Care Home: Credenhill Court

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CARE HOMES FOR OLDER PEOPLE Credenhill Court Credenhill Hereford Herefordshire HR4 7DL Lead Inspector Philippa Jarvis Unannounced Inspection 28th January 2009 08:30 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 DS0000024702.V373969.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. DS0000024702.V373969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Credenhill Court Address Credenhill Hereford Herefordshire HR4 7DL 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) 01432 760349 01432 760755 thebarnoffice@btconnect.com Mr Narendra Nauth Mrs Sheila May Nauth Mrs Karen Elsie Evans Care Home 35 Category(ies) of Dementia (35), Mental disorder, excluding registration, with number learning disability or dementia (35), Old age, of places not falling within any other category (35) DS0000024702.V373969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 35 Dementia (DE) 35 Mental disorder, excluding learning disability or dementia (MD) 35 The maximum number of service users who can be accommodated is: 35 22nd February 2007 2. Date of last inspection Brief Description of the Service: Credenhill Court is registered primarily to provide accommodation and personal care for thirty five people over the age of 60 who need care due to their age or because they have care needs due to the effects of dementia related illnesses. There are also some people who have lived at the home for a while who are under 60 and have learning disabilities or mental health related needs. The home is no longer offering places to people under 60 or to people with learning disabilities. Credenhill Court is a large country house set in large grounds and has lovely rural views, especially from the rooms at the front of the house. Credenhill village church is reached from the same driveway and is just a few minutes walk from the Home. The village of Credenhill (with a post office and general stores) is about a mile away. Hereford city centre is 4 miles. The accommodation is on 3 floors with the majority of bedrooms being single. There are bathroom and toilet facilities on each floor and 2 sitting rooms and 2 dining rooms on the ground floor. DS0000024702.V373969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. We spent a day at the home, talking with the people who live there, the staff and the manager. We also looked at the records that must be kept by the home to show that it is being run properly. These include the records relating to the care of people who use the service. In this inspection we also used an Expert by Experience. These are people who have direct experience of using care services themselves. She spent time in the home with residents and staff and provided us with a report about her findings. These findings are reflected in our report. Before the inspection the home completed an Annual Quality Assurance Assessment (AQAA). This told us how they thought they were performing. We took this information into account in planning our inspection. It also gives us some numerical information about the service. Some of the manager’s comments have been included in this inspection report. We also received completed survey forms from people who use the service, from staff and from health and social care professionals who work with the home. The information from them helps us to understand how well the home is meeting the needs of the people who use the service. What the service does well: The home provides a homely environment for people to live in and to visit. There is written information available for people to help them decide if they wish to move into Credenhill Court. They are also welcome to visit or for a short stay to help them make up their minds. There is an open atmosphere in the home with ready access to the complaints procedure. The expert commented that: “It was apparent that the residents felt free to engage with me on any issue partaking to their level of care, without feeling they were letting the staff or home down.” People who live in the home are well presented and receive appropriate personal care. The home provides a varied menu of nutritious home-cooked DS0000024702.V373969.R01.S.doc Version 5.2 Page 6 food. The home has achieved a four star rating for food safety from the environmental health department of Herefordshire Council. The premises are clean and the home provides a safe and comfortable environment for the people who live there. People who use the service have freedom of movement around the home. Staff know how to prevent the spread of infection. The staff who work in the home are kind and caring. People who use the service speak highly of them. This was also confirmed by the expert who said, “The care staff carry out their duties with great respect for the residents and they show great respect and empathy for their needs.” There is an active training programme and most staff have received most relevant training. This includes training in how to ensure that vulnerable people are protected from abuse or neglect. The management of the home promotes the health and safety of the people who live there and the staff who work there. The service provider carries out formal monthly visits and also provides support for the home in between these visits. What has improved since the last inspection? What they could do better: DS0000024702.V373969.R01.S.doc Version 5.2 Page 7 The home should prepare an initial plan of care for people as soon as they move into the home. All care plans should be kept under regular review so that the home is confident that the staff know how to meet the current health and personal care needs of everyone who lives there. The home also needs to ensure that it makes suitable provision for health care professionals who visit the home so that they can see residents in an area that is private and has suitable facilities. Medications must be administered more carefully so that there are no mistakes. Then people can be assured that they will receive their medicines safely and as prescribed. There are times of the day when the care staff are very busy and the home needs to keep their staffing arrangements under review so that they can be certain that they have sufficient staff cover at busy times of the day. Whilst people have ready access to the complaints procedure we were not confident that all complaints received were detailed in the complaints log. 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. DS0000024702.V373969.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 DS0000024702.V373969.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 and 3. 6 is not relevant in this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is written information available to help people decide if they wish to move into Credenhill Court. They are welcome to visit the home to help them make up their minds about whether it is the right home for them to live in. The home needs to make sure that there is an initial care plan to guide staff about how to meet their care needs. EVIDENCE: We received surveys from twelve people who use the service. Ten of these told us that they had been given enough information to help them decide whether they wished to live at Credenhill Court. The home has a Statement of DS0000024702.V373969.R01.S.doc Version 5.2 Page 10 Purpose and a Service User Guide that provide appropriate details about facilities at the home. In their AQAA the home told us that, “People are encouraged to look round and even stay overnight to help them make a decision about whether this is the right home.” We looked at the records of one person who had come to live in the home recently and found that an assessment had been carried out before she was admitted and information had been gathered from the referring agency. These help the home to understand peoples care needs and to make an assessment as to whether they can meet them. However this had not been written up as a plan of care to inform care staff about the care to be provided although the person had been resident in the home for over a week. We spoke with this resident who told us that they had been helped to settle in the home. DS0000024702.V373969.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are set up for each permanent resident in the home and they are reviewed although not as regularly as is appropriate. These provide staff with guidance about how to meet people’s care needs. Whilst there are systems in place for the administration of medication, there have been errors which have placed people at risk. EVIDENCE: We observed daily life in the home in general terms and we looked at the experience of three people who use the service in detail. This included looking at their files, meeting them, talking to relatives if possible and observing their life in the home. DS0000024702.V373969.R01.S.doc Version 5.2 Page 12 We found that each person was well presented, in a manner to suit themselves. The expert by experience commented that, “The residents were cleanly presented wearing freshly laundered clothes; some of the ladies had manicured polished nails and assured me the beautician visited each month.” We found that there was a plan of care in the files of people who had lived in the home for a period of time, but not for the person who had been recently admitted. There were details of people’s needs in their care plans. These had been reviewed every few weeks, but not at least monthly as is the expected standard. We saw evidence that the manager has now set up a system for the senior carers to review them monthly and the manager reported that she intends to keep a check on this process although it was not fully in operation at the time of the inspection. We found that assessments of people’s needs were usually carried out in relevant areas such as moving and handling, pressure area assessment and nutritional needs. The information from these assessments was then translated into plans of care. These were available for staff to use. Whilst there was a reasonable amount of detail, care needs to be taken to ensure that guidance is provided in all areas, for example we read the file of one person who had a contracted hand but there was no information about this and how to care for it appropriately. Staff were able to tell us verbally how they provided suitable care in this situation. We found there were manual handling assessments in place and that the home had equipment for meeting people’s manual handling needs. We looked at the records of one person assessed as at risk of malnutrition. Her care plan said to monitor her food and fluid intake and there were charts in her room to do this. Her plan also said she was at risk of choking although there was no guidance about how to manage in such an event and her weight had not been recorded since August 2007. Her nutritional assessment was not dated. There was a daily record kept for each person living in the home. This was written in some detail. In this we found information about people’s care needs that was not always transferred into their plan of care. In one situation that we found we were unable to confirm whether a health care professional had been asked to attend to identified needs. There was written information available that confirmed that people had received personal care including a bath or shower at suitable intervals. All the residents who responded to the surveys told us that they thought their health care was well attended to. We were able to speak to one visiting health professional from the dental access clinic during our visit and they confirmed that the home made appropriate contact with them. A visiting GP comes to DS0000024702.V373969.R01.S.doc Version 5.2 Page 13 the home on a regular weekly basis and district nurses also visit regularly as required. We had one contact form a health care professional who indicated that health care referrals were not always made in a considered and timely way. Concerns were also raised about the lack of a suitable room in which health care professionals could see residents. The manager reported that the home is in the process of setting up a more appropriate room. The home appropriately reported two errors in medication to us in the two months before the inspection. These included people being given double doses of prescribed medication. They put steps into place to help remove the risk of this happening again. We looked at the storage of medication and this was done in an orderly manner. We also looked at the record of administration; this was well maintained. The home has changed to a monitored dosage system to help reduce the risk of mistakes being made. They have also introduced a system where two members of care staff take part in each medication round to provide oversight and guidance. The errors were reported to the GP who provided guidance about how to manage each situation and they were also been reported to us as required by regulation. All staff who administer medication receive training in how to carry out this task. DS0000024702.V373969.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a limited range of activities for people to take part in and needs to ensure that they carefully assess each person’s preferences for these. There is a varied menu of nutritious food available. EVIDENCE: In their surveys people who live in the home told us that there were activities available, five said always and six said sometimes. However all but one member of staff said they thought there should be more activities provided. On the day of our visit there was a film shown in the main lounge and a number of residents chose to watch this. There was a good size screen available suitable for the size of the room. There was a list of what was to be provided each day displayed in one corridor. There are a number of activities that people particularly enjoy and the expert found that: DS0000024702.V373969.R01.S.doc Version 5.2 Page 15 “Each Thursday a delivery of flowers is made by Sainsbury’s and several ladies take part in a floral arrangement session.” We spoke to the relatives of two residents who said they had seen limited activities provided. One told us that last summer they had been aware that she was taken out into the garden in her wheelchair. The home told us that they have plans to make an area in the garden where residents can go out unescorted if they choose. We found limited information in people’s files about their previous interests and hobbies and little guidance for staff about how to ensure that their needs for occupation or activity were met. Care plans should be developed to look at how each person’s preferences can be taken into account. In the afternoons the staff are expected to spend time with the residents and to involve them in activities. These include bingo, pamper sessions and a weekly sing-along. In their report the expert commented that: “Although at present there is no delegated member of staff charged with overall responsibility to implement and maintain a level of activity appropriate to the diverse needs of the residents, very shortly a well established staff member will develop this role. At present many of the residents sit in the main sitting room with the television on and no one is viewing it.” Residents and staff confirmed that they are able to choose what time to get up and go to bed. Visitors also told us that they were able to visit the home at any time and that they were always made welcome. They also told us that the home communicates well about relevant issues concerning their relative. People that we spoke with told us that they enjoy the food that is provided. Relatives also told us that they thought the food was of a high standard. The menus showed a varied selection of meals based on nutritional home cooking. Emphasis is placed on trying to ensure that people eat at least five portions of fruit and vegetables each day. We saw that the bananas taken out in the afternoon were a popular choice. Although the cook has many years experience of cooking for older people she is currently doing a nutrition course at a local college to enhance her understanding of how to cater for the nutritional needs of older people. Meals were provided at regular intervals with drinks also provided throughout the day. In the AQAA the home indicated that menus are changed regularly with an emphasis on ensuring that those needing special diets such as diabetic or low fat were catered for. There was a water dispenser in the lounge and we saw residents using this for extra fluid intake. The home has achieved a four star rating for food hygiene from the local environmental health department. DS0000024702.V373969.R01.S.doc Version 5.2 Page 16 The expert commented on the provision of food. “There are two dining rooms one for the males and the other for the females. Each room is bright and clean with plenty of drinks accompanying the meals. Residents unable to access the dining area are served in an area suitable to them e.g. one of the sitting rooms.” DS0000024702.V373969.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 and 18. Quality in this outcome area is good. People have access to a complaints procedure and are kept safe through good procedures for managing abuse and neglect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the homes complaints procedure in the hall and all residents are given a personal copy within their Service User Guide. Since the last inspection we have referred one complaint to the home for the service provider to investigate. However we were told in the AQAA that the home has not received any complaints in the last year. When the home employs new staff, there are checks which must be carried out to ensure that unsuitable people are not employed and therefore help to protect the people living there. These include CRB checks and two written references. We found that the home was carrying out recruitment procedures appropriately. The home makes sure that people who work there receive training in the protection of vulnerable people. We were shown a training matrix that confirmed that all but three staff have trained in this aspect of practice and DS0000024702.V373969.R01.S.doc Version 5.2 Page 18 that further training was planned to take place in March to include these staff and to provide updates for other staff in the home. Staff we spoke were able to tell us what action they would take if they thought that a resident was being abused or neglected. People told us that they feel safe living in the home. DS0000024702.V373969.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and comfortable environment for the people who live there. There is continuing work to upgrade the premises. EVIDENCE: Credenhill Court is a large detached house, about four miles outside the city of Hereford, set in spacious grounds. The expert commented that: “Credenhill Court is situated in an elevated position overlooking beautiful countryside. It has acres of good gardens but alas as yet they are unsafe as an outdoors facility for frail, elderly or confused residents. During the course DS0000024702.V373969.R01.S.doc Version 5.2 Page 20 of my visit I learned a portion of the garden close to the home is due for transformation into a safe haven for the residents.” There are two lounges, one with a television, and one designated as a smoking lounge. The smoking area will shortly be moved when work on moving the laundry, currently well underway, is completed. The second lounge will then provide a lounge suitable for all residents to use and which is designated particularly for activities. Both lounges are comfortable and furnished with armchairs and bookcases. There are two dining rooms both of which are pleasant and fitted with suitable furniture. We looked in a sample of residents’ rooms and found that they were comfortable and well personalised. One room we visited had vinyl floor covering although the family f the resident did not know why. The manager told us that there was a particular reason and that it would be replaced with carpet when the room was vacated. There is a programme of upgrading of the premises that is ongoing. In their AQAA the service told us that a number of areas have been redecorated, that a new bathroom with wheelchair access has been completed and new furniture purchased. The home has also introduced the use of a maintenance log to help the maintenance man identify and prioritise maintenance needs accurately. In the AQAA the home also identified a number of areas that they intend to improve in the next twelve months such as installing a dishwasher, installing a sluice room, improving the ground floor toilet block to make it more domestic in style and creating an enclosed garden so people with dementia can go out independently in a safe environment. We found that the home was clean and fresh throughout with no unpleasant odours. This was confirmed by the residents in their surveys. The expert also said that: “The home is kept very clean. “ In the AQAA the home told us that all staff take training in infection control. We found that care staff showed good understanding of the principles of infection control and that there was appropriate equipment throughout the home to help prevent the spread of infection. DS0000024702.V373969.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that staff are kind and caring. They support the people who live in the home well although there are times when the staff are busy. There is an active training programme to help ensure that staff have the right knowledge to meet their needs. EVIDENCE: We spoke with the manager, some staff and observed staff during the day. The staff rota shows that the home aims to have five care staff on duty in the morning, four carers form 1pm to 6pm and five from 6pm to 11pm with three on duty overnight. At all times one of the care staff is a designated senior carer. In addition there is the manager and the deputy manager both of whom are supernumerary. We spoke with staff, and were also told by them in their surveys, that there were times when they were very busy, “We are always rushing about.” Two particular times of pressure were identified: the mornings when residents may get up very late because of lack of availability of care staff (two of the five on duty are involved in the medication round) and tea time. A carer told us, “in the afternoons they send a carer into the kitchen to make sandwiches, tea, that normally takes the whole afternoon. Then that only DS0000024702.V373969.R01.S.doc Version 5.2 Page 22 leaves 3 carers on the floor.” In the afternoons this situation should improve when the home employs a member of staff with designated responsibility for activities. In addition to the care staff there is domestic, catering and maintenance staff for the home. We checked three staff files and the information in these showed that staff are recruited in a way that protects people. Background checks were carried out and the files contained proof of their identity and a photograph of the staff member. Following recruitment staff undergo an induction programme that meets the right standard. They also shadow experienced staff until they feel sufficiently competent to work independently. We read information about the training that staff receive. There is an ongoing training programme with plans to address some shortfalls in training e.g. some staff have not trained in moving and handling for over a year but there is a date for further training scheduled in February. There were also a number of staff who have not received any fire safety training for over a year. The home aims for all staff to take training in working with people with dementia illnesses. We read one file where the staff member had not completed this training but was enrolled on a distance learning course. In the AQAA the home told us that there are eight members of staff with an NVQ and a further five working towards this competency based award. The number of staff assessed as competent within the NVQ framework within the home needs to increase to meet the expected standards. In the AQAA the home told us that staff are required to undertake an NVQ as part of their contract of employment. We spoke to and observed staff with people using the service and they appeared to have the right knowledge and understanding of the people they are supporting. In all twelve surveys we received the residents told us that they receive the care and support they need from staff and eleven told us that the staff always listen to them. We saw staff treating residents with kindness and respect throughout the day of the inspection. DS0000024702.V373969.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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in a way that promotes the health and well-being of the people who use the service. EVIDENCE: The manager has been recently registered at Credenhill Court although she has previous experience of managing a home for older people. She continues to take training to ensure her knowledge is up to date and is currently taking a distance learning course in managing diversity. She is supported by a deputy manager and an administration assistant to help with administrative tasks. DS0000024702.V373969.R01.S.doc Version 5.2 Page 24 The service provider is also actively involved in the home and writes monthly reports on the progress of the home under the requirements of Regulation 26. The manager completed the AQAA and the information in this generally reflects what we found during the inspection. The home does not encourage people who live there to hold money. They do hold some money on people’s behalf. We saw a record in which this is recorded and found that it is accountable. There was no information in the care plans that we read to indicate the arrangements in place for the handling of their personal monies and how to ensure that residents had access to items that they needed. The process of staff supervision and appraisal is starting in the home. The AQAA indicated that these are all up to date but we read the files of two new staff neither of whom has yet received supervision. On the file we read of a more established staff member there was a form to indicate that they have taken part in a supervision session but this was not dated to indicate when it had taken place. The home has a dedicated health and safety officer who works in the two homes in the group and who ensures that all appropriate health and safety checks and tests are carried out. We reviewed the fire log and found that all tests and checks were carried out with appropriate frequency. We also saw that water temperatures are checked. In the AQAA the home reported that equipment in the home is regularly serviced. The maintenance man carries out minor repairs. We found that the manager carries out the moving and handling risk assessments for residents but she has not received dedicated training in how to undertake risk assessments. The manager confirmed that all senior staff have completed training in first aid. This means that there is always someone on the premises who has a qualification in this area. We saw the accident and incident book for the home. This appears to be recorded with the right detail. DS0000024702.V373969.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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 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 DS0000024702.V373969.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 15 Requirement Timescale for action 30/06/09 2 OP7 15 3 OP9 13(2) 4 OP38 13 Each person living in the home should have a plan of care for daily living based on the needs assessment done by the home or the Care Management assessment so that staff have clear guidance about how to meet each persons health and personal care needs. The plans of care must be 30/06/09 written in sufficient detail so that staff have clear guidance about how to meet the residents needs in all areas. The plans must be kept under review so that staff have up to date guidance about how to meet all aspects of people’s health and personal care needs. The home must ensure that they 30/05/09 have suitable systems in place for the administration of medication so that they protect people who use the service form risk of harm caused by the incorrect administration of medication. The manager, deputy or a senior 30/06/09 member of staff must undertake DS0000024702.V373969.R01.S.doc Version 5.2 Page 27 training in how to carry out risk assessments so that they have the knowledge and skills to carry out this task in a way that helps prevent residents being at risk of harm or injury. 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 The home should ensure that it keeps a record of all complaints that it receives and the action that it takes to resolve them. This will help people who use the service to feel their concerns are taken seriously. Staff supervision and appraisal needs to be carried out regularly and a record kept of this activity to help the professional development of care staff and to help the agency monitor whether they are working in the right way. The registered person should consider obtaining information about residents preferred daily routine on admission to the home so that they can ensure that the home is staffed to cope with periods of peak activity. 2 OP36 3 OP12 DS0000024702.V373969.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. 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