Care Home: 39 Harvard Road

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What the care home does well Staff was observed to deliver care with dignity and respect. Three service users who were asked felt the care provided respected their privacy and dignity. The relative`s surveys stated that the home always or usually meet service users care needs and supported people to live the life they choose. All of the service users surveys stated they received the care and support they needed, and comments received from service users and their representatives were, `very good, ` ` all marvellous staff,` ` very happy here,` `very pleased with staff and home in general,` ` I would like to thank ESCC for all the help I have received,` `I have been well cared for and I am grateful to everyone,` and ` my experience of my stay at Harvard Road has been one of real happiness and I feel I have moved on in my recovery here. The staff work extremely hard, often beyond what is supposed to be required of them.` The home continues to hold the Clean Catering Award by Lewes District Council. Staff work with service users to regain their independence and where possible return home. There is good support from healthcare professionals to help facilitate this. What has improved since the last inspection? Leisure activities have been developed and the AQAA details that it is planned to continue to develop the activities provided. A copy of the initial assessment/review is available for staff to reference. The result of the home`s quality assurance audit has been collated and is available to view. The recording of the testing of the fire equipment now details the checks, which have been completed. What the care home could do better: CARE HOMES FOR OLDER PEOPLE 39 Harvard Road Ringmer Nr Lewes East Sussex BN8 5HH Lead Inspector Judy Gossedge Key Unannounced Inspection 19th November 2007 11:00 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 39 Harvard Road DS0000041389.V353141.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. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 39 Harvard Road Address Ringmer Nr Lewes East Sussex BN8 5HH 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 812125 01273 814468 heather.wilson@eastsussex.gov.uk www.eastsussex.gov.uk/socialcare East Sussex County Council Mrs Heather Pauline Wilson Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The maximum number of service users to be accommodated is thirtyseven (37). One (1) service user to be accommodated in the self-contained flat in the home. Service users must be older people aged sixty-five (65) years or over on admission. Four places are available for service users between the age of fifty-five (55) and sixty-four (64). Three places are available on the Hampton Unit providing rehabilitation and the one place in the self contained flat can accommodate service users between the age of fifty (50) and fifty-four (54). 4th July 2006 Date of last inspection Brief Description of the Service: 39 Harvard Road is run by East Sussex County Council (ESCC) and is a purpose built property on two floors, set in its own grounds in Ringmer, with the village centre nearby. Service user accommodation comprises of thirty-six single bedrooms, one of which can be used as a double bedroom where service users have chosen to share and there is a self contained flat. Divided in to three units within the home each with dining and lounge facilities, situated on both floors with level access facilitated in the home with the provision of a passenger lift. Two units are for service users receiving respite care or short term care for periods of up to six months. One unit is for service users on the Living at Home Programme, a rehabilitation scheme run by ESCC to work with service users to return home within an agreed timescale of up to six weeks. There is a conservatory and garden for service users to access. Fees charged are in accordance with ESCC policy and procedures and at the time of the Inspection the charges are £98.60-£523.02 per week. The level of fees charged will depend on the outcome of a financial assessment. Where intermediate care is provided the service is free for up to six weeks. Additional charges are made for hairdressing, chiropody and newspapers/magazines. The Statement of Purpose, Service Users Guide and a copy of the last Inspection report are available to view in the main reception area at the entrance to 39 Harvard Road. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Inspection took place over five and three quarter hours on 19 November 2007. Prior to the Inspection the Registered Manager completed an Annual Quality Assurance Assessment (AQAA) and information detailed is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms and care records were inspected. Thirty service users were resident and nine service users were spoken with individually. The care that four of the service users received was reviewed. The opportunity was also taken to observe the interaction between staff and service users in the communal area. Fifteen service user surveys were sent out on this occasion and eight completed surveys were returned. One senior care worker and five care workers, a home care worker, the cook, a laundry assistant and a domestic, a maintenance person, a nurse, a physiotherapist and physiotherapy assistant, an occupational therapist, an administration assistant and the Registered Manager were all spoken with. Five relatives and visitors surveys were sent out and two completed surveys were returned. Two relatives/visitors were spoken with during the Inspection. What the service does well: Staff was observed to deliver care with dignity and respect. Three service users who were asked felt the care provided respected their privacy and dignity. The relative’s surveys stated that the home always or usually meet service users care needs and supported people to live the life they choose. All of the service users surveys stated they received the care and support they needed, and comments received from service users and their representatives were, ‘very good, ‘ ‘ all marvellous staff,’ ‘ very happy here,’ ‘very pleased with staff and home in general,’ ‘ I would like to thank ESCC for all the help I have received,’ ‘I have been well cared for and I am grateful to everyone,’ and ‘ my experience of my stay at Harvard Road has been one of real happiness and I feel I have moved on in my recovery here. The staff work extremely hard, often beyond what is supposed to be required of them.’ The home continues to hold the Clean Catering Award by Lewes District Council. Staff work with service users to regain their independence and where possible return home. There is good support from healthcare professionals to help facilitate this. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential new service users are individually assessed prior to any admission to ensure that their care needs can be met in the home and there is information about the home for service users and their representatives. There is good support from healthcare professionals to enable service users to regain their independence and work towards returning home. EVIDENCE: The Statement of Purpose and Service Users Guide are detailed and with a copy of the Inspection report is available to read in each of the service users bedrooms. Feedback from the service users surveys was that three felt that they had received enough information about the home prior to moving in and five felt they had not. Three commented that they had been moved to the home as an emergency admission. This was discussed with the Manager who 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 9 stated that a number of service users are admitted to the home as an emergency following an incident or to prevent an admission into hospital. But that this would be re-looked at where there are planned admissions to the home. The service user surveys stated that five of the service users felt they had received a contract, two stated they had not and one did not answer the question. Completed contracts were not in place for all of the service users documentation viewed, and the Manager stated that they could be in the process of completion or awaiting a signature. Service users have an initial assessment completed by an assessor working for one of ESCC’s Adult Service Departments Assessment Teams. Where care is provided at short notice perhaps following an admission to Accident and Emergency or an incident at home then the assessment may be completed by a health care professional. All of the service user files viewed had a copy of an initial assessment. Staff spoke of improved access to initial assessments and updated information where service users are being provided with regular respite care, but that there have been occasions when it is found that service users care needs cannot be met in the home. One service user who had been admitted as an emergency the previous night, care needs were found to be not appropriate to be met in the home and staff were arranging for a transfer for later in the day. One flat in the home is used to accommodate service users for a period of rehabilitation for up to six weeks. Occupational therapy and physiotherapy staff were spoken with and observed working in the home during the Inspection with service users to return home. Service users spoke of activities they had participated in and had range of equipment, which had been provided to assist their mobility. Records were viewed of home visits in preparation for a service users return home. Additionally there is a self-contained flat within the home, which service users have accommodated as part of their preparation to return home. It must be ensured that there is clarity within the staff team as to when this facility is occupied and the staffing arrangements to be put in place to support service users resident in the flat. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 10 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 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have individual plans of care, but it should be ensured that all the service users care needs are identified on admission. Personal care and support is provided in a way that maintains and respects the privacy, dignity and lifestyle of the service user. There are detailed policies and procedures in place to manage medicine to be followed to ensure the protection of service users. EVIDENCE: The AQAA detailed that there are policies in place to ensure that equality and diversity issues for individual service users are both identified and incorporated into service users individual plans of care. Eight of the service users individual care plans were viewed. A new recording format has been introduced and five care plans were very detailed and gave clear guidance to staff of the care to be 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 11 provided, service users health care requirements, dietary needs, social and leisure interests. Supporting risk assessments were also viewed and where there are any identified risks the recording detailed how these will be managed. For one new service user who had been admitted the night before and was being transferred the care plan had not commenced and there was no interim guidance for staff prior to any transfer. A further service user admitted to the home on 12 November did not have a care plan drawn up, was self administering medication and there was no supporting risk assessment. One service user who was being discharged during the day after a period of respite care, their care plan was only half completed. This was discussed with the Manager who stated this should be completed on admission and that this would be rectified with immediate effect. There was evidence that documents had been reviewed. All service users are registered with a local General Practitioner (GP) and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans that were examined, that appointments with or visits by health care professionals are recorded. Service users spoken were asked about access to a GP, chiropodist optician or a dentist. Not all had required these services, some they stated they had accessed these services. Seven of the service users stated that they felt that their medical care needs were met in the home and two felt the question was not applicable. One commented, ‘I have found the nurse available for my small needs.’ The AQAA detailed that medication policies and procedures are in place. The storage and a sample of the recording of the administration of medication were also viewed and were adequate. Further improvements have been made to the temperature of one storage area, which has previously been highlighted to be very warm. A number of service users were responsible for their own medicines and policies and procedures are available to facilitate this. Staff spoken with confirmed they had received medication training and the Manager stated that only staff that has attended the required training would administer medication. Also that further medication is due to be facilitated by the organisation shortly. Staff was observed to deliver care with dignity and respect. Three service users who were asked felt the care provided respected their privacy and dignity. The relative’s surveys stated that the home always or usually meet service users care needs and supported people to live e the life they choose. All of the service users surveys stated they received the care and support they needed, and comments received from service users and their representatives were, ‘very good, ‘ ‘ all marvellous staff,’ ‘ very happy here,’ ‘very pleased with staff and home in general,’ ‘ I would like to thank ESCC for all the help I have received,’ and ‘I have been well cared for and I am grateful to everyone,’ ‘ my experience of my stay at Harvard Road has been one of real happiness and I feel I have moved on in my recovery here. The staff work extremely hard, often beyond what is supposed to be required of them.’ 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 12 39 Harvard Road DS0000041389.V353141.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. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Where possible service users are enabled to exercise choice in their lives whist resident in the home, there are opportunities to participate in social and recreational activities provided which continue to be developed, service users are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: A weekly activities programme is available to read in the home. The AQAA detailed that the home now offers more activities and these are being continually reviewed for further improvements. Chair-based activities are provided and there is a monthly church service. Service users spoke of some activities they had participated in. During the morning some service users were watching on the television the sixty years celebrations of the royal wedding and during the afternoon a small group of service users were involved in a quiz on one of the flats. It was observed that there was a good atmosphere and interaction between staff and service users. Feedback from 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 14 the service user surveys was varied and five stated activities were always provided, two usually and one sometimes arranged. Service users spoken with on the day confirmed activities were provided, although some stated they also liked to read or stay in their room and did not always with to join in. Comments received were ‘I try to meet as many people as possible by joining in bingo, crosswords puzzles, quizzes, dominoes, exercises, etc which are very jovial and sometimes hysterically funny events. I have also enjoyed small musical events which are arranged by members of staff and am so grateful for this,’ ‘ I enjoy most of the activities that take place and have been on trips out in the bus,’ ‘ and ‘exercises, knitting squares for blankets, bingo and walking in the garden.’ Visitors spoken with on the day and service users who had had visitors commented that there was flexible visiting and that staff are very welcoming. The relatives survey commented, ‘ we are able to visit anytime we like.’ When asked what the home does well commented, ‘ make us feel very welcome at all times.’ The care and support provided was observed to enable service users where possible to exercise choice whilst at 39 Harvard Road. The five detailed service user care plans viewed and service users spoken with confirmed this. The home continues to hold the Clean Catering Award by Lewes District Council. The cook working on the day stated he held an advanced food hygiene certificate. There is a rotating eight-week menu in place detailing a choice at all meals and service users spoke of choosing from the choice available on the day. Once a week a full cooked breakfast is provided. Special diets are catered for. The meals are served on each of the units in the dining room and staff were observed on one unit and were available to offer any assistance to service users if required. Lunch on the day was braised lamb chops or eggs mornay with potatoes, green beans and carrots followed by apple pie and custard. Fresh fruit was observed to be available on the flats. Detailed records had been maintained of individual food consumption to help ensure service users have had an adequate diet. The feedback from the service users survey was varied and stated that five always, two usually or one sometimes liked the meals. Service users spoken with on the day spoke well of the food provided. Comments received were, ‘the meals that are served to us are really marvellous. They are attractively served, very nutritious and varied. I thoroughly enjoy eating them and look forward to every meal,’ ‘very good and cook excellent,’ ‘ the meals seem to be of a good quality,’ and ‘the cook is excellent.’ 39 Harvard Road DS0000041389.V353141.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 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse. EVIDENCE: ESCC has a detailed compliments and complaints policy and procedure in place. Any complaints received are monitored through the line management arrangements in place within the organisation. The AQAA detailed that three complaints have been received since the last inspection. The CSCI have not received any concerns in relation to 39 Harvard Road. Five of the service users surveys stated they always knew who to speak to if they were not happy and three usually, and six service users stated they knew how to make a complaint and two did not. One commented, ‘if I have any problems I mention them to any member of staff’ and another stated,’ I would certainly know who to speak to if I was unhappy in any way. I find that there is nearly always someone around to come to my aid if needed and I have been and am, very happy here.’ Both the relative’s surveys stated they knew who to speak to if they wished to make a complaint. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 16 There are detailed policies and procedures in place in relation to the safeguarding of vulnerable adults and a whistle blowing policy. All care workers spoken with had an awareness of safeguarding adult procedures and stated they had received training/update. The AQAA detailed that this is an area, which has improved over the last twelve months, and that it is planned to ensure that all staff attend regular updates over the next twelve months. 39 Harvard Road DS0000041389.V353141.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 and 26. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A maintenance plan is in place to ensure that the standard of the environment continues to be improved so that service users are provided with a safe, attractive and homely place to live. EVIDENCE: The standard of décor, carpeting and furnishings in the home continues to be variable. The AQAA details that there is a maintenance programme in place in the home to work towards improving the environment. That the carpets are replaced in all the bedrooms as required, new net curtains have been provided for all the building, new bedding and towels and flannels have been purchased 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 18 and some bedrooms and bathrooms have been redecorated. Corridors, some lounges, dining rooms and the foyer are due for redecoration in the 2007-2008 budget and it is planned over the next twelve months that all curtains are to be replaced. There are thirty-six single bedrooms, one of which could be used as a double bedroom. Service users are able to control the temperature in their own bedrooms. All bedrooms have an emergency call bell system and two service users who had used this facility confirmed that the call bells were answered promptly. Some of the bedrooms seen reflected a range of individual styles and interests. Additionally there is a self-contained flat comprising of a bedsitting room, kitchen and bathroom. There are no en-suite facilities, but there are separate toilets on each of the units and close to the communal areas. There are four communal assisted baths within the home, which is the same ratio as provided at 31.03.02. The bathing facilities should be kept under review to ensure that adequate facilities are available for service users use. The service users spoken with confirmed that there was adequate heating and access to hot water. The homes records of checks of the hot water supply were viewed to ensure that outlets accessed by service users remain close to the recommended safe temperature of 43°C. It was found that the temperatures of the baths had been omitted to be checked. The Manager stated that this would be rectified immediately so a Requirement has not been made on this occasion. There is a dining room and lounge area on each unit. One room on the first floor is designated for the use of service users who wish to smoke. There is a passenger lift between the ground, and first floor within the home. The AQAA details that there is a policy in place for managing infection control. The home was clean and free from offensive odours at the time of the Inspection. Feedback from all but one of the service users surveys was that the home was always fresh and clean and one stated usually. Comments received were, ’the team make a good job of keeping the home clean,’ and ‘ as far as I am concerned I have found no fault with the freshness or the cleanliness of the home. There is plenty of fresh air, windows are always open, and the staff who clean are absolutely marvellous, nothing escapes them,’ and another commented that sometimes the toilets were not very clean. Two domestic assistants were spoken with and who both stated they received training/guidance in infection control or the control of substances hazardous to health regulations (COSHH) and that there was good access to protective clothing. Recording was viewed of routine fire checks that had been carried out in the home. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 19 There is an attractive garden, which has a level access walkway. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are provided with opportunities for training to develop their skills and ensure the individual care needs of service users can be met, with adequate staffing levels being maintained and recruitment policies and procedures evidenced to be in place to protect service users. EVIDENCE: On the day of the Inspection there were seven care workers on duty during the morning and six in the afternoon with a Senior Care Officer on duty. The Registered Manager was on duty during the day. Discussions with staff and records viewed confirmed that improved staffing levels and deployment of staff in the home have been put in place and maintained. Recruitment to care worker posts has lessened the reliance on agency and relief staff to work in the home. Ancillary staff were also on duty covering domestic, catering, maintenance and administrative tasks. As the majority of service users are only resident for short periods of care there is a high number of admissions and discharges. The dependency and care needs of individual service users continually changes and the Manager stated that the number of care staff on 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 21 duty is continually kept under review to ensure adequate staffing to meet the needs of the all the service users resident. Feedback from the service users surveys stated all the service users felt they always received the care and support they needed, staff listened and acted upon what they said and that staff are always available when they need them. One comment received was, ‘night staff are always available and very kind.’ The AQAA detailed that seventeen of the thirty-three care staff hold an NVQ Level 2 in care or above and that three further care workers are working towards this qualification. Also that two of the nineteen of the agency/pool/bank care staff also hold this qualification and a further two are working towards this qualification. All recruitment of ESCC staff is co-ordinated by the Personnel Section at ESCC’s head office. Evidence of the recruitment process followed for staff is held at the home. The documentation for four care workers who have been recruited since the last Inspection were viewed. The information was wellstructured and easy to reference and evidenced the recruitment practice in place with the completion of an application form and two written references being received. The Manager was able to confirm that all staff has completed a Criminal Records Bureau (CRB) check. The AQAA details that ESCC has a induction training programme in place, which meets the Skills for Care requirements and new care staff are expected to complete. The records for the four new members of staff evidenced the completion of an induction. The organisation has a yearly appraisal process in place for staff, which the Manager stated this was in the process of being completed with staff. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The overall management of the home is good with quality assurance procedures in place to monitor the service provided, and systems in place to protect service users. EVIDENCE: The Registered Manager has worked for East Sussex County Council for a number of years as a senior manager participating in a range of training opportunities and holds a Certificate in Management Studies, and HNC Care (Elderly) and stated she has sought clarification that this meets the training requirements for a Registered Manager. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 23 ESCC has a quality assurance plan in place. The AQAA details there are opportunities for service users and carers to put forward their views about the home and the care that they receive through service users forums to be held bi-monthly and a questionnaire for service users to complete at the end of each stay in the home, or at a review of their care if a service user stays for a longer period in the home. The minutes of the last service user forum held on each unit was viewed. Feedback from the quality assurance process undertaken at 39 Harvard Road for 2006/7 was available to view at the time of the Inspection. This details how the service is monitored and feedback from consultations with service users. The feedback stated of the one hundred and thirty-seven questionnaires returned during the last year, ninety-six percent of the service users stated they were very satisfied/satisfied with the service. The AQAA detailed that policies and procedures were in place, but had not been fully completed to detail if these had been subject to regular review. This was discussed with the Manager to ensure this information is recorded in future. Regular quality assurance visits by a representative of ESCC are completed and recorded to meet the requirement under Regulation 26 and the last two reports were viewed. Where a small ‘float’ of money is held for some service users a sample of the financial records to support this activity were viewed and were adequate. Care workers spoken with and records viewed confirmed that individual staff supervision and team meetings occur on a regular and ongoing basis. But that some staffs individual supervision had not met the requirements of the standard. The Manager stated she was aware of this and was due to changes in staffing, and was working on ways to ensure that this was addressed. Care staff spoken with had attended a range of training opportunities and spoke of good access to training opportunities for personal development. All confirmed they had attended moving and handling, basic food hygiene and first aid training. Records completed also evidenced that the staff had received training/updates to meet the organisations requirements and where this was over due the Manager stated training was in the process of being provided. The AQAA detailed that a fire risk assessment is in place. A detailed check of the environment and fire precautions had been carried out to meet the timescales as detailed in ESCC’s policies and procedures. Staff training records viewed and staff spoken with evidenced that staff have attended fire training as required. There were also detailed recorded of fire drills which have been organised. It was not clear from these that all the staff had taken part and if all night staff had participated. The Manager stated this would be checked and rectified to ensure all staff had participated, so a Requirement has not been made on this occasion. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 24 The organisation has a system in place to evidence that the maintenance of equipment and services has been carried out. Accident records were viewed and filed so that any trends can be been identified. 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 25 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 3 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 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 15 (1) Requirement That service users individual plans of care are started on admission to ensure all their care needs have been identified and staff are provided with adequate guidance to protect service users. Timescale for action 30/11/07 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 39 Harvard Road DS0000041389.V353141.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 39 Harvard Road DS0000041389.V353141.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. 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