Inspection on 04/08/06 for Zetland Court

This inspection was carried out on 4th August 2006.

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

The inspector 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

Zetland Court 21/05/07

Zetland Court 17/01/06

Zetland Court 06/09/05

Zetland Court 31/01/05

Zetland Court 14/07/04

Zetland Court 30/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Zetland Court 128 Alumhurst Road Westbourne Bournemouth Dorset BH4 8HU Lead Inspector Debra Jones Unannounced Inspection 4th August 2006 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000020457.V307867.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. DS0000020457.V307867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Zetland Court Address 128 Alumhurst Road Westbourne Bournemouth Dorset BH4 8HU 01202 769169 01202 764980 zetland@rmbi.org.uk arichards@rmbi.org.uk Royal Masonic Benevolent Institution Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Miss Tina Beament Care Home 63 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (58) DS0000020457.V307867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate a maximum of 13 service users who require nursing care. The home may accommodate up to 5 service users in either category DE (E) or MD (E) at any one time. 17th January 2006 Date of last inspection Brief Description of the Service: Zetland Court is a large care home for older people registered to accommodate up to 13 people who require nursing care and up to 5 people who have past or present mental health disorders or dementia. The home has 63 places altogether. The home is one of 18 run by the Royal Masonic Benevolent Institution (RMBI) and provides accommodation and care for older freemasons and their dependants. The home receives substantial support from their Association of Friends. Zetland Court is situated in the Westbourne area of Bournemouth, close to local shops and transport links to the centre of Bournemouth. The home was originally a summer home for a local landowner and has landscaped gardens leading down to the cliff tops. The communal areas of the home are on the ground floor and include a large and a small lounge, a library and a billiard room as well as a large dining room. The lounge and library overlook and provide access to the rear garden. The home has two pet cats, 2 cockatoos and 2 budgies. The building is on 4 floors with a passenger lift enabling easy access around the home. A call system is installed in all rooms. Meals are prepared on the premises. The weekly charge for living in the residential area is between £489 and £595. In the nursing and mentally frail area the charge is £750. DS0000020457.V307867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 days and was the anticipated key inspection of the year. There were no requirements or recommendations made at the last inspection to follow up and only two were made at this. The home was alerted to the recent amendments to the Care Home Regulations relating to contracts, quality and improvement plans. During the inspection some records were looked at. The Inspector walked around the building and met and chatted with a few residents. Tina Beament (Registered Manager) and her staff helped the inspector in her work. Zetland Court continues to be well managed and has a sustained track record of high performance. Prior to the inspection the home sent out comment cards on behalf of the Commission to people living in and interested in the service so that they could give feedback about their experience of the home. 18 were returned from residents and 6 from relatives. All comment cards returned were positive about the staff and service provided at Zetland Court and all said that they were satisfied with the overall care provided there. ‘If all homes were run as Zetland Court all elderly people would be well looked after’ (a resident) ‘Having been a resident for four years I have found I made the right choice, as the home is friendly and provides a happy safe haven for the residents, where their ‘individuality’ is respected, and choice of activities provided give stimuli shared with other residents. Visitors are always welcomed and we enjoy our pets (my own, the homes or visitors pets).’ (another resident) ‘I am very happy here. I have been here 13 years and feel like one of the family.’ (another resident) ‘Everyone has been so kind to me – no regrets coming here.’ (another resident) ‘In my opinion one could not wish for a better home. Zetland Court and staff together with care and excellent food, combined with outstanding cleanliness, must surely be the very best.’ (a relative) ‘The staff are generally friendly and attentive and my husband is happy here.’ (another relative) ‘Excellent attentive, concerned, caring, helpful, gentle. (another relative) DS0000020457.V307867.R01.S.doc Version 5.2 Page 6 What the service does well: Zetland Court provides an excellent service for older people in a well decorated home that is furnished to a high standard. The home has a welcoming, tranquil and relaxed atmosphere and residents are clearly at ease. The home is well organised and the care and contentment of residents is at the heart of the way the home is run. A good admissions procedure is in place that ensures that only people whose needs can be met are offered places at the home. Prospective residents and their representatives have the opportunity to visit the home to see if they like it before they move in. Assessments and care plans are of a high standard. They are thoroughly completed and regularly updated to make sure that staff know how to care for the residents living at the home. A range of community health professionals support the nursing and care staff in caring for residents. There is a good system for medication administration at the home. Staff were observed throughout the inspection to be treating residents with courtesy, patience and kindness ensuring that the privacy and dignity of residents is respected at all times. There is a good programme of activities on offer at the home that residents can join in with if they choose to. Visitors are always welcome and residents are encouraged to maintain and develop relationships with people in the home, with their families and friends and in the local community. Meals are varied and a choice is always available. Dining rooms are very pleasant and comfortable. The complaints and adult protection procedures reassure residents and their representatives that the well-being and comfort of residents is important to the home and that any concerns raised will be properly investigated and resolved. The home and grounds are very well maintained, comfortable and safe for the residents living there and anyone visiting. The home is kept clean and smells pleasant. The numbers and skill mix of staff are sufficient to meet the needs of residents. Staff are appropriately qualified and well trained in nursing and care work. DS0000020457.V307867.R01.S.doc Version 5.2 Page 7 Records relating to staff recruitment are of a high standard with all information required being held on file ensuring that only suitable people are employed there. Every year the home carries out a quality assurance survey to find out more about what people with an interest in the home think about it. Any areas for improvement highlighted by this survey are then addressed. Residents can be assured that if they wish the home to look after money for them this will be done in a responsible and professional manner. Systems are in place and records kept, that demonstrate the homes commitment to keeping residents safe. What has improved since the last inspection? 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. DS0000020457.V307867.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 DS0000020457.V307867.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good admissions procedure enables prospective residents to make informed decisions about admission to the home and ensures that only residents whose needs can be met by the home are offered places there. EVIDENCE: Files for residents who had recently moved into the home were inspected. These showed that the home has a good procedure in place. Prior to anyone moving to the home their needs are fully assessed by a senior member of Royal Masonic Benevolent Institution staff. It was clear from the assessments where information had come from and who had been involved in the assessment. Where prospective residents live a long way from the home a Royal Masonic Benevolent Institution assessor from another part of the country visits them to DS0000020457.V307867.R01.S.doc Version 5.2 Page 10 carry out the assessment. The assessment is then passed to the Zetland Court manager who makes all decisions about offering places. Prospective residents are given the opportunity to visit the home, as are their representatives. One prospective resident had visited the home with her son between the inspection days. The opportunity was taken to carry out her pre admission assessment at this visit. Another resident had recently had to spend time in hospital and her needs had changed. A new assessment was carried out to ensure that on her return the home was prepared to meet her new needs. The home does not confirm in writing to prospective residents that following the pre admission assessment the home can meet their needs. 16 of the 18 residents who returned comment cards said that they had enough information before they moved in to the home to decide if it was the right place for them. ‘by being able to enjoy periods of ‘respite breaks’ over three years my husband and myself were able to find out what it would be like to like at Zetland Court, before we asked to become residents; a happy decision for us both.’ (a resident) Ten remembered being issued with contracts. ‘A detailed contract as to what the Royal Masonic Benevolent Institution are contracted to provide and information as to what the residency is also contracted to do, together with a ‘complaint procedure; should a resident wish to complain about any issue.’ (another resident) DS0000020457.V307867.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good care planning system in place to make sure that staff have the information they need to meet the needs of the residents. The health needs of the residents are also very well met with evidence of good support from community health professionals. The medication at this home is generally well managed promoting the good health and well being of residents. Residents are treated with dignity and their privacy is respected. EVIDENCE: Care plans seen were of a high standard and echo the ethos of the home to provide total care to the person and treat them with respect and dignity. Plans flow from the extensive range of assessments carried out by the home. Plans are easy to read and informative about the needs of the resident and how the home is to meet their needs. Care plans are backed up by appropriate risk assessments and the action to be taken where risk is identified is clear. DS0000020457.V307867.R01.S.doc Version 5.2 Page 12 In addition to the regular reviews of care plans and assessments care plan documentation relating to each resident is thoroughly audited monthly by senior members of staff. Records are kept of the reviews and findings. Daily notes support and evidence the delivery of care to residents. These notes give a good picture of the daily lives of residents and the care that is delivered to them by staff in the home. Information from these notes feeds into the care plan reviews. When asked ‘do you get the care and support you need?’ 9 of the 18 residents who returned comment cards prior to the visit replied ‘always’ and 7 ‘usually.’ When asked ‘do the staff listen and act on what you say?’ 16 residents said ‘yes.’ With added comments ‘most of the time,’ ‘usually.’ ‘occasional exceptions.’ All the relatives who responded by comment card said that they were informed of important matters in respect of their relatives and consulted about their care where appropriate. Records are kept of the interventions of health professionals e.g. GPs, chiropodists etc. A GP holds a weekly clinic at the home. Residents can choose to visit their Doctor at the community surgery if they prefer. Arrangements are made for any new residents to see a Doctor when they move into the home. In the nursing area of the home staff ensure that residents see a Doctor at least every three months. Residents also have access to community services such as chiropodists, dentists and opticians. Specialist services and advice are also accessed e.g. advice re diabetes and wound care. Nutritional assessments are carried out and residents are regularly weighed to monitor their weight. Eleven residents who returned comment cards said that they ‘always’ received the medical support they needed, four said this was the case ‘usually’ and one ‘sometimes.’ ‘ Dr XXX always listens to what one says.’ (a resident) Care plans include a section on medication. Medicines and dressings are tidily stored in appropriate places. Medication administration records (MARs) sampled were up to date and were in the main properly completed. Photographs of residents are kept with the MARs along with sample signatures of staff administering medicines. In the residential care ‘any allergies known’ were clearly recorded on the MARs, and where there are none known this is noted. Records were clearer than at the last inspection as to what time of day medicines are to be given e.g. not just ‘morning.’ Some MARs were not completed with the quantities of medicines received in blister packs. A couple of packs in the residential area were found to have either a tablet more than expected or one less. The records could not explain DS0000020457.V307867.R01.S.doc Version 5.2 Page 13 these anomalies. Where one resident was taking certain tablets ‘when required’ it was clear from the records how many had been administered but not how many should be left in the home. In the nursing area medicines sampled, both in blister packs and in boxes, accorded with the MARs. Where staff had made handwritten changes these were not always double signed as per good practice. Whether residents had allergies or not had not been noted on the set of MARs currently in use. The fridge where medicines are stored is regularly checked for temperature. The home has made appropriate arrangements for the disposal of medicines that have not been used through a licensed waste disposal company. Staff were seen to treat residents in a respectful and dignified way during the course of the inspection. To further support privacy and independence 3 machines have been purchased and are available in the home that enlarge print so residents are more easily able to read letters and correspondence they receive unaided. Between inspections positive comments were received from residents in respect of how they are treated responding that they felt that staff treated them ‘very well!’ All relatives who returned comment cards said that they were able to visit in private. DS0000020457.V307867.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 at least once during a 12 month period. 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’ lives are enriched by the social opportunities afforded by their visitors and the stimulating social activities available in the home. Visitors are made welcome at the home and can come whenever it suits the residents. Residents are helped and encouraged to exercise choice in their daily lives at the home. The meals in this home are good offering both choice and variety and are served in pleasant dining rooms. EVIDENCE: Zetland Court has a dedicated and proactive activities organiser. Activities are arranged for groups and 1-1 support is also available. Regular outings are arranged in the home’s minibus e.g. to places of local interest, local shopping centres, theatres etc. In the morning of the first day of inspection the art group was meeting and on the afternoon of the 2nd day of inspection some residents went to the main shopping centre in Poole. Information about activities is displayed on notice boards around the home, in the lift and on a white board outside the dining area. Something is on offer every weekday and DS0000020457.V307867.R01.S.doc Version 5.2 Page 15 sometimes at weekends. Activities are open to all residents e.g. from both the residential and nursing areas. Records are kept of who joins in with each activity. Hobbies and interests are explored with residents when they first move to the home. A summary of the persons past life is also made. Some events also help raise money for the home, most recently a summer fete. A calendar has been produced and is for sale using some of the work of the art group. Artists include some residents from the nursing wing and others who are mentally frail. Money that is raised goes towards improving the lives of the residents e.g. a new bath hoist, refurbishment of the hairdressing area and creation of a summer house in the grounds. A hairdresser is available at the home four days a week. The home library service visits. At the request of residents a communion service is held monthly at the home. Residents are also able to go out to services if they wish to. Of the 18 residents who returned comment cards 7 said that they it was ‘always’ the case that there are activities arranged by the home that they can take part in and 6 said that this was true ‘usually.’ ‘but we don’t have to take part if we don’t want to.’ (a resident) ‘a wide range of activities are provided which enables one to make a choice, also trips out and occasional theatre trips and entertainers who visit the home, besides an in house shop run by the Friends of Zetland Court, also a library service.’ (another resident) All relatives who returned comment cards to the Commission said that they felt welcome in the home at any time. During the inspection some visitors were enjoying walking and sitting in the garden with their relatives. A guest room is available for visitors to stay. The visitors’ book confirmed the number and range of visitors to the home. People are encouraged to make choices about how they live their lives at the home. Preferences such as when they like to get up and go to bed are noted in the care records. Residents can do as they wish, choose to eat what they like and join in with activities as it suits them. During the inspection staff were observed offering residents choices and supporting them in their choices. ‘Residents are treated as individuals.’ (a relative) Residents meet regularly with managers and at times senior staff from the Royal Masonic Benevolent Institution. This gives residents a real say into the way that the home. Minutes are kept of these meetings showing that they are able to express their views about a range of issues. At a recent meeting that focussed on the catering at the home over 40 residents attended. DS0000020457.V307867.R01.S.doc Version 5.2 Page 16 The menus are currently on a five-week rotation. A weekly menu sits on each table in the dining room. Residents are offered meal choices the day before. A cooked breakfast is always available in the morning. There is a choice of hot meals or salad at lunchtime. A salad bar is available for residents to choose exactly what, and how much they want. Hot and cold puddings are on offer and / or cheese and biscuits. A range of alternatives is available in the evening. The meals on offer on the 2nd day of inspection were steak and mushroom pie or pork stroganoff served with a choice of vegetables. Dessert was rhubarb and custard or yoghurts or ice cream or cheese and biscuits. There was a large bowl of fruit in the dining room for residents to help themselves from. Special diets are catered for e.g. diabetic. On the afternoon of the inspection two residents were celebrating birthdays on the nursing wing. After candles had been blown out residents settled down to enjoy the cakes. Most residents have their meals in the pleasant dining rooms. There are two in the home – one in the residential area and one in the nursing area (east wing). The east wing dining room was refurbished last year. Residents can have their meals in their rooms should they wish / need to. Due to the strength of feeling of residents changes are being made to the catering arrangements and from October 2006 the catering service will return to be provided in house. Comment cards to the Commission from residents reflected this desire for improvement which the Royal Masonic Benevolent Institution have now taken on board. Two of the 18 residents who returned comment cards said that they ‘always’ liked the meals at the home, with 10 saying that they liked them ‘usually’ and 3 ‘sometimes.’ Comments included:‘new catering routine about to take place.’ ‘I say ’usually’ because sometimes they are very good but at others they leave much to be desired, but our chef is trying to put that right.’ ‘We have experienced a period of ‘unhappiness’ with the catering firm supplying our meals, the matter, after a formal complaint by the residents , to the Royal Masonic Benevolent Institution is being ‘resolved’ and improvements are now taking place, along with other changes.’ ‘The standard is not as high as it could be.’ During the heat wave residents are being encouraged to drink plenty of liquid and take up the ice cream and ice-lollies on offer at the home. Sun cream and sun hats have also been provided by the home. DS0000020457.V307867.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A system is in place to deal with complaints that are made by residents and their representatives. The home’s adult protection policy, pre employment checks and ongoing staff training demonstrates the homes commitment to understanding abuse and of protecting residents. EVIDENCE: The home has a complaints procedure and keeps a record of any complaints made, the investigation of the complaint and the outcome to the complainant. No complaints have been received by the Commission for Social Care Inspection since the last inspection. Some complaints have been received by the home. Records continue to demonstrate that the home takes complaints seriously, conducts full investigations in a timely fashion, looks to resolve complaints and learn from them, changes general practice where necessary and feeds back to the complainants in an appropriate manner. The Royal Masonic Benevolent Institution is not an organisation that is afraid to apologise if they get it wrong. One resident spoken to said that ‘if there was anything wrong, I’d moan!’ DS0000020457.V307867.R01.S.doc Version 5.2 Page 18 The comment cards sent to residents asked the question ‘Do you know who to speak to when you are not happy?’ 18 residents sent back cards. Thirteen answered ‘always’ to this question and 4 said ‘usually’. In respect of knowing how to make a complaint 13 said yes ‘always’ and 5 ‘usually.’ ‘The home manager is always available to discuss any problems with the residents.’ (a resident) ‘I have been here five years and not had to complain.’ (another resident) Of the 6 relatives who returned comment cards 5 said that they were aware of the complaints procedure. The home has an adult protection policy and there is staff training in this subject at the home from induction onwards. DS0000020457.V307867.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Ongoing investment in the upkeep of the home maintains the comfortable and safe environment for the residents living there and anyone visiting. Bedrooms are well decorated, well furnished and personalised to suit the residents. Adequate facilities are available to meet the number and needs of the people living there. The home is kept clean and smells fresh thereby making daily life for all in the home more pleasurable. EVIDENCE: The home has a warm and relaxed atmosphere. The home is well decorated throughout. Lounges and dining areas are comfortably furnished. Since the last inspection work has continued around the home to keep the environment up to its high standard. Improvements have been made to the hairdressing room. Also a conference / meeting / training room has been DS0000020457.V307867.R01.S.doc Version 5.2 Page 20 created from a little used room on the ground floor. The grounds are glorious, providing an outstanding outlook for the home. Residents can enjoy walks around the gardens and plenty of seating is provided. The new summerhouse is now in use. The majority of bedrooms are single occupation. About half the single rooms and all 5 double rooms have en suite facilities. In addition there are a number of communal bathing areas in the home. Aids and adaptations are available throughout the home e.g. raised toilet seats, grab rails etc - and some residents with particular needs have their own personal equipment to assist with their independence. Residents are able to personalise their rooms with furniture and general belongings as they wish and in agreement with the home. There is a passenger lift in the home, enabling easy access between the floors. There are emergency alarm bells throughout the home – in each bedroom and in communal areas. Areas of the home visited were clean and there were no unpleasant odours. The laundry was also clean and tidy. The inspector alerted the home to the new June 2006 Infection Control Guidance from the Department of Health. Seventeen of the 18 residents that returned comment cards said that the home is ‘always’ fresh and clean, with the other saying that this was the case ‘usually.’ DS0000020457.V307867.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Sufficient, well-trained nursing and care staff are employed and deployed to ensure that the needs of residents can be met. Robust recruitment procedures are in place to protect residents from the risk of unsuitable staff working at the home. EVIDENCE: Clear staffing rosters are in place that show who is on duty, where, when and what jobs they do. On the 2nd day of inspection 9 care assistants were on duty in the morning and 6 in the afternoon. A nurse is always on duty in the nursing area. Kitchen staff, cleaning staff, maintenance men, gardeners, office staff and management, support nursing and care staff in keeping the home running at the high standard it achieves. Since the last inspection the staff complement has been increased by a laundry assistant at weekends. Residents were asked are the staff available when you need them? Seven who responded said ‘always’ with 10 saying ‘usually.’ One resident commented ‘until recently I could look after myself. Now old Father Time is beginning to catch up with me!’ Residents spoken to said how staff were ‘very kind’ and worked ‘really hard.’ ‘I take my hat off to them!’ DS0000020457.V307867.R01.S.doc Version 5.2 Page 22 Four out of the six relatives who returned comment cards to the Commission said that in their opinion there were always sufficient numbers of staff on duty. Well ordered staff records/ personnel files demonstrate the homes’ recruitment procedure in action. The files of four of the latest members of staff to join the home were inspected. All documents that should be on file were. A good system is in place to check that all information is in place before staff begin working at the home. For example CRB disclosures and POVA 1st checks are applied for and received prior to the commencement of duties and appropriate references are obtained. Records are kept of training that staff undertake. Staff receive induction and foundation training to the industry standard. The home is ready to implement the new induction standards being introduced in October 2006 by Skills for Care. In addition staff receive 3 days of ‘orientation’ training when they first start work at the home and a system of mentoring is being introduced. Each member of staff has a ‘passport’ in which all their training is recorded. Ongoing training is discussed at supervision sessions and where needs are identified these are addressed in the homes ongoing training programme. During the last twelve months staff have had training in manual handling, control of substances hazardous to health, infection control, basic food hygiene, fire training, supervision training and medication updates. Plans are in place for future training in first aid, abuse, dementia and diabetes. The number of care staff with the NVQ level 2 in care qualification is now over 70 which is in excess of the 50 target set by the Department of Health. Some staff have also, or will be going on to do, NVQ level 3. DS0000020457.V307867.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well organised and the daily management and running of the home centres round the care and contentment of residents. Good management practice, systems in place, and records kept, confirm the health and safety of all in the home. EVIDENCE: The home is managed by Tina Beament who has successfully completed her NVQ level 4 in management. Ms Beament is a qualified nurse and is registered with the Nursing and Midwifery Council. DS0000020457.V307867.R01.S.doc Version 5.2 Page 24 Representatives regularly visit the home from the company that owns it – Royal Masonic Benevolent Institution - and reports are made of these visits and copied to the Commission for Social Care Inspection. All records were available as requested at the inspection. An up to date insurance certificate was on display along with the home’s registration certificate. The home sent out and made available comment cards for the Commission as requested prior to this inspection. Those that came back were generally very positive about home and demonstrated that residents have, and feel free to express opinions. Last year the home extended their annual quality assurance survey, whereby they find out more what people think about the home, to other people who have an interest in the service. The response was positive. Steps were taken to address the few criticisms made. This annual audit is due to take place in October 2006. The home looks after some money belonging to residents who choose to take up this service. An excellent system is in place to do this. Clear records are kept of expenditure and balances along with receipts. Statements of the history of transactions are readily available. In order to ensure a safe environment for residents to live in equipment is regularly maintained. Most recently monthly checks of bed rails have been introduced. Maintenance records are kept at Zetland Court and the Royal Masonic Benevolent Institution’s regional property operations manager regularly reviews them Fire records seen were up to date and internal checks of fire safety equipment are being carried out at appropriate intervals. An external company carries out quarterly checks of the fire equipment. Staff receive regular fire training and records are kept. The last fire drill took place on in May 2006. Dorset Fire and Rescue visited the home in May 2006 and their comments have been acted upon. Risk assessments are carried out on hazardous substances used in the home and data product sheets are available. This information is kept on each floor for easy reference. Accident records were looked at. Accident forms seen were well completed. Records were clear about how staff came across accidents or if they had witnessed them, what they did and any follow up that was needed. Accident records are regularly analysed and where appropriate, measures are put in place to minimise further risks to residents and anyone visiting or working at DS0000020457.V307867.R01.S.doc Version 5.2 Page 25 the home. An incidents and occurrences book is also kept. Appropriate notifications about incidents and accidents are made to other bodies. DS0000020457.V307867.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 4 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 4 x x 4 DS0000020457.V307867.R01.S.doc Version 5.2 Page 27 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. 1. Standard OP4 Regulation 14 Requirement Timescale for action 01/10/06 2. OP9 13 The registered person must confirm in writing to the service user that having regard to the assessment in the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. The registered person shall make 01/10/06 arrangements for the recording of medicines received into the care home. 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 DS0000020457.V307867.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000020457.V307867.R01.S.doc Version 5.2 Page 29 - 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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