Care Home: Arbrook House

Similar services:

• Springfield House
• The Shelley
• Sutton Lodge Nursing Home
• St Helier`s Residential Hotel
• St Joseph`s
• Ridgemount
• Wingham Court
• Old Hastings House

What the care home does well People who use the service have information about the home in order that they can make an informed choice about moving to the home. The homes admission and assessment procedures ensure that individual`s needs are appropriately identified and met.The health and personal care that people receive is based on their individual needs set out in their care plans. People in the home felt that the service promoted their rights to exercise choice in the daily lives. Contact with family and friends is encouraged and maintained. The staffing numbers are considered sufficient to meet the needs of the residents currently in the home. Staff recruitment practices are robust to safeguard people in the home. The management and organisation of the home reflects the best interests of people who use the service and health and safety in the home is promoted. What has improved since the last inspection? Monitoring of risk assessments is maintained to ensure the safety of people in the home. Residents are consulted about taking part in social, religious and recreational activities in the home. People who use the service are able to express their concerns and have access to a complaints procedure and complaints are fully investigated by the home. People who use the service are fully protected from abuse and all staff have received safeguarding adults training to ensure that people in the home are protected. The planned refurbishment of the home has been completed and the homes environment is safe, well-maintained, clean, pleasant and hygienic. Staff training has improved to ensure all staff receive mandatory training in order to ensure the safety and wellbeing of people in their care. The homes arrangements for people`s financial affairs are robust. What the care home could do better: It is recommended that the manager should seek clarification from the local multi agency safeguarding teams regarding any complaints received by the home, which may need to be referred under the multi agency safeguarding vulnerable adults protocols. CARE HOMES FOR OLDER PEOPLE Arbrook House 36 Copsem Lane Esher Surrey KT10 9HE Lead Inspector Suzanne Magnier Unannounced Inspection 28th November 2007 10:15 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 Arbrook House DS0000013300.V353596.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. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Arbrook House Address 36 Copsem Lane Esher Surrey KT10 9HE 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) 01372 468246/7 01372 470760 MILLARK@BUPA.com www.bupa.com BUPA Care Homes (BNH) Ltd Ms Keena Sinclair Millar Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 44 Residents accommodated, 4 may also fall within the category TI(E) Terminally ill, Elderly 18th June 2007 Date of last inspection Brief Description of the Service: Arbrook House is situated close to Esher town centre and Claremont Landscaped gardens. The home is situated in its own landscaped grounds with its own lake. The home is registered for forty-four older people and the accommodation is provided over two floors and can be accessed by a shaft lift. All rooms are for single occupancy and all have en-suite facilities. The home has a large communal sitting room and a large dining room. There is a conservatory and a patio area to the rear of the house overlooking the grounds and the lake. Parking is available at the front of the building. Fee’s range from: £ 980.00- £1,100per week. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards have been assessed during the inspection process. Ms S Magnier Regulation Inspector carried out the inspection and the registered manager represented the service. For the purpose of the report the individuals using the service are referred to as people living in the home. The inspector arrived at the service at 10.15 and was in the home for six and a half hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspector spent time talking with people living at the home and visitors to the home in order to seek their views about the home and the care they receive. No questionnaires had been sent out by the Commission. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included individuals care/person centred plans, daily records and risk assessments, medication procedures, staff files, a variety of training records, health and safety records and several of the services policies and procedures. Following the previous key inspection in June 2007 the service has met all the requirements made. From the evidence seen the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. The inspector would like to thank the people living in the home, the staff and the manager for their time, assistance and hospitality during this inspection. What the service does well: People who use the service have information about the home in order that they can make an informed choice about moving to the home. The homes admission and assessment procedures ensure that individual’s needs are appropriately identified and met. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 6 The health and personal care that people receive is based on their individual needs set out in their care plans. People in the home felt that the service promoted their rights to exercise choice in the daily lives. Contact with family and friends is encouraged and maintained. The staffing numbers are considered sufficient to meet the needs of the residents currently in the home. Staff recruitment practices are robust to safeguard people in the home. The management and organisation of the home reflects the best interests of people who use the service and health and safety in the home is promoted. What has improved since the last inspection? What they could do better: It is recommended that the manager should seek clarification from the local multi agency safeguarding teams regarding any complaints received by the home, which may need to be referred under the multi agency safeguarding vulnerable adults protocols. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 7 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. Arbrook House DS0000013300.V353596.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 Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5, 6. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. People who use the service have information about the home in order that they can make an informed choice about moving to the home. The homes admission and assessment procedures ensure that individual’s needs are appropriately identified and met. People are encouraged to visit the home prior to residency and respite care is available. EVIDENCE: Since the previous inspection the home have updated the Statement of Purpose and Service User Guide which are written in plain English and were accessible to prospective individuals and people living in the home. The home is considering offering information regarding the home via e-mail. The home has a new brochure, which has been published following the refurbishment of the home. The inspector observed that there was a variety of information about BUPA and the home in general available to residents and visitors in the home. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 10 The inspector met the deputy manager who explained that he was going to undertake a pre admission assessment with a prospective client. Whilst sampling care plans the inspector evidenced that the home undertakes full assessments of individual’s needs, preferences and lifestyle assessments prior to their admission to the home in order to ensure that the home can meet the individual’s needs. Whilst touring the premises with the hotel service manager the inspector was advised that individuals are encouraged to visit the home prior to admission. The inspector observed that a room was prepared for an individual being admitted to the home that day and the staff member advised that the persons lifestyle and particular needs would be assessed on admission with regard to the comfort of their room. The staff member confirmed that the prospective resident had visited the home and chosen the bedroom of their choice, which had also been confirmed with the registered manager. The home offers a variety of types of stay depending on the level of support required by the individual which includes long stay care for those who need daily nursing, respite care for a short period and post operative and convalescent care. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,10. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The health and personal care that people receive is based on their individual needs set out in their care plans. Monitoring of risk assessments is maintained to ensure the safety of people in the home. There was clear demonstration that medication was administered to all individuals in a safe and appropriate way. Disposal/procedures of medicines were appropriate. People’s dignity and respect is promoted. EVIDENCE: The inspector sampled three individual’s plans of care and found them to contain well-documented care plans and a variety of risk assessments including moving and handling. The individual or their representative had signed each care plan. The plans have been maintained to include the individuals preferred name, their next of kin or significant person, documents regarding medication, their GP (general practitioner) and any other health care professionals support. The Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 12 individuals choices regarding gender specific care, their communication abilities, preferred lifestyle and daily living choices, their support needed regarding personal care, sleeping patterns, their emotional, nutritional needs and preferences. The home has sitting weighing scales and scale attachments for hoists in order that people’s body weights can be monitored and recorded. Staff have, since the previous inspection, received training and awareness in the preparation of the residents personal plans, the reviewing of care plans and the importance of recording changes within the residents care plans. The care plans indicated that they were kept under review to reflect the changing needs of any individual and daily notes continued to be well documented to reflect the care and support offered and provided by staff. The home continues to have strong links and support with local general practitioner (G.P.) who visits the home regularly. The home also has links with the out of hours Thames Doc service for emergencies. Records evidenced that there is continued support from other practitioners, which include the Macmillan nurses, tissue viability nurse, physiotherapist, dietician, opticians and chiropody. The inspector noted that files contained healthcare professional records, which had been signed and dated following a consultation visit. Comments from residents and visitors to the home regarding the healthcare provided by the home were favourable and positive. Whilst sampling the care plans the inspector noted that documented risk assessments had been completed where individuals and staff had identified hazards in the individuals daily life. Requirements had been met following the previous inspection in June 2007 and all trained nurses had received written instructions regarding updating risk assessments following incidents of note in the home, which affected the welfare and well being of residents. Records seen by the inspector indicated that any un witnessed falls are recorded and monitored and the CSCI informed promptly of any incidents, which affect the well being and welfare of residents. The home has also, since the previous inspection, sought training from the quality manager to undertake awareness and training of risk assessments regarding admission assessments, nutrition and tissue viability and moving and handling. The home has continued to have the support of a local pharmacy for all their medication needs. The home has a monitored dosage (MDS) system and blister packs are used and delivered every month. The medication is stored in the locked clinical room and all medication policies and procedures are available for the nurses. Arrangements remain in place with a clinical waste company for the removal and destruction of unused medicines. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 13 The inspector sampled one mid morning medication round and observed that the trained staff member undertook the administration of medicines appropriately. The medication administration charts were well recorded and all records contained a recent photograph and known allergies of the person. During the inspection the inspector observed staff knocking on bedroom doors and seeking permission prior to entering an individual’s room and speaking courteously to individuals. It was brought to the managers attention that the inspector overheard a comment which did not reflect the dignity and respect of one resident and the manager was prompt to assure the inspector that this was not the general conduct of the home and would be addressed in full at the staff meeting to be held that evening. Arrangements have been maintained for individuals to receive their visitors and visiting professionals in private and the newly refurbished lounges and quiet areas were observed to be available to residents and visitors. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. People in the home felt that the service promoted their rights to exercise choice in the daily lives. Contact with family and friends is encouraged and maintained. Residents are consulted about taking part in social, religious and recreational activities in the home. The home provides a healthy and balanced diet in a pleasant spacious dining area and quiet rooms in the home. EVIDENCE: The home continues to employ an activities organiser who works thirty-five hours per week. The inspector met with the activities co-ordinator during the afternoon and discussed the hobbies, leisure pursuits and activities available in the home. The activities organiser explained that she had passed her mini bus test, which gave more opportunities for residents to travel further a field for activities and outings from the home. Some residents had requested to go ten pin bowling in Guildford and the activity organiser had arranged for this activity using the homes mini bus. The inspector noted that current activity programmes were displayed throughout the home and included resident’s individual time, group activities Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 15 including crosswords, art workshops, scrabble, church services, sherry party, gentle exercises, sing along, supper socials and SKY TV. The home have arranged small group tea parties which enable people to get to know each other and have established PAT dog visits. The home has recently purchased a computerised Wii consul and games, which the inspector was advised has been a huge source of entertainment for the residents. The home has a library, which contains large print books, talking books and videos. A bar is available for residents who which to socialise with friends, family or other residents. The inspector noted that the grounds of the home were well maintained and the patio areas were free from obstructions and hazards in order that residents could walk safely in the areas. Several residents told the inspector that they liked to watch the birds and squirrels on the feeders, which were hung from the various trellis and gazebos in the grounds. The inspector was advised that during the Christmas festivities the home receives visits from resident’s family and friends, local school children who bring gifts to the home and sing carols and other voluntary organisations who entertain the residents. During the inspection an interdenominational church service was being held in the home and the inspector observed that this was well attended. Residents with specific religious/spiritual needs or cultural differences are supported by the home to exercise their lifestyle choices. The home continues to offer a hairdressing and manicure service, daily newspapers were available to individuals throughout the home and the inspector observed residents moving freely around the home and in the garden. Visitors were seen and spoken with during the inspection and all spoke favourably of the home and the staff and advised the inspector that in general they were satisfied with the service provided by the home. Several residents confirmed that they felt that they were able to exercise choice in their daily lives, this was observed by the inspector that one resident had attached a note to their bedroom door advising staff that they did not want to be disturbed during certain hours of the day. Staff were observed to have professional and welcoming responses to visitors in the home and the inspector observed that during lunchtime one person living at the home had a guest invited to share lunch and tea. The home employs a full time chef and menus are available to all people in the home to choose from on a weekly basis. The inspector met with the deputy chef who explained that the chef’s write a menu plans using a points system to ensure that all individuals in the home receive a nutritious well balanced diet. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 16 The inspector observed the lunchtime and noted that all people were offered a choice of wine or soft drinks. The dining area was well lit, spacious and clean. Dining tables were available for people to sit at with up to two or three people. Condiments and appropriate crockery was available. Staff were available to support people with their mealtimes should they need any assistance and meals were provided promptly by staff. Residents confirmed with the inspector that the standard of food was consistently good and they enjoyed their meals and would be comfortable to ask for a something different if they did not want what was on the menu. The home have arrangements in place that if residents require one to one support this is offered during meal times in a separate quiet room away from the main dining room in order to reflect the individuals rights to dignity and respect. The inspector observed staff supporting residents with their meals in a professional and competent manner in order to ensure that the individual was not rushed and enjoyed their meal. Arbrook House DS0000013300.V353596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. People who use the service are able to express their concerns and have access to a complaints procedure and complaints are fully investigated by the home. People who use the service are fully protected from abuse and all staff have received safeguarding adults training to ensure that people in the home are protected. EVIDENCE: The home has a complaints procedure, which has been recently updated. The inspector observed that the complaints procedure is available throughout the home and is also documented within the homes statement of purpose and service users guide. No complainant has contacted the commission with information concerning a complaint made to the service since the last inspection. The home has received seven complaints since the last key inspection. Whilst sampling the complaints log the inspector noted that the registered manager had met the previous requirements and a clear chronology of events for example dates of correspondence and outcomes regarding complaints received by the home had been recorded to demonstrate that effective responses have been made following the home receiving a complaint. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 18 The home continues to address concerns or complaints which people may have regarding the general facilities and their bedrooms. The concerns are addressed by the hotel service manager and documented in a complaints book. The concerns are addressed with the manager on a weekly basis to ensure that appropriate action has been taken and the concern/resolved. Two written complaints sampled by the inspector used the words ‘abuse ‘ and ‘suffering’. It was recommended by the inspector that the manager should inform the local multi agency safeguarding teams regarding the complaints in order to seek clarification if the complaints should have been referred initially under the multi agency safeguarding vulnerable adults protocols. People spoken with during the inspection advised the inspector that they would feel comfortable to raise concerns or complaints and felt that sometimes misunderstandings could be resolved quickly. The inspector sampled that the home has the local authorities multi agency procedures for safeguarding adults and inspector was assured that the home follows these procedures. The home has confirmed that there have been no safeguarding referrals under these procedures since the last inspection. Staff spoken with during the inspection demonstrated an understanding of the procedures for safeguarding adults. The requirement that all staff undertake safeguarding adults training has been met to ensure that staff are aware of the protocols regarding reporting and detecting abuse in order to safeguard people in their care. Arbrook House DS0000013300.V353596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26. Quality in this outcome area is excellent. This judgement has been made using a range of evidence including a visit to this service. The physical layout of the home enables people who use the service to live in a safe and well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: The home has completed the extensive planned refurbishment, which includes painting and decorating, new furnishings for example sofas, chairs, fashionable ornaments, new furniture including side tables and coffee tables, soft furnishings of curtains carpets, cushions and comfortable window seats. The general ambience and atmosphere in the home was calm and orderly with all staff members undertaking their duties. The home was noted to be clean and hygienic throughout and this was fed back to some housekeeping staff during the inspection. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 20 The inspector sampled the homes bathrooms and toilets, which were clean and offered adequate equipment to ensure that the personal care needs of individuals were met. The home has a variety of portable hoists and hoists for supporting residents into baths. Records sampled indicated that regular checks are maintained in order to ensure the safety of residents when being bathed. The inspector noted that the bathrooms were less attractive in décor than the other areas in the home and this was addressed with the hotel services manager who advised that the home have plans to make the bathroom areas more homely for residents. Specialist equipment was noted t be available to residents which included raised toilet seats, walking frames, ramps, handrails and use of wheelchairs. Resident’s private accommodation was well decorated and several of the resident’s told the inspector that they enjoyed their rooms and felt comfortable. Some residents had profiling beds, which assisted their mobility and personal possessions, which also included items of furniture, photos, radios, bedding and items of personal sentimental value. The laundry and sluice areas of the home were viewed as orderly and well managed and no malodours were present throughout the home. Arbrook House DS0000013300.V353596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The staffing numbers are considered sufficient to meet the needs of the residents currently in the home. Staff recruitment practices are robust to safeguard people in the home. Staff training has improved to ensure all staff receive mandatory training in order to ensure the safety and wellbeing of people in their care. EVIDENCE: The manager and the inspector discussed the staffing numbers on the day of the inspection. The home have furnished the CSCI with staffing rotas since the previous inspection requirement that the home review the deployment of staff. The staffing levels at the home on the day of the inspection were considered adequate to meet the current needs of the residents residing in the home. The manager advised that the home is seeking to recruit more care staff in order to have ten carers on duty during the morning shift and seven carers on an afternoon shift and staff deployment is monitored on an ongoing basis. The manager explained that a meeting of the registered nurses was being held that evening to discuss the roles and responsibilities of the registered nurses when on duty and also to discuss a proposed new management structure of shifts. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 22 Comments regarding the staff during the inspection were all favourable with residents and visitors to the home stating that the staff were kind, caring and always willing to help. The home has a ticket system, which details the time that a call bell is ringing and then, answered. The inspector sampled a variety of tickets and noted that the majority of calls were answered within two to five minutes. The inspector sampled three staff recruitment files. The files evidenced that the home undertake safe vetting practices concerning the recruitment of staff in order to ensure the safety and protection of people living in the home. Following the previous inspection the home have introduced distance-learning training for all staff. The inspector sampled some books, which had been completed by staff and also some books for guidance. The manager advised that all staff are currently undertaking all statutory training and the common induction standards at differing levels dependant on how long the staff have been employed by the home. It is the intention of the home to set a matrix, which will clearly identify any gaps and refresher courses for staff to ensure that all staff statutory training remains up to date. Arbrook House DS0000013300.V353596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The management and organisation of the home reflects the best interests of people who use the service. The homes arrangements for people’s financial affairs are robust and health and safety in the home is promoted. EVIDENCE: The manager of the home represented the service during the inspection and demonstrated knowledge and experience of running a care home. The manager explained that the management style of the home includes delegation of tasks for example hotel services, house keeping, health and safety, administration, bursar, catering and activities. It was observed that the manager sought information from the heads of department regarding these Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 24 operational areas of the home during the inspection yet was clear that she was accountable for the responsibility of the day to day management of the home. The home has undertaken some quality assurance programmes based on the company’s policy and procedure to seek the views of people using the service and the inspector sampled some completed questionnaires which were generally favourable about the services provided by the home. The manager explained that the information would be collated and used to inform improvements at the home. Following the previous inspection information regarding the availability of the homes bursar has been added to the Statement of Purpose and Service User Guide. Residents relatives or significant others have been consulted regarding the homes management of residents personal allowances. And staff protocols regarding handling residents finances have been reviewed in order to safeguard the residents and the home from any allegations of misuse of finance. The inspector noted that housekeeping trolleys had been left unattended in corridors and all chemicals were stored in the locked storage container on the trolley. Records sampled by the inspector evidenced that the home has a robust system for the maintenance and servicing of the homes equipment for example fire drills, fire tests, servicing of fire equipment, water temperature checks, safe bathing policies and wheelchair checks to ensure the safety and well being of all persons in the home. The inspector observed that there were adequate facilities for individuals to wash their hands around the home with gel hand rub available for all staff. The manager explained that the home is in the process of installing hand gels in all resident’ s en suite facilities in order to maintain the infection control practices in the home. The home have also ensured that staff are aware of the homes written infection control policy and procedures and have implemented distance learning courses for infection control and health and safety training which commenced in September 2007. Arbrook House DS0000013300.V353596.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 X 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 X 3 4 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Arbrook House DS0000013300.V353596.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. 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. 1 Refer to Standard OP16 Good Practice Recommendations It is recommended that the manager should seek clarification from the local multi agency safeguarding teams regarding any complaints received by the home, which may need to be referred under the multi agency safeguarding vulnerable adults protocols. Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Arbrook House DS0000013300.V353596.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!