Care Home: Autumn Lodge

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What the care home does well Autumn Lodge presented as a well maintained, warm and comfortable environment. Areas viewed appeared clean and hygienic and residents were observed to be relaxed and comfortable in their home environment. A relative reported; "Autumn Lodge is always warm and cosy and has a relaxed but efficient atmosphere." Assessment systems had been established to ensure the needs and support requirements of the people using the service had been identified prior to admission and supporting documentation confirmed residents had access to appropriate health and personal care. Comments from three residents included; "The girls [staff] are so kind. I am so well cared for"; "The carers are very good" and "I could never fault the care I receive." The daily routines at Autumn Lodge remained as flexible as possible and residents spoken with confirmed they were encouraged to exercise choice and control over their lives. A weekly activities programme had been developed, which detailed that a good level of activities was on offer and residents spoke highly of the meals provided. For example, comments included: "The food is very nice"; "I am well looked after and the food is good"; "I like the food. I can have alternative choices. They [staff] are very kind." Systems had been established to enable residents and their representatives to provide feedback on the service and to express concerns or complaints. Likewise, policies and procedures had been developed to provide guidance to staff on how to protect residents from abuse. The service continues to be managed by an experienced manager who manages the home in an open and transparent manner. This ensures positive relationships with staff, residents and their representatives. What has improved since the last inspection? The Statement of Purpose and Service User Guide had been reviewed, to ensure information on the service was up-to-date. All residents had been issued with a contract of residence to ensure they are aware of their rights and obligations. Information on the needs of residents had been kept up-to-date, to provide information for staff on the assessed needs of the people using the service. Furthermore, risk assessments had been completed to ensure the welfare of residents was safeguarded. Staff recruitment practice had improved and all the necessary pre-employment checks had been undertaken for staff recruited since the last inspection. What the care home could do better: The Statement of Purpose and Service User Guide should be updated to include the correct contact details of the Commission for Social Care Inspection, the admissionprocess and the fire procedures in the home. The documents should also be produced in alternative formats, subject to the individual needs of residents. This will ensure prospective residents have access to key information on Autumn Lodge and assist them to read and understand the information more easily. A care plan form should be completed to clearly identify the health, personal and social care needs of each resident and the support they require from staff to meet their needs. This will help to provide more succinct and accessible information for staff to follow. The date that medication is received into Autumn Lodge should be recorded on the medication administration chart to provide a clear audit trail. All staff should complete the `Skills for Care` Common Induction Standards within the first 12 weeks of their employment, to ensure they are inducted in accordance with national standards. All staff should be supported to complete Safe Working Practice and other training relevant to their role and responsibilities, to safeguard health and safety. The actual date that staff commence employment in the home should be recorded on staff files, to provide a clear audit trail. This will help to provide evidence that preemployment checks have been received prior to staff working in Autumn Lodge. The fire alarm system, emergency lighting and call bell system should be serviced periodically in accordance with guidance issued by the local fire officer and manufacturer. This will help to safeguard the health and welfare of the people using the service. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Autumn Lodge 41 Moss Lane Orrell Park Liverpool Merseyside L9 8AB     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Daniel Hamilton     Date: 2 8 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Autumn Lodge 41 Moss Lane Orrell Park Liverpool Merseyside L9 8AB 01515250555 Telephone number: Fax number: Email address: Provider web address: autumnlodgeliverpool2007@hotmail.co.uk Name of registered provider(s): Type of registration: Number of places registered: Mr Delpinto,Mrs Delpinto care home 34 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: 5 day care places for older people over the age of 65 years in addition to the 33 places for Older People over the age of 65. To provide care for thirty-three older persons (aged over 65 years) and one named person with dementia, excluding learning difficulty or mental disorder over 65 years of age Date of last inspection Brief description of the care home Autumn Lodge is situated in the Orrell Park district of Liverpool and is easily accessible by public transport. Gardens are at the rear of the home and there is car parking to the front aspect. The service is registered with the Commission for Social care inspection to provide personal care for 34 older people. All accommodation is provided in single rooms. A passenger lift and wide corridors facilitate access to all areas of the home. The home has aids in place to promote the independence of residents such as assisted baths, grab rails and staff call system. The home is managed by an experienced manager and has a stable well-qualified workforce. Fees at Autumn Lodge range from £360.00 to £390.00 per week, depending upon type and source of funding. Care Homes for Older People Page 4 of 29 Over 65 34 0 Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means that the people who use the service experience good quality outcomes. This unannounced inspection took place over one day and lasted approximately 9 hours. A partial tour of the premises took place and observations were made. Four care files were examined and a selection of staff and service records were also viewed. The Owner, Registered Manager, Assistant Manager (referred to as the management team), three care staff and ten residents were also spoken with during the visit. Survey forms were distributed to a number of residents or their representatives prior to the inspection in order to obtain additional views and feedback about the service. All Care Homes for Older People Page 6 of 29 the key standards and previous requirements and recommendations from the last key inspection in November 2006 were also reviewed. Reference was also made to an Annual Quality Assurance Assessment which was completed by the owner. This document enables a Registered Provider to undertake a self-assessment on a service prior to an inspection. The Care Home Fees for this service range from 360.00 to 390.00 pounds per week. What the care home does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide should be updated to include the correct contact details of the Commission for Social Care Inspection, the admission Care Homes for Older People Page 8 of 29 process and the fire procedures in the home. The documents should also be produced in alternative formats, subject to the individual needs of residents. This will ensure prospective residents have access to key information on Autumn Lodge and assist them to read and understand the information more easily. A care plan form should be completed to clearly identify the health, personal and social care needs of each resident and the support they require from staff to meet their needs. This will help to provide more succinct and accessible information for staff to follow. The date that medication is received into Autumn Lodge should be recorded on the medication administration chart to provide a clear audit trail. All staff should complete the Skills for Care Common Induction Standards within the first 12 weeks of their employment, to ensure they are inducted in accordance with national standards. All staff should be supported to complete Safe Working Practice and other training relevant to their role and responsibilities, to safeguard health and safety. The actual date that staff commence employment in the home should be recorded on staff files, to provide a clear audit trail. This will help to provide evidence that preemployment checks have been received prior to staff working in Autumn Lodge. The fire alarm system, emergency lighting and call bell system should be serviced periodically in accordance with guidance issued by the local fire officer and manufacturer. This will help to safeguard the health and welfare of the people using the service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to assess and monitor individual needs, ensuring that a suitable service is provided based on personal needs and preferences. Evidence: A Statement of Purpose and Service User Guide had been developed in a standard format to provide prospective residents and their representatives with information on the service provided at Autumn Lodge. The documents had been updated during November 2008. It was noted that both of the documents did not include the correct contact details of the Commission for Social Care Inspection and the Statement of Purpose did not include information on the admission process or details of the fire procedure. The management team was recommended to include this outstanding information and to also produce the document in large print and other formats subject to individual need. Care Homes for Older People Page 11 of 29 Evidence: A selection of residents files were examined and each contained a Contract of Residence. The management team reported that all residents had been provided with a copy of this document since the last inspection, regardless of whether an individual resident was self funding or funded via the local authority. A sample of four care files were examined during the visit. Records confirmed that a pre-admission assessment of needs had been completed prior to admission and the management team reported that they would always endeavour to obtain a copy of an assessment undertaken by Social Services for funded residents. Previous inspection records detailed that assessments were carried out with the involvement of the prospective resident, family, social services if relevant and any other health care professionals involved in providing care. The pre-admission assessments viewed were sufficiently detailed to enable staff to prepare a plan of care and to obtain any necessary services or aids. Residents spoken with confirmed they were encouraged to visit the home before deciding whether to move in, in order to assess the service and facilities at Autumn Lodge. A tour of the building confirmed the premises has appropriate aids such as hand and grab rails, assisted baths and raised toilet seats in place, to assist people to mobilise safely. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that residents receive is based upon their individual needs and the principles of respect, dignity and privacy are put into practice. Evidence: The Annual Quality Assurance Assessment (AQAA) for Autumn Lodge detailed that policies and procedures had been developed for individual planning and review and for the control, storage, disposal, recording and administration of medicines. The files of four residents were viewed during the visit in order to review care planning processes. Records viewed confirmed the service continued to use a commercially produced care planning package and that following a pre-admission assessment, the manager or senior staff had completed a more detailed assessment which included information on how the needs of residents were to be met. The management team were strongly recommended to complete the green care plan form which was part of the care planning package, to ensure information on the Care Homes for Older People Page 13 of 29 Evidence: individual health, personal and social care needs and support requirements of residents were transferred to a more appropriate document. The assistant manager started to address this issue during the visit. Information on the needs of residents had been kept under review. A range of supporting documentation was also available for reference. This included risk assessments, activity records, daily report sheets, personal care records, weight records and information on the outcome of health care appointments. Feedback received from residents via surveys and discussion confirmed the people living in Autumn Lodge had access to a range of health care professionals including; doctors, chiropodists, district nurses and opticians subject to individual need. Medication was stored in a locked room inside a drugs trolley and drugs cabinet. A fridge was also in place to store medication requiring refrigeration. The management team was advised to secure the medication trolley to the wall when not in use and to monitor and record the room and fridge temperatures. Since the last visit a photographic identity system had been established however a record of staff authorised to administer medication was not in place. Furthermore, written assessments of competency had not been undertaken in accordance with best practice. Previous inspection records detailed that all staff responsible for medication administration had undergone appropriate training. A sample of Medication Administration Records (MAR) were viewed during the visit. Overall, records viewed had been correctly completed to account for the administration of medication however the date that medication had been received into the service had not been recorded to provide an audit trail. Advice was also given regarding the recording of variable dosages. Staff spoken with demonstrated a satisfactory understanding of the principles of good care practice and the needs of the residents living at Autumn Lodge. Staff were observed to be attentive to the needs of residents during the day and feedback received from residents via care home surveys and discussion confirmed they received the care and support they required. Comments from three residents included; The girls [staff] are so kind. I am so well cared for; The carers are very good and I could never fault the care I receive. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Daily life and social activities are flexible and geared towards the needs and expectations of the people using the service. This enables people to exercise choice and control over their lives. Evidence: Autumn Lodge has an activities coordinator whose role is to plan and organise a range of activities for the residents to participate in. A weekly activities programme had been developed, which detailed that a good level of activities and social interaction was available for residents. The activities co-coordinator also produced a monthly newsletter for residents detailing what was happening at the home such as new members of staff, birthdays and forthcoming activities. A copy of the programme had been displayed in the reception area of Autumn Lodge. Activities on offer at the time of the visit included: exercises, manicure and hand massage, hairdressing, cookery, board games, bingo, singing, dancing, karaoke, craft work, picture painting and movie afternoons. Residents were positively encouraged and facilitated to maintain their links with Care Homes for Older People Page 15 of 29 Evidence: friends, family and the local community. Children from a local school had started to visit the residents at Autumn Lodge since the last visit and have presented school plays. Outside entertainers and a local regeneration group also visit periodically and organise sing-a-long sessions etc. There were also opportunities for occasional day trips. A roman catholic priest and church of england minister also visit residents, subject to individual religious beliefs. Visiting was unrestricted and residents confirmed they were able to receive visitors in their own room or any of the communal areas as they wish. One relative reported: All staff here are very pleasant to us and another stated; Autumn Lodge is always warm and cosy and has a relaxed but efficient atmosphere. The daily routines at Autumn Lodge remained as flexible as possible and residents spoken with confirmed they were encouraged and facilitated to make choices and exercise as much control over their lives as possible. A four week rolling menu had been developed and an alternative menu plan was available so that residents had an alternative choice on offer. The menu viewed confirmed that residents received a wholesome and nutritious diet. The menu plan was kept under review via the residents meetings, to reflect individual preferences and seasonal fruit and vegetables. Previous inspection records detailed that special diets could also be accommodated if required, for medical or cultural reasons. Meals were served in the homes dining room which provided a pleasant and comfortable environment for residents to have their meals. Although meals were generally served at set times, arrangements were flexible to accommodate individual needs. Residents also have the option of eating meals in their own room if they wish. Mealtimes were observed to be unhurried and staff were observed to be available to provide assistance to residents in a discrete and sensitive manner. Feedback received from residents regarding the meals was positive. For example, comments included; The food is very nice; I am well looked after and the food is good; I like the food. I can have alternative choices. They [staff] are very kind. Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their representatives are able to express their concerns via a complaints procedure and systems are in place to protect residents from abuse. This protects the rights of residents and ensures an appropriate response to suspicion or evidence of abuse. Evidence: The Annual Quality Assurance Assessment (AQAA) for Autumn Lodge confirmed that a Complaints Procedure had been developed for the service and a copy was displayed in Autumn Lodge for residents and their representatives to view. A recommendation was made to also display a copy of the Complaints Procedure in large print, to enable people to read and understand the information more easily. Examination of the complaints record book revealed that only one complaint had been received in the last 12 months. The complaint concerned the welfare of a resident and was later retracted by the complainant. Recording of complaints and concerns had improved since the last visit and no concerns or complaints had been received by the Commission for Social Care Inspection in the last 12 months. The management team demonstrated a commitment to encouraging people to express their comments and concerns and to listening and responding in a timely manner to resolve issues of concern. Likewise, feedback received from residents via care home Care Homes for Older People Page 17 of 29 Evidence: surveys and through discussion confirmed that the people living in the home knew who to speak to if they were not happy and how to make a complaint. Examination of the AQAA and previous inspection records confirmed policies and procedures were in place for the protection of vulnerable adults. The manager and staff spoken with demonstrated a satisfactory understanding of how to recognise and respond to suspicion or evidence of abuse. Training records highlighted that only nine of the 26 staff had completed formal training in adult protection. The management team were able to provide evidence that Protection of Vulnerable Training had been booked for fifteen staff to attend during December 2008 and reported that this training would be completed by all outstanding staff as a matter of priority. Care Homes for Older People Page 18 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment at Autumn Lodge is good providing a safe, homely and comfortable place to live. Evidence: Autumn Lodge was suitable for its stated purpose and presented as a well maintained, warm and comfortable environment. A maintenance book was in place to record work in need of attention and minor maintenance was undertaken by the owner and deputy manager. Contractors were hired for major and specialised work. The management team reported that the environment continued to benefit from ongoing maintenance and refurbishment which was clearly evident on the day of the inspection. All rooms and communal areas were pleasantly decorated and furnished and residents rooms had been personalised with various memorabilia and other personal possessions. The Annual Quality Assurance Assessment (AQAA) for Autumn Lodge detailed that the premises had been updated since the last inspection to include: a new walk-in shower; the installation of new vanity units and the fitting of new carpets and redecoration of eight bedrooms; the installation of new UPVC windows on the side and rear of the premises and the redecoration and fitting of a new carpet in the hallway. Care Homes for Older People Page 19 of 29 Evidence: Residents spoken with confirmed they continued to have access to all areas of the home and were enabled to maximise their independence via a range of specialised equipment and relevant aids. Handrails, assisted bathrooms and a passenger lift were available together with a call system in rooms and all areas of the home. (Please refer to the Brief Description of the Service section for more information on the premises). The AQAA detailed that policies and procedures had been developed for communicable diseases, infection control and the control of substances hazardous to health. The service employed one part-time domestic and a part-time laundry assistant to ensure the home was kept clean and hygienic. On the day of the visit Autumn Lodge was clean, tidy and free from any odours and the laundry and kitchen were both clean and well organised. A relative reported; The home is always clean and fresh. Likewise, a resident reported; Its very nice and spotlessly clean. Records were in place which confirmed the Environmental Health Officer had visited since the last visit. Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in Autumn Lodge are supported by a team of staff who know them well however induction and ongoing training and development needs further improvement to ensure best practice. Evidence: Rotas for Autumn Lodge detailed that the service was staffed with a manager and three care assistants from 9.00 am until 9.00 pm. During the night, three waking night staff were on duty. The management team was advised to also record the details of hours worked by the Owner and his family, as they also provided additional care and support to the people using the service. Feedback received from residents and their representatives confirmed the people living in Autumn Lodge received the care and support they required and that staff were available when required. For example, comments received from three residents included: Staff are always attentive; If staff are not available at the time, I have a bell to ring which is a good idea. Staff arrive in no time and They [Staff] always make time - no matter what. My life is the best it has ever been. The management team and staff were observed to apply a hands on approach to their role and staff were observed to communicate and engage with residents in a Care Homes for Older People Page 21 of 29 Evidence: respectful and positive manner. The Annual Quality Assurance Assessment (AQAA) for Autumn Lodge confirmed that policies and procedures were in place for recruitment and employment. Four staff had commenced employment during the last twelve months. Examination of recruitment records confirmed that recruitment practice had improved since the last visit and that the necessary records required under the Care Home Regulations 2001 had been obtained. The management team were advised to record on staff files the precise date that staff commence working in Autumn Lodge, to ensure a clear audit trail. Examination of staff files confirmed staff had received an in-house induction however this did not meet the requirements of the Skills for Care Common Induction Standards. Advice was given to the management team on where to obtain guidance, training logs and certificates to ensure compliance with national training standards. At the time of the visit the service employed 24 care staff. The training matrix and AQAA detailed that 15 staff (62.5 ) had a National Vocational Qualification at level 2 or above in Care. Three staff were also working towards a National Vocational Qualification. Previous inspection records detailed that a training programme had been developed for staff which covered all relevant specialist areas in addition to the mandatory topics such as fire awareness and prevention. Examination of the training matrix highlighted gaps in training for a range of subjects including fire safety, moving and handling, health and safety, infection control, food hygiene and dementia. The management team was able to provide evidence that training in first aid, COSHH, and Infection Control had been booked for 15 staff during December 2008. Advice was given to record the dates of staff training on the matrix and to ensure that all outstanding staff complete the full range of training applicable to their role. Care Homes for Older People Page 22 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed by an experienced manager and is run in the best interests of the residents. Evidence: The Registered Manager of Autumn Lodge (Mrs Kathryn Delpinto) is registered with the Commission for Social Care Inspection. Mrs Delpinto has managed the home for approximately 19 years and is supported in her role by her family, who take an active role in the operation of Autumn Lodge. Plans are in place for the assistant manager to apply for the registered managers position in the near future and consequently the assistant manager has been supported to complete the level 4 National Vocational Qualification Registered Managers Award. Feedback received from residents, their representatives and members of staff confirmed the manager was well respected and managed the home in an open and transparent manner. It was clear that the manager applied a Hands on approach to Care Homes for Older People Page 23 of 29 Evidence: her role and that she had a positive relationship with staff, residents and their families. Prior to the inspection, the Registered Provider (Owner) completed an Annual Quality Assurance Assessment (AQAA) for the service which provides key data and numerical information on the service. All sections of the document were completed, however there were areas were more supporting evidence would have been useful to illustrate what the service has done in the last year and how it is planning to improve. Advice was given to the management team on this issue. The Registered Provider (Owners) continued to visit the home on a daily basis and remained very involved in the running of Autumn Lodge. The Annual Quality Assurance Assessment (AQAA) detailed that the service had developed an Annual Development Plan for Quality Assurance. Records confirmed that questionnaires had been distributed to both residents and their representatives during July 2008, in order to obtain feedback on the quality of the service provided. The results of the survey had been recorded and discussed with residents during a residents meeting during October 2008. The manager reported that she did not act as an appointee for any of the residents as the people living in the home received support from family members or personal representatives to manage their finances independently. At the time of the visit, the management team looked after the personal spending money for 15 residents. Records of transactions were in place, cash balances checked were correct and receipts had been obtained to account for expenditure. The AQAA for Autumn Lodge detailed that health and safety policies and procedures had been kept up-to-date for all key areas. Service certificates were viewed for the fire extinguishers, electrical wiring, portable appliance testing and gas safety. It was noted that the emergency call equipment had last been inspected / serviced during November 2005. Furthermore, although the fire alarm system had been checked during September 2008, the owner was advised to ensure the fire alarm system and emergency lighting is periodically serviced and maintained, in accordance with guidance from the local fire officer. Some staff had not completed training in Safe Working Practice topics as identified in Standard 30. Care Homes for Older People Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 1 5, 6 The registered person shall 31/01/2007 ensure that the homes Statement of Purpose and Service Users Guide is reviewed and revised to make sure that residents and their representatives have the up to date information required to make an informed decision in relation to choice of home The registered person shall ensure that all residents have a contact (if privately funded) or appropriate Statement of Terms and Conditions. 31/01/2007 2 2 5 3 7 15 The registered person shall 31/01/2007 ensure that care plans are kept up to date so that staff have all the information required in respect of current assessed care needs The registered person shall ensure that appropriate risk assessments are carried out in a timely way to eliminate as far as possible unnecessary risks to the health and safety of residents. 31/01/2007 4 7 13(4)(c) Care Homes for Older People Page 25 of 29 5 29 19(1)(b) The registered person shall 31/01/2007 ensure that all the required information and documentation is obtained before a person can commence employment at the home in order to support and protect the residents. (Previous requirement of 31/03/06 not met) Care Homes for Older People Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The Statement of Purpose and Service User Guide should be updated to include the correct contact details of the Commission for Social Care Inspection, the admission process and the fire procedures in the home. The documents should also be produced in alternative formats, subject to the individual needs of residents. This will ensure prospective residents have access to key information on Autumn Lodge and assist them to read and understand the information more easily. A care plan form should be used to clearly identify the health, personal and social care needs of each resident and the support they require from staff to meet their needs. This will help to provide more succinct and accessible information for staff to follow. The date that medication is received into Autumn Lodge should be recorded on the medication administration chart to provide a clear audit trail. The actual date that staff commence employment in the home should be recorded on staff files, to provide a clear audit trail. This will help to provide evidence that preemployment checks have been received prior to staff working in Autumn Lodge. All staff should be supported to complete Safe Working Page 27 of 29 2 7 3 9 4 29 5 30 Care Homes for Older People Practice and other training relevant to their role and responsibilities, to safeguard health and safety. 6 30 All staff should complete the Skills for Care Common Induction Standards within the first 12 weeks of their employment, to ensure they are inducted in accordance with national standards. The Fire Alarm System, emergency lighting and call bell system should be serviced periodically in accordance with guidance issued by the local fire officer and manufacturer. This will help to safeguard the health and welfare of the people using the service. 7 38 Care Homes for Older People Page 28 of 29 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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