Care Home: Cottage Christian Nursing & Residential Home

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What the care home does well On this occasion the home more than met minimum standards for older people, from the stage where people are thinking about moving into the home, its day to day management, and its care and support provided by a committed and loyal team. Inspection findings confirmed the opinions expressed by a regular visitor to the home who stated, `Cottage Christian has a very homely atmosphere which helps residents settle easily. The carers take a keen interest in their residents, especially their likes and dislikes.` People in particular made comment about the excellent management of their health care needs, and the home demonstrated this with their meticulous recordkeeping for many aspects of nursing care, especially for wound care. The care team have a high percentage of staff who have attained the minimum expected care qualification, and nursing staff have developed themselves to keep up to date with current professional practices. The home is committed to continuously improving the service it provides and has thorough monitoring systems to make sure they explore and act upon opinions and suggestions of all people living visiting and working at the home. Excellent administration systems in the home mean that people can be confident that important issues like managing the safekeeping of their finances and valuables are well taken care of. What has improved since the last inspection? What the care home could do better: There were no requirements made at this inspection. It is considered that Cottage Christian care home continues to raise its standards and is setting its own objectives for continual improvement with the full involvement of its residents. CARE HOMES FOR OLDER PEOPLE Cottage Christian Nursing & Residential Home Granville Road Newport Shropshire TF10 7EQ Lead Inspector Janet Adams Key Unannounced Inspection 11th December 2007 09:30 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 Cottage Christian Nursing & Residential Home DS0000065121.V345287.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. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cottage Christian Nursing & Residential Home Address Granville Road Newport Shropshire TF10 7EQ 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) 01952 825557 01952 820883 thecottage@schealthcare.co.uk www.southerncrosshealthcare.co.uk Trinity Care Limited Mrs Beverley Harvey-Howson Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (29), Physical disability (6), Terminally ill (5) of places Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate a maximum of 6 persons with a Physical Disability. The home may accommodate a maximum of 5 persons who are Terminally ill. Staffing levels in the home must meet the minimum levels required throughout the 24 hr day, including weekends, for service users who have low to medium nursing needs. Additional staff must be on duty when high dependency service users are accommodated. These minimum levels are for direct nursing and personal care only. They do not include ancillary staff. 07:30-14:00 08:00 30-34 clients Assistants 34-39 clients Assistants 40 clients Assistants Date of last inspection 31st October 2006 2 RN`s 6 Care Assistants 2 RN`s 2 RN`s 5 or 6 Care Assistants 2 Care 2 RN`s 6 Care Assistants 2 RN`s 5 Care Assistants 1 RN 3 Care 2 RN`s 5 Care Assistants 2 RN`s 4 Care Assistants 1 RN 2 Care 14:00-20:30 20:00- Brief Description of the Service: Cottage Christian is a purpose built care Home registered to provide both personal and nursing care for up to a maximum of 40 Older People. This may include people with a physical disability and people with terminal illness. The Home is owned by Southern Cross Healthcare and is situated near the centre of the small Shropshire town of Newport, which means it is accessible by public transport. Shops are to be found within walking distance nearby and a modern Health Clinic is immediately adjacent. All bedrooms are fully furnished and have en suite facilities. The communal Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 5 areas are homely and comfortable. The gardens are well maintained and easily accessible. Current weekly fees were not specifically listed in the home service user guide. The reader may wish to obtain further up to date information from the care service itself. Information about the home and the service it provides is detailed in the statement of purpose and service user guide. Copies of these are readily available upon request as you enter the home. Commission for Social Care Inspection Reports for this service are available from the provider or can be obtained from www.csci.org.uk Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector and lasted six and a half hours. Some time before the inspection, we wrote to the home to request some up to date information to assist with this process. This meant that although Cottage Christian knew the inspection was imminent, they were not aware of the date or time the inspection would take place. The inspection included observing activity within the home, inspecting the premises, an ‘in depth look’ at records for residents and staff, as well as observing, talking and listening to over half of the 37 people living there. Several of the staff on duty at the time of the inspection also shared their views about working at Cottage Christian care home. Discussions with people were carried out in private with people on their own, or together in groups in the lounges. Everyone was happy to share their comments, which are included in the main body of the report. A total of 5 residents, 6 relatives and 5 staff members also returned written comments about the home to us. Everyone, including residents and staff, was very welcoming and helpful throughout the inspection. A total of 22 out of a possible 38 National Minimum Standards for Older People were assessed on this occasion. Discussions with the Registered Manager took place throughout the day, and feedback about the conclusions of the inspection was given at the end of the inspection and upon receipt of all the CSCI Survey information. What the service does well: On this occasion the home more than met minimum standards for older people, from the stage where people are thinking about moving into the home, its day to day management, and its care and support provided by a committed and loyal team. Inspection findings confirmed the opinions expressed by a regular visitor to the home who stated, ‘Cottage Christian has a very homely atmosphere which helps residents settle easily. The carers take a keen interest in their residents, especially their likes and dislikes.’ People in particular made comment about the excellent management of their health care needs, and the home demonstrated this with their meticulous recordkeeping for many aspects of nursing care, especially for wound care. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 7 The care team have a high percentage of staff who have attained the minimum expected care qualification, and nursing staff have developed themselves to keep up to date with current professional practices. The home is committed to continuously improving the service it provides and has thorough monitoring systems to make sure they explore and act upon opinions and suggestions of all people living visiting and working at the home. Excellent administration systems in the home mean that people can be confident that important issues like managing the safekeeping of their finances and valuables are well taken care of. What has improved since the last inspection? What they could do better: There were no requirements made at this inspection. It is considered that Cottage Christian care home continues to raise its standards and is setting its own objectives for continual improvement with the full involvement of its residents. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 8 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. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 9 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 Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 10 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 & 6. Quality in this outcome area is excellent. Admission procedures clearly demonstrate the home can meet needs of people thinking about moving into Cottage Christian care home. This makes sure that if prospective residents and relatives choose this home, it will meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a welcome pack, which is given to all interested parties or people thinking about moving into the home. It contains a statement of purpose, a service user guide, home newsletter, menu and company brochure that offers details of all aspects of the services Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 11 the home provides. The welcome packs were seen to be freely accessible in the reception area. An in depth look at the admission records of two people admitted to the home since the last inspection confirmed that excellent standards of recordkeeping have been maintained for this matter. Details seen written down confirm staff collect as much information as is necessary for the home to decide whether they can meet the person’s personal and health care needs before they move in. An initial plan of care is generated at the point of admission based on these assessments. Whenever possible the person or their representative is fully involved in the care planning process. Two family members confirmed that visits were made to the home prior to making the decision to move in. In addition to using a comprehensive form to record a detailed assessment of a person’s needs, the home also use an ‘admission checklist’ when the person moves in, and the staff sign and date it to demonstrate any newcomer gets welcomed with the right information about the home. All eleven people who sent written comments to CSCI confirmed they received enough information about the home before they moved in, and praised the home for being supportive and helpful during this time. One person wrote, ‘ Our mother has only lived at the home for a short time, and the way they handled her admission has transformed all of our lives. Cottage Care have been absolutely brilliant’ The home does not offer an intermediate care service. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 12 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 excellent. The health and personal care carried out by support team is based on the specific needs of the person, making the individual feel valued and unique. The principles of respect, dignity and privacy are put into practice. The medication at this home is safely managed to make sure it promotes good health for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care staff were observed to be assisting residents with personal care discreetly and in a manner which promotes a persons dignity. Staff, residents and visitors were observed to be interacting well with lots of chatter and conversation occurring. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 13 All of the of written comments received about the care carried out for the residents of Cottage Christian care home were complimentary. 100 of the people who made comments to CSCI stated people living at the home received the medical support they need and that the staff listen and act on what the residents say. One person wrote, ‘Medical problems are dealt with very promptly, and the nursing care is very good’. Whilst another stated, ‘I am confident Mum is well looked after and safe. Mum says she has a new lease of life’. A staff member also wrote to CSCI to say, ‘If a member of my family needed to live in a home, this is the one I’d recommend’ Information provided by the home before the inspection stated, ‘We implement detailed care plans for our clients. The care plan includes personal preferences, likes and dislikes, for each individual’. In order to check out this comment, an in depth look at the records of five people living at the home who have a variety of support and nursing needs was carried out. Each set of records was of an excellent standard. Attention to details in the care records gave a realistic ‘pen picture’ of all people’s daily needs being carried out. They were presented in a way that made the information easy to read and understand. Colour coded forms were helpful for the reader to refer to each section of interest. Care assessments had been kept up to date, and contained enough detail so everyone knew how to keep the individual safe whilst promoting personal well being and independence. Monthly reviews of this information, or sooner when a change was identified, showed the resident and/or relative being fully involved in the process. For example, examination of records for people who required wound care showed that they were being managed to a very professional standard. Weekly photography of any wound is carried out to make sure there is a permanent record of any progress a wound makes. Likewise, the recordkeeping for people who need bedrails to keep them safe was seen to be meticulous. It was obvious the staff that had written the assessment for this equipment have up to date knowledge about the professional guidelines for this matter. Assessment of the home medication management systems showed the home staff follow robust policies to make sure they are handled safely at all times. A very knowledgeable nurse who was on duty during the inspection explained systems for the safe receipt, storage, administration and disposal of medications. Spot checks of record keeping for this matter reflected team expertise in these procedures. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 14 The home also makes sure there are safe working systems for people who choose to administer their own medication. One person with eyesight problems continues to get the support she needs to enable her carry out this task herself. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 15 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 Excellent. People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments received from people living at the home and their visitors all confirmed the home has a strong commitment to enabling residents to develop or maintain their skills, including social, emotional, communication, and independent living skills. Written comments from visitors were unanimous to confirm the home always made every effort to help individuals living at the home keep in touch. Communication between staff, residents and their next of kin was also reported to be good. One person wrote. ‘Even though I visit mum several times a week they also contact me with any queries about her.’ Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 16 100 of people who replied to the CSCI survey confirmed the care service supported people to live the life they choose. One commented, ‘Staff take a lot of care and listen to people ’ The home has an open visiting policy and also issues a monthly newsletter so all interested parties are kept up to date with news concerning the home. A wealth of information was collected during the inspection to confirm Cottage Christian care home arranges social and recreational activities based on individual’s abilities and interests. Discussion with the newly appointed activity coordinator confirmed she was getting to know residents wishes and feelings by spending time to compile ‘life histories’ to explore any potential hobbies and interests which could trigger stimulation for meaningful pastimes. The home has a notice board designated specifically to display articles of interest for residents and visitors, including the monthly activity programme and current mealtime menus. The activities programme of December identified 17 different activities being held, including shopping outings, concerts and a pantomime trip. This was also seen on display near the upstairs lounge. Religious services and Holy Communion are arranged regularly throughout the month for anyone wishing to partake. The statement of purpose contains information for assisting with the upholding of spiritual needs. Inspection findings confirm that the quality of meal provision in the home continues to improve. • The home has continued to attain a ‘Gold ‘ healthy eating award following inspection by the local environmental health department. • An innovative practice launched by the company that owns Cottage Christian Care home known as the Nutmeg system also confirms the quality of meals the home provides. As part of this computer system when the planned meals are displayed on the weekly menu there is a ‘nutmeg’ graph also on display to show people the food content and dietary balance that is being offered. From the chefs point of view the system identifies any nutritional imbalance and suggests how to adjust it simply and quickly. Observations and discussions with staff on duty confirmed they were knowledgeable about people’s dietary needs, and the best way to serve their residents’ food so they can dine independently. All residents who made comments about the meal provision were in agreement that the food was very good, and they always had plenty of choice of alternative options if they did not fancy the main meal of the day. During the inspection a lunch of fish was seen being served cooked in a variety of ways. When people in the dining room were asked what they thought of their meal they all nodded in agreement with a comment made by Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 17 one person who said the food was ‘grand’. This reflected many positive written comments CSCI also received about the food. For example another person wrote, ‘Excellent food and good cups of tea’ Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 18 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 excellent. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Review of the complaints management system shows that the company welcomes this type of issue in order to improve the service it provides. The information to welcome complaints and comments is clearly displayed in communal areas of the home. The service has a complaints procedure that is up to date, clearly written, and is easy to understand. It is on display in the reception area of the home, and included in the information people receive in their welcome pack. All written comments received from people living at the home and those spoken with said they would know who to talk to if they wanted to make a complaint. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 19 Two concerns have been raised within the home since the last inspection, and are clearly accounted for in the home complaints register, and confirm the comments in the information the home sent to us before the inspection that the home: • Answers all complaints within the allocated time span. • • Have a complaints file kept in the administration office with all relevant paperwork. Provide an open door policy were you can raise any concerns with the manager. Improvement in staff training and general home management show the home works hard to make sure satisfactory systems are in place to safeguard residents. Training records stored in the manager’s office were available to confirm all staff have received adult abuse awareness training in the past twelve months. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 20 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 & 26 Quality in this outcome area is good. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Cottage is a purpose built home fully suited to the needs of the people currently living there. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 21 All residents who made comments to CSCI about the home were unanimous to confirm the home always smelled fresh and had a welcoming, clean and tidy appearance. One person wrote, ‘The home has a good standard of décor and furnishings.’ The fire officer inspection of the premises in July 2007 was satisfactory, as was the outcome of the visit by the Environmental Health Officer in November 2007. Inspection of the kitchen showed that all health and safety measures were being carried out to make sure this important area is being kept in a safe clean and hygienic condition At the time of the inspection all areas of the home were clean and well presented although hand washing facilities in some parts of the home were in need of improvement, especially in the laundry and the staff room. At the time of the inspection the home was awaiting the report as a result of a follow up infection control audit by the Health Protection Agency, who also observed this to be an issue –however the manager reported that actions to provide necessary equipment such as pedal bins had already been actioned. The home has an ongoing refurbishment programme to keep it maintained and a maintenance man is employed 30 hours a week to carry out essential works including bedrail safety checks. Random testing of hot water in bathrooms showed they were within safe limits in the region of 43 degrees Centigrade, and the home records confirmed they continue to get checked at least weekly. The inspector saw in excess of 14 bedrooms. All were well furnished, decorated, maintained and adapted to meet the wishes of the people who occupied them. Attention to minor detail in the provision and layout of furnishings in bedrooms shows that maximising day to day independence is also promoted. For example, a mirror located at eye level on a wardrobe door meant one gentleman could continue to shave himself in the comfort of his armchair. It was positive to see where bedrails were installed there was evidence they had been checked to be kept safe. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 22 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 & 30. Quality in this outcome area is good. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments received by people living at the home were unanimous to confirm that staff always listen and act upon what they say and that they were usually available when they needed them. Relatives and visitors were generally in agreement and many comments such as, ‘The staff are very caring and willing to help’ were received. There were some comments about the home being short staffed and to explore this further, staff duty rotas were examined, and comments were sought by discussions with staff members and the manager. Findings confirmed the home:• Is adequately staffed with the appropriate skills of nurses and carers to meet the needs of residents. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 23 Some agency staff are still employed at the home, and the week before the inspection three shifts had been covered by these staff for night duty. The home has had to resort to agency use in recent times to cover shortfalls from losing overseas staff due to work permit challenges as well as to cover staff sickness. However a recent successful recruitment drive has enabled the manager to appoint enough suitable staff to put this right. Examination of the records of two new starters since last inspection demonstrated a robust recruitment and vetting process for this matter. It was positive to see thorough ‘new employee training’ records in both people’s records. All staff comments received agreed their induction covered most aspects of their job role and responsibilities. In order to further improve on this matter new starters have been allocated more time to shadow experienced staff when they first start work in the home. It is also positive to report that many aspects of staff training continue tom progress well during the past 12 months. The information the home provided before the inspection confirmed that 72 of the care team have the minimum expected care qualification and that 16 of the care team are in the progress of attaining it. All staff were in agreement they received enough information in order to care for the people living at Cottage Christian care home, and many positive comments were received. All were in agreement that they receive training relevant to their role to keep them up to date with new ways of working. One commented, ‘Most training is in house – it is good we get paid for all training we attend.’ Another stated, ‘Recently we have been in contact with nurse specialists in the head and neck unit at the local hospital and a motor neurone disease nurse specialist so that we can deliver appropriate care’. • Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 24 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 excellent. The management and administration of the home is based on openness and respect, with effective corporate quality assurance systems. A competent company management team closely supports the manager to ensure the effective running of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Beverly Harvey – Howson, the registered manager for the home is a first level nurse with the knowledge and experience to successfully manage the home on Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 25 a day-to-day basis. Since the last inspection she has developed herself to attain her Registered Managers Award qualification. Throughout the duration of the inspection she demonstrated a sound knowledge of the current resident group and her team. There are very clear lines of accountability both within the home and with the external management structure of Southern Cross Healthcare. Since the last inspection, changes within the home now mean that Cottage Christian care home benefits from new management structure which has been implemented since the recruitment of a Deputy Manager and a Sister. Between the three of them they submit statistics about 18 different aspects of the service it is responsible for, to Southern Cross Head Office on a monthly basis, about issues such as such as complaints, accidents and resident health. These facts are in turn monitored by a company operational manager. The quality of service Cottage Christian care home provides is considered priority, and any comments received from the people living visiting and working there are valued most highly and acted upon. The home continues with its monthly quest for comments through satisfaction surveys, and resident and relative meetings, and shares all news about the home by their monthly newsletter and by displaying the latest information in the reception area of the home. The robust methods the home follows to manage all monies and valuables held in safekeeping for its residents assure CSCI this aspect of resident well being is safeguarded. Records of staff meetings and supervision sessions show the staff team have been motivated and encouraged to embrace all training offered. A system to keep a check that all staff get the supervision and appraisals they require continues to be been successfully established. Records confirmed that over 83 of staff have received supervision sessions in the past two months. As a result of the introduction of new ‘Southern Cross’ record books improvements in recordkeeping for essential maintenance and Health and Safety records now more than meets basic requirements of current legislation. For example, the Southern Cross accident record book has clear easy to follow guidance specifically designed to enable care home staff record the right details about an individual who is involved in such an incident. The home also has the benefit of an in in-home trainer, and trained an inhouse moving and handling trainer for both day and night duty to maximise the opportunity of maintaining health and safety practices in the home. One staff member commented, ‘I have only worked at CC for a short time but I am impressed by the way it is run, with mutual respect for clients and staff’ Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 26 In October 2007 the home was subject to an unannounced ‘Patient and Public involvement in Health’ visit. The report reflected good practice. No recommendations were made. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 27 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 3 X 4 Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Not applicable. 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 OP26 Good Practice Recommendations In order to maximise the management of infection prevention for people living working and visiting the home, it is recommended the home follow any guidance recommended following a recent infection control audit by the Health Protection Agency. Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Cottage Christian Nursing & Residential Home DS0000065121.V345287.R01.S.doc Version 5.2 Page 30 - 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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