Inspection on 09/03/07 for Z & M Care

This inspection was carried out on 9th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

Z & M Care 24/10/05

Z & M Care 01/06/05

Z & M Care 23/11/04

Z & M Care 24/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

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

CARE HOMES FOR OLDER PEOPLE Z & M Care 8 Lyndhurst Road Hove East Sussex BN3 6FA Lead Inspector Linda Boereboom Key Unannounced Inspection 9th March 2007 13:00 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 Z & M Care DS0000014211.V331264.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. Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Z & M Care Address 8 Lyndhurst Road Hove East Sussex BN3 6FA 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) 01273 323814 01273 748172 Lyndhurstcarehomes@hotmail.com Z & M Care Limited Mrs Zara Fatemeh Moussavi Care Home 37 Category(ies) of Learning disability (20), Old age, not falling registration, with number within any other category (37) of places Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is thirtyseven (37). Service users accommodated will be older people of which twenty (20) may have a learning disability. Service users will be aged sixty (60) years and over on admission. That the home may admit one named service user who is under the age of sixty-five (65) years of age. 24th October 2005 Date of last inspection Brief Description of the Service: Z&M Care older peoples unit is registered for 37 residents, 20 of whom have a learning disability. Z&M Care also have an adjacent and integral group home, which is registered for 7 adults (18-65) years with a learning disability. They are inspected as separate homes, this report if for the home for 37 Older People aged over 65 years. The home is part of an Edwardian terrace that has been extended to meet the needs of its residents. It is situated in a quiet residential road near to the busy Seven Dials area of Brighton and Hove City that has facilities for shopping, including a bank and post office, cafes and a restaurant. There is a corner shop almost opposite the home where the shopkeeper knows many of the residents who are able to go out independently. The home is close to both Brighton and Hove mainline stations. Parking is available in the roads near to the home and is either resident parking only or via a meter system for up to 4 hours at any one time (total cost £2) at the time of this inspection. The Registered Provider also has designated car parking spaces for the disabled outside. Public transport is available locally to all parts of the city. The area is well served for parks, churches, pubs and leisure activities including the Sussex County Cricket Ground. The home has the Investors in People Award and the Clean Food Award. The main ethos of the home is to provide the residents with a homely environment and to promote independence; both the Registered Manager and staff are proactive and committed in giving residents encouragement and support in achieving this goal. Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Z & M Care will be referred to as ‘residents’. This inspection was unannounced and took place in conjunction with the home for young adults that is also owned by Z & M Care and is part of the same building, although run separately and inspected independently. The Inspector was able to speak to a large number of residents, either in a group or individually, and four staff excluding the Registered Provider/ Manager Mrs Moussavi, and the Deputy Manager Mr Jess Marsden, who helped with the inspection. Ten resident surveys and care staff surveys were sent out randomly by the Commission for Social Care Inspection prior to the inspection and at the time of writing this report seven resident surveys had been returned. Comments made in the surveys and to the Inspector during the Inspection have been reflected throughout this report. The Inspector discussed the outcome of the inspection with the Registered Provider/Manager and Deputy Manager as the inspection progressed and again during the evening at the end of the inspection. During the inspection the Inspector also spoke with three relatives of residents in the home, and two care workers who worked for agencies outside the home and visited regularly to take residents out. The cost of care in the home varies from £350 - £1035 a week depending on need, with the majority of residents being funded by Brighton and Hove Council; items not covered by the fee include hairdressing, chiropody, some activities, some toiletries, personal shopping and newspapers. The Inspection was both enjoyable and positive and the Inspector would like to thank Mrs Moussavi and Mr Marsden, the care staff and residents for their helpfulness and hospitality throughout. What the service does well: Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 6 The staff at Z & M Care continue to provide a good service to the residents in pleasant and homely surroundings. The Registered Provider/Manager and her team provide care in a friendly and relaxed atmosphere taking into account the needs of individual residents, helping them to be as independent as possible. Leadership in the home is good, the Registered Provider/ Manager has an ‘open door’ policy to her office and makes sure staff are well informed about each resident and staff views are listened to not only on the progress of each resident but on the running and organisation of the home. She also works with the care staff throughout the day to promote good practice and communication. Care staff told the Inspector that they felt extremely well supported in their work and they are encouraged to treat all residents as family members; one relative told the Inspector it was ‘home from home’ where the staff were lovely and nothing was too much trouble. All residents spoken with said they found staff very kind and polite and more than one said ‘we have a good laugh’. What has improved since the last inspection? What they could do better: All issues arising from this inspection were fully discussed during the process and as agreements were made the Inspector decided there would be no need for requirements. Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 7 The Registered Provider/Manager and Deputy Manager agreed to provide more training for care staff in dementia as this was something they felt necessary to help them in their role. The future of the redundant and aged assisted bath in one of the upstairs bathrooms was also discussed and it was agreed that the Registered Provider/Manager would look into replacing this with a more suitable shower unit to provide more space and make a more congenial room for residents to use. It was agreed she would ensure that any resident preferring a bath would be helped to use one of the other bathrooms in the home. 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. Z & M Care DS0000014211.V331264.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 Z & M Care DS0000014211.V331264.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): 1,2,3,4,5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a statement of purpose and service user guide that is available for residents and relatives; in addition the home ensures the latest inspection report is also available. There is a procedure in place for residents to be properly assessed before admission and residents are invited to visit the home before making a decision to move in. The home is not registered to provide intermediate care. EVIDENCE: Z & M Care has sufficient information for residents and their relatives to read that is available in the home with the latest inspection report. The Care Manager takes responsibility for all the pre-admission assessments and at that time she verbally gives information about the home and offers prospective residents written information. Prospective residents are offered the Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 10 opportunity to visit the home prior to admission to enable them to meet the other residents and staff before making a decision to move in. During the inspection the Inspector was aware of two telephone conversations between senior staff and relatives arranging visits for the following week. Pre admission care needs assessments are undertaken by the Care Manager, who has a nursing qualification, and used in conjunction with the Brighton and Hove Council assessments to provide the basis for care planning throughout each resident’s stay in the home. Staff confirmed they are given training in specialist areas should it be necessary. Two visitors spoken with by the Inspector confirmed their relatives had been assessed prior to moving in and had been given sufficient information. Although the home is not registered for intermediate care the Registered Provider/Manager said that sometimes residents move in for a short while following hospital discharge to gain strength and confidence before returning home again. When the Inspector spoke with residents and looked at the surveys the following comments were made; ‘I had been to the home several times before I decided to stay’ ‘I visited the home often before I decided to move in’ and ‘I lived up the road so I knew the place well. I knew exactly what I was moving in to’ Z & M Care DS0000014211.V331264.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 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home delivers a good quality of care that is well documented. All residents’ have an individual plan of care that is well maintained. Trained staff take care with the administration of medication. Residents are treated with respect and their privacy acknowledged. The home is empathetic to the care of residents nearing the end of life. EVIDENCE: The home has a senior care officer who takes full responsibility for the care planning and reviews. Care plans are formulated following admission and are reviewed monthly. During the inspection the Inspector spoke with residents about their care needs and all said they felt their needs were being fully met, relatives later supported this. The Inspector noted that residents are weighed monthly, blood tests are taken routinely for residents whose medication Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 12 requires regular blood tests and staff are trained to take blood pressures and blood sugars where appropriate. Staff confirmed they are given relevant specialised training and during conversation with the Inspector, one member of staff said the Registered Provider/Manager was pro-active in helping staff with training to allow them to do their job properly. The home has a key worker system in place to enable staff and residents to form good relationships and communication. The Inspector spoke to residents and asked if staff were friendly and polite and all confirmed they felt respected and were well treated, later relatives agreed this was so. The Inspector noted throughout the day in the home that staff spoke pleasantly and kindly and knocked on doors before entering. One resident commented ‘the staff always listen to me’ and another told the Inspector ‘ because the staff are busy it is difficult for them to have time for everyone but I think they manage well’. Residents have access to all services within the National Health Service locally and arrangements are made for them to be accompanied for GP and hospital appointments. Medication is only administered by five specifically trained staff, this was confirmed by the Deputy Manager and written in the pre-inspection questionnaire sent out by the Commission for Social Care Inspection prior to the inspection taking place. Medication is kept in a locked cupboard with a separate internal cupboard for any controlled medication. Residents who self administer and look after their own medication are risk assessed to do so and the Inspector was able to speak with one and discuss the process with her. She told the Inspector that staff monitored the medication and were always on-hand if she required help. Staff are trained in the uses of medication and the home uses either Brighton and Hove Council training department or a local pharmacist. The Inspector checked the procedure for recording of medication should a resident be away from the home on an outing and was satisfied this was addressed. The home has a death and dying policy and residents are able to die in the home with the support of the care staff and relatives as long as the home can fully meet their needs. Often support is sought from the local District Nursing Teams in the area. The Deputy manager told the Inspector that the policy was under –review. The Inspector read a letter from a local GP, which read; ‘I was very pleased that a former resident was able to die peacefully in this home, it was a kind and decent decision to let home stay there and he was well tended…The staff clearly demonstrated they can look after dying patients very well indeed’. Z & M Care DS0000014211.V331264.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home are encouraged to maintain contact with family and friends, who are made welcome and encouraged to visit. Care staff provide regular activities for those residents who wish to participate and are pro-active in providing residents with a social environment that they enjoy. Residents have choice in their everyday lives and benefit from a varied and balanced diet. EVIDENCE: Residents in the home are actively encouraged to socialise and the Inspector noted during this inspection as with other unannounced inspections in the past that many of the residents were downstairs in the dining room, sitting room or smoking room and few chose to be alone in their individual rooms. Those residents who are able to go out are risk assessed to do so. The home has a member of staff who frequently takes residents out for shopping trips, to the local park or for coffee locally. One relative told the Inspector that residents Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 14 are always ready when they are being picked up to go out, they are always well dressed, clean and tidy. For those who stay at home there are activities organised. These were listed in the pre-inspection questionnaire prior to the inspection and include, bingo, knitting and jig saw puzzles. Surveys returned to the Inspector did confirm that some residents prefer to sit alone and this is respected. The home has multi racial care staff and the Inspector spoke with them about the different needs of residents from different cultural backgrounds. They showed empathy and understanding and said the Registered Provider/Manager was committed to everyone living happily together especially as the home has residents with varying degrees of special needs. The home has a smoking lounge for those who wish to smoke however the Registered Provider/Manager and Deputy Manager told the Inspector this would be reviewed later in the year when the no-smoking legislation changes and, arrangements will be made to enable residents to smoke outside the home in a sheltered place. Residents fund their own holidays that are arranged jointly between the home and local charitable organisations. The Inspector observed residents going out either alone or with relatives. Brighton and Hove City Mission and someone from the local catholic church visit the home to provide any spiritual requirements residents may have, with one resident being collected by church transport to enable him to attend church services. All residents are risk assessed for their activities. The ethos of the home is to provide a home from home environment and help residents to be as independent as possible. Relatives told the Inspector they are always made welcome and offered refreshments. In the sitting room there is an area where residents can make their own drinks and those that do so had been risk assessed to use the kettle. Residents have person-centred plans to ensure they are completely involved in the decision making around their everyday life. The system is also used for residents in the Learning Disability home but in a different format. The Inspector received positive comments about the food and noted that residents had a varied evening diet with the majority choosing to eat together in the main dining room. The Inspector saw that menus are posted daily and one resident said ‘the food is good and the cook makes sure there is a choice and will change it to suit!’. One relative told the Inspector that the resident she visited liked the food and had put on weight, looking so much better. The home has the Clean Food Award and now uses the Safer Food, better Business Working File. The last environmental check had taken place within the six months prior to the inspection. Z & M Care DS0000014211.V331264.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): 16,17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home are protected by the home’s attitude towards complaints and staff have an awareness of protecting staff from potential abuse. Residents are able to participate in the process of voting if they so wish and information on advocacy services is made available to them if necessary. EVIDENCE: The pre-inspection questionnaire sent to the home prior to the inspection was returned to CSCI saying there had been one complaint and no incidences reported since the last inspection. The Registered Manager was aware of the need to record all concerns and complaints no matter how minor. The Inspector was satisfied that the senior staff in the home communicated well with both CSCI and Brighton and Hove Council if they felt concerns were being raised by or on behalf of the residents. Prior to the inspection the CSCI received an anonymous telephone call from a person raising concerns about the home relating to the quality of food and attention to care when a resident fell outside the home. This was discussed in full between the Registered Provider/Manager, Deputy Manager and the Inspector and the areas of concern looked at. Records in the home showed the concerns were not substantiated and appropriate action including a visit by the emergency services had Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 16 occurred. The Inspector looked at the menus, checked food bills and spoke to residents and relatives about the quality of food. All were very happy with the meals provided as reflected in the previous quality area of this report. The home has the postal voting system in place and residents, if able, are assisted in visiting the local polling station should they prefer to do so. The Inspector spoke with staff about the protection of vulnerable adults and they confirmed having received training. Adult abuse is covered in the basic induction programme then followed through with training by Brighton and Hove Council Training department, however the Deputy Manager told the Inspector there is often a long waiting list. The Inspector interviewed three staff and gave them a protection of vulnerable adults scenario, all showed a common sense approach and were clear on who they should report to and what the outcome might be. They were aware of the latest guidelines relating to the investigation process of an adult protection incident. Z & M Care DS0000014211.V331264.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): 19,20,21,22,23,24 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The maintenance person and management staff for Z & M Care makes sure that attention is paid to any work, inside or out to maintain the safety and comfort of the residents and staff. The home has sufficient lavatories and washing facilities and each resident has a room that suits their individual needs. The home is kept clean and tidy and is equipped to maximise the independence of residents. EVIDENCE: The Inspector noted during the inspection that requirements from the last report relating to the environment had been addressed. Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 18 The inspector saw a maintenance book used by the home with an improvement plan, which included general repairs, improvements to some bathrooms and toilets and on-going decoration to the individual bedrooms. The Laundry room had been completely refurbished since the last inspection and a ramp in place to replace steps on the first floor making the area accessible to wheelchair users from the lift exit, also on the first floor. The Registered Provider/Manager told the Inspector that planning permission had been refused to extend the lift shaft from the first to second floor of the home and plans are now in place to install an appropriate chairlift. An occupational therapy assessment was undertaken within the eighteen months prior to the inspection, however any resident requiring specific aids or adaptations would, the Deputy Manager said, be referred to the OT department at the local hospital. The Inspector spoke to both residents and relatives about their views on the home and whether they thought it was kept clean and tidy. Comments were also made in the resident’s surveys, overall they included ‘regular cleaning is obvious when one comes in’, ‘I am happy with my room being cleaned everyday’ ‘I think the home is kept very clean’ and ‘The staff try hard to keep the home clean’. During the inspection the Inspector and Deputy Manager toured the premises and discussed one of the shower rooms housing an old ‘assisted bath’ that is no longer used by residents. They concluded that to make the room more pleasant and accessible for residents the removal of the bath and installation of a complete shower unit would solve the damp and space problems. The Inspector outlined the importance of residents who preferred a bath still being able to have one in one of the other bathrooms. The Registered /Provider Manager said she would address the matter and let the Inspector know the outcome. The Inspector visited some resident’s rooms and found them all to be individualised, clean and tidy with evidence of residents being surrounded by their own pictures, ornaments and flowers. Z & M Care DS0000014211.V331264.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment practice is thorough and protects residents as far as it is able. Care staff undertake mandatory training in addition to being offered NVQ training thus ensuring they are competent in the work they do and care they offer to residents. On the day of inspection the home appeared to be adequately staffed. EVIDENCE: Each day the Registered Provider/Manager is on duty with the Deputy Manager they ensure one or the other is always on duty to cover weekends and time off. In addition to this there are five carers on duty each day including the Care Manager who is also a qualified nurse. The home also has staff with nursing backgrounds employed as care workers and a doctor of medicine from another country who is taking his exams to enable him to transfer and work in the UK. The cleaner and cook are in the home daily and the maintenance person works on a part-time basis. On the day of the inspection the home appeared to be well staffed. Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 20 All staff receive induction and mandatory training with 100 of staff either having achieved or are attaining NVQ level 2 and 3 with some going on to take NVQ 4. The Care Manager is currently taking the registered manager’s award. The Inspector spoke to staff about their training and they said they would like more training in dementia to help them in their work. The Inspector later spoke of this to the Registered Provider/Manager who said she would address the issue. One member of staff told the Inspector that the Registered Provider/Manager was very enthusiastic, especially in helping staff with training’. The home was awarded by a local training college the Company of the Project award, which ran from 2004-2006 for their commitment to NVQ training. The Registered Provider/Manager also received an award for her input into training staff. The home has a thorough recruitment process in place and staff are asked to complete application forms and supply at least two references. They all undertake CRB (Criminal Records Bureau ) checks prior to employment. Staff confirmed this when speaking to the Inspector and all were aware that the checks could not be transferred from one home to another outside Z & M Care. Z & M Care DS0000014211.V331264.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): Quality in this outcome area is (excellent, good, adequate or poor). This judgement has been made using available evidence including a visit to this service. The home is well managed and the outcomes for residents’ are good. The home has systems in place to ensure it runs smoothly and residents are safeguarded by accounting and financial procedures. Residents and staff are protected by the home’s attitude to health and safety and are involved and included in the running of the home. EVIDENCE: Requirements from the last inspection had been addressed. The Registered Provider/Manager is fully involved in the running of the home and is on-site daily with cover provided during the weekends, staff confirmed Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 22 this. She has the support of the Deputy Manager and the Care Manager. All are experienced in care of the elderly and suitably qualified for their roles within the home. During the time the Inspector was in the home residents and relatives continually popped in to speak to the Registered Provider/Manager to discuss something or just to say hello. The Registered Provider/Manager is committed to providing staff with training and encouraging good communication between the management, staff and residents. The Inspector spoke to staff about the support they receive and was told they attend regular staff meetings to which a resident’s representative is invited. Staff are included in helping form the agenda and are asked to attend meetings six weekly. The Deputy Manager told the Inspector that management meetings take place prior to the staff meeting to discuss the agenda and any extra information that needs to be passed on. Residents meetings take place in the dining room on a three monthly basis. The past year has seen the introduction of annual meetings for family and friends, where they are invited for afternoon tea with the chance to discuss any comments, complaints and concerns. Matters raised are referenced in the annual quality assurance report. The Inspector was shown minutes of the meetings. The home has its own quality assurance system in place that was shown to the Inspector. The collated outcomes were filed away to be viewed at inspection. Questionnaires are sent out to residents, relatives and healthcare professionals involved with the home. They are given out in –person and collated fro the home’s information to help staff continue to provide a good service. The Inspector also saw letters of appreciation from relatives and residents, one commenting on the thoughtfulness of the staff in replacing a skirt that had become spoiled. The home has the Investors in People Award. The Registered Provider/Manager told the Inspector that an accountant is employed to ensure the home’s financial stability with her taking the major role in ensuring it is financially viable. Insurance policies were on view along with the CSCI registration certificate and awards for staff training that are also evident in other parts of the home. All residents have their own inventory of furniture and possessions on admission and the Registered Provider/Manager confirmed that residents money is dealt with by relatives or advocates and records are kept of any personal allowances residents have; these were seen by the Inspector. All other records in the home are kept in locked cupboards and the office is locked when the senior staff are working in the home. Staff and resident information is not kept on the computer data base within the home. Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 23 The inspector spoke to the Deputy Manager about the new fire legislation, he takes full responsibility for health and safety within the home ensuring staff receive training and instruction in Moving and Handling, food hygiene, fire safety, control of infection and first aid. The home has three appointed persons for first aid in addition there are currently two qualified nurses on the staff. The Deputy Manager undertakes all risk assessments on the environment and ensures records relating to health and safety are kept up to date; in addition he reviews all the home’s policies and procedures and included details of this in the pre-inspection questionnaire. The home has an accident book in place that is used for all accidents on-site. The Deputy Manager and Inspector discussed accidents happening outside the home to residents and decided they would also in future be entered in the accident book in addition to in the resident’s own care notes. One person spoken with by the Inspector who regularly visits the home to take a resident out said ‘the home is pleasant place to be, the staff and management are great and take very good care of everyone’, she followed this by saying ‘it is nice to be part of something doing so good for people’. Z & M Care DS0000014211.V331264.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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 3 3 4 3 3 Z & M Care DS0000014211.V331264.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 Z & M Care DS0000014211.V331264.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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