents spoken to generally felt the staff respected their right to privacy and made complimentary remarks about the staff. Comments from relatives, however were varied. Respect for residents is not as it should be with issues around privacy. The home operated a monitored dosage system for the administration of medication. Information received at the Commission showed a number of staff had been trained in medication procedures. Records showed the receipt, administration, and disposal of medication. Resident’s doctors approved homely remedies for individual residents. DS0000065186.V343246.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home did not provide residents with a sufficient range of suitable activities that would meet their needs and expectations. Visiting arrangements were good. Residents were offered a balanced and varied selection of food, however resident supervision needs to improve. EVIDENCE: Although an activities organiser planned and presented activities and arranged outings, this still requires some development work. Activities in the home were not person specific for everyone. Residents stated they need to improve and focus more on what they wanted. The notice board showed what events were planned. Observations during inspection showed residents in the dementia unit attending the hairdresser and the walls were themed with activity boards. The residents’ preferences in respect of choice in relation to routines of daily living was recorded in care plans for example times for getting up and going to bed. For example ‘She will alert staff by using the nurse call bell when she wants to go. To promote a good nights sleep staff to offer her something to eat DS0000065186.V343246.R01.S.doc Version 5.2 Page 14 and a warm milky drink before she retires. Staff to check every two hours during the night.’ People were up for the day at different times and residents said there were no rules imposed on them such as when they went to bed or got up in the morning. They had their own routine personal to them. ’Residents considered staff gave them as much time as they could but said they were ‘always changing staff and new ones had to learn their routine.’ Comments from residents and relatives showed visiting arrangements to be satisfactory. They all felt they could see their relative in private. One relative visiting said he came every day and thought the staff were ‘marvellous’. He was always offered a drink and felt he could chat to the key worker involved in his relatives care. The residents made varied comments about the food such as ok and all right and good. There was a choice of meals offered and portions served were generous. Menus seen showed a varied diet was provided. Records were kept of meals served. Meal time in the dementia unit could improve as residents were very restless wating for the meal to arrive. This made it difficult for staff as residents became upset and agitated at disturbances and unrest. DS0000065186.V343246.R01.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. Residents and relatives/visitors had access to a complaints procedure. Complaints were dealt with properly. Staff were trained in Adult Protection and knew what to do to protect residents. EVIDENCE: There had been several complaints made to the Commission about the service provided. These had been dealt with properly. Two complainants criticised the attitude of management when raising issues of concern. One complaint was under investigation by the manager. Not all residents and relatives who sent written comments to the Commission said they knew how to make a complaint. However a copy of the complaints procedure was given to residents when they were admitted to the home, and a copy was displayed in the home for visitors to see. Most people knew whom they could speak to, such as ‘care staff and talk to a member of staff, ‘my son’. Residents said they had no complaints against the staff. Most were described as being ‘very good’. One relative visiting said he would know who to speak to if unhappy about anything, but up to present he had never had any reason to make a complaint, as the staff were very good. Information received at the Commission showed the managers response to abuse was dealt with efficiently and involved other agencies such as health and social care professionals. Staff working at the home said they were trained in DS0000065186.V343246.R01.S.doc Version 5.2 Page 16 adult protection and were aware of the abuse policies and procedures, which included whistle blowing. Staff confirmed they had regular contact with the area manager of Southern Cross and could approach her with any problem. Staff contracts precluded them from financial reward or assisting in or benefiting from the service users’ wills. DS0000065186.V343246.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment both internally and externally was adequate. There had been some general improvement to create a safe and attractive environment for residents living there. EVIDENCE: The home is a large adapted detached property set in its own grounds in a residential area of Bamber Bridge. The front of the home is next to a park boundary and a number of large trees gives the home privacy. Car parking is to the front of the home. Residents can sit outside at the back of the home during warmer weather. DS0000065186.V343246.R01.S.doc Version 5.2 Page 18 The home is divided into two units for residential and dementia care. Access to these units is via a controlled lock; push button to access and key pad to leave. Following a tour of the premises, the following observations were made. The dementia unit was clean and odour free. Adjoining doors in bedrooms in the dementia unit had handles removed to help prevent residents becoming confused as to which door to use. Furniture in some bedrooms had been replaced and there continues to be improvement since the last inspection. Not all bedrooms had emergency call leads attached. Lighting in the bedrooms was dull and required to be upgraded. Peoples names were on on doors, and doors were kept locked according to peoples wishes. The decoration in the dementia unit corridors was bright and corridors were themed for residents. The dining areas and lounges were pleasant and resident benefitted comfortable chairs in recesses off the corridors. Smoking areas was controlled. The residential unit still requires some upgrade in appearance but was adequate. The manager said a new carpet was being fitted in the lounge. The kitchen minor repairs ad been attended to and high cleaning was being managed. Residents were generally pleased with their accommodation. The laundry was well organised and clean. Laundry management was the responsibility of one staff employed specifically for this. Keeping the sluice facilities clean could improve to prevent the risk of cross infection. Temperature in the home was comfortable. The manager said the water temperatures were regularly monitored, and all the bathing facilities had controlled thermostats fitted for safety. Temperatures were set as given in guidance. DS0000065186.V343246.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The level of staffing was not satisfactory to make sure resident’s needs were satisfactorily met. Recruitment practices were good and protected residents., however the high turnover of staff did not provide residents with a continuity of care. Staff were trained to care for residents safely. EVIDENCE: The manager had maintained a written staff rota. These showed how the level of staffing was arranged to support residents needs being met. Both units were staffed seperately and consisted of a unit manager and senior carers. The numbers of staff employed however did not make sure the needs of the residents were being fully met. Observations made during inspection found staffing levels did not always meet with residents needs for example during meals. A large number of staff had left their employment since the last inspection. Reasons for leaving were recorded. This high turnover of staff did impact on residents confidence in the staff. Residents commented on this and thought that a regular staff team would be better as it takes time to get to know people. Relatives also commented on ways to improve the service by ‘having regualr staff. DS0000065186.V343246.R01.S.doc Version 5.2 Page 20 At the previous inspection an internal staff survey showed that the terms and conditions of work could improve. There was no indication this had been looked at or any improvements made. Staff on the units work long hours. Some staff liked this arrangement, as it meant they followed their work through. Residents considered the staff to be very good and looked after them well. They were always busy though and because of the constant change ‘you never know who will be helping you next.’ Residents liked the staff who worked at the home for a long time. The use of agency staff was kept to a minimal. There had been new staff employed and records showed good recruitment practice was carried out. Staff files showed recruitment checks to be complete. Satisfactory references and Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) register check had been applied for, prior to employment. The manager said these were held at head office. On appointment members of staff were issued with a contract of terms and conditions of employment. In addition to induction training, all staff were trained in essential mandatory training such as moving and handling. Senior staff were also trained in medication administration. Specialist training in dementia care was provided. New staff on duty were working their induction training. This had covered policies and procedures and basic care. Both said they were enjoying the work. Information received at the Commission showed that the percentage of staff having accomplished NVQ level 2 and above was over 50 . Staff had a written training assessment and profile which showed other mandatory training had been provided. The manager said further training had been planned. DS0000065186.V343246.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home was not always run in the best interests of residents. The health and safety of residents and staff was generally considered. EVIDENCE: Unit managers and senior carers managers are employed to support the registered manager to maintain a management presence in the home at all times. The manager is qualified and experienced to run the Home. Part of her role is to manage within the corporate business plan and budget for the home. Southern Cross Limited as Registered Provider have overall responsibility and senior management visit the home unannounced every month; looks at DS0000065186.V343246.R01.S.doc Version 5.2 Page 22 records, interview staff and residents, and send a report of this visit to the Commission. The manager has responsibility to make sure staff are competent and knowledgeable to care for the residents. However more development is needed to make sure monitoring practice and compliance with the plans, policies, and procedures of the home is efficient. Quality assurance systems are in place, such as using questionnaires. Relationships between the management and staff had improved, however more attention should be made to customer care. Written comments from relatives in relation to what the home does well included, ‘the home could improve by ‘providing regular staff’. Not all requirements made at the last inspection have been addressed in a satisfactory way. Southern Cross Limited promotes equal opportunities for staff and residents. Staff meetings were held, and staff had regular formal supervision to monitor staff and help them develop professionally. Residents had meetings and relationships between staff and those living in the home were observed as positive. Insurance cover was in place to meet any loss or legal liabilities. The home encouraged residents/relatives to manage their own financial affairs. Residents who are able manage their own finances continue to do so. Some money was managed for residents wanting this service. Records were kept of transactions made on behalf of people providing a clear audit trail. If a large amount of money accumulated belonging to individual residents this was transferred to a corporate bank account. The manager said that interest was not payable on this account to residents. There was a set of policies and procedures, and according to written documentation sent to the Commission, these had been reviewed in line with current good practice and legislation. To make sure staff read and understand these documents they are included in staff meetings and supervision. The health, safety, and welfare of residents and staff had been considered. The home had a good range of policies and procedures and practice aimed at keeping everyone safe. Risk assessments however should be completed to take into account planning the care and routines of the home. Written working procedures and training opportunities were available to support development of good care practice. All new staff members were receiving induction and essential training. Arrangements had been made for some essential mandatory training to be renewed. Information received at the Commission indicated that essential services such as gas and electricity were regularly serviced. The storage of cleaning products DS0000065186.V343246.R01.S.doc Version 5.2 Page 23 was satisfactory. Management kept the Commission informed throughout the year of significant events and occurrences. DS0000065186.V343246.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 2 2 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 3 2 3 3 2 DS0000065186.V343246.R01.S.doc Version 5.2 Page 25 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 2 Standard OP7 OP8 Regulation 12(1)(a) 13(4)(c) Requirement The manager must make sure care as outlined in residents care plans is provided. Risk analysis and action required for the management of sustained weight loss, must be dealt with better for residents well being. Activities should be made available for all residents to meet their individual needs in relation to promoting their wellbeing. Timescale 26/06/06 and 04/06/07 not met. Residents requiring assistance at meal times must be given proper care and supervision. 01/09/06 Lighting in bedrooms must be improved. Emergency pull cords must be made available for residents at all times. Sluice rooms must be kept clean. Sufficient numbers of staff must be employed for the health, welfare, and safety of residents. Previous timescale 07/07/06 and 04/06/07 not met. The registered manager must in relation to the conduct of the DS0000065186.V343246.R01.S.doc Timescale for action 28/09/07 28/09/07 3 OP12 16(2)(n) 28/09/07 4 5 6 7 8 OP15 OP23 OP24 OP26 OP27 12(1) (a)(b) 23(2)(p) 16(2)(c) 16(2)(e) 18(1)(a) 28/09/07 28/09/07 28/09/07 28/09/07 26/10/07 9 OP33 12(5) 28/09/07 Version 5.2 Page 26 home maintain good personal and professional relationships with residents/representatives. 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 2 3. 4 5 6 Refer to Standard OP8 OP19 OP27 OP32 OP35 OP38 Good Practice Recommendations Residents request for a Doctor visit should be followed through and a full explanation given if this is not possible. The residential unit requires some up grading to improve the general appearance of lunge areas, corridors, and some bedrooms. It is recommended management take a positive attitude to the terms and conditions of staff employment. It is recommended a system be in place to monitor practice and compliance with plans, policies, and procedures. It is recommended residents be paid interest on money deposited in Southern Cross Residents Bank account. Consideration should be given to improving the homes monthly risk management audit sent to the area office of southern Cross, that provides a more accurate account of risk management, particularly in relation to diet. DS0000065186.V343246.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 DS0000065186.V343246.R01.S.doc Version 5.2 Page 28 - 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. 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