Care Home: Faith House

Similar services:

• Fairfields Country Rest Home
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home
• Belma
• Hunters Care Centre
• Manor Lodge

What the care home does well Generally the home was found clean, warm, well lit and free from unpleasant odours. The atmosphere of the home was noted to be relaxed; individuals living in the home looked well cared for in their homely environment. Staff were interacting with service users in an informal, respectful, personalised and dignified manner. Prospective service users have detailed needs assessment, using different tools, before admission to the Home to ensure that the home is able to meet the individual`s need. The deputy manager stated that the Home ensures that a Service Users Guide is sent or given to the prospective service user or their relatives when they make enquires to enable them to make an informed choice about moving to the Home. Individuals spoken with at this visit confirmed this information. Evidence from the visitors book shows that families, friends, relatives and other visitors are encouraged to visit the home to ensure that regular contact is maintained. Service users we spoke with stated that they were satisfied withthe care provided for them, staff are kind and that their relatives are able to visit the home at any time without restrictions. There are ongoing training courses to enable staff to meet individual service users needs and to ensure that staff were aware of how to protect individuals from harm and abuse. Individuals living in the home are enabled to complain through a robust complaints procedure and the home would ensure that all complaints are thoroughly investigated and all required action (if any) implemented. What has improved since the last inspection? A review of the last inspection requirement in relation to medication administration evidenced that this has been met in order to provide adequate protection to the individuals from medication errors. However some discrepancies noted on the day regarding medication administration were remedied on the day. The manager told us that the steps at the front and sides of the home that were slippery and unfriendly to wheelchair users have been replaced with nonslip concrete and hand rails to enhance the health and safety of the service uses, staff and visitors. New carpets have replaced badly worn ones and stepping-stones placed across the rear lawn to increase service users` safety whilst accessing different areas of the home and the garden. The home stated in their Annual Quality Assurance Assessment that they have given the service users freedom to make choices and to lead active, secure, safe lives that includes practising their own religions and customs. What the care home could do better: To minimise accidents to identified individuals, accidents must be followed up and the risk assessments and care plans completed/reviewed. Individuals living in the home would receive appropriate care if care plans were in place for all identified needs. Prospective service users and their families would receive accurate information if the Statement of Purpose and the Service Users guide were updated. To ensure that staff are aware of actions to be taken in actual fire emergency it could be better if they regularly attended fire drills.Staff would be able to protect the service users from harm and abuse if they undertake training on the protection of vulnerable adults from abuse. Furthermore, service users would be adequately protected if staff undertake training on First Aid and Control of Substances Hazardous to Health (COSHH). CARE HOMES FOR OLDER PEOPLE Faith House Station Road Severn Beach South Glos BS35 4PL Lead Inspector Grace Agu Unannounced Inspection 13th March 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Faith House DS0000066329.V359995.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. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Faith House Address Station Road Severn Beach South Glos BS35 4PL 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) 01454 632611 owlsnest04@btinternet.com Mrs Toni Sylvana Stevens Mr Gary Brian Stevens Mrs Toni Sylvana Stevens Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Faith House is a privately owned care home providing accommodation for eight elderly people. The property is a bungalow with first floor extension. On the ground floor there are six single bedrooms, four of which have en-suite facilities. There are a further two en-suite bedrooms on the first floor as well as a staff sleeping-in room. The home has one bathroom with an assisted bath. The large kitchen/diner is very much the heart of the home, with a large dining room table where the service users and staff take meals and spend time together. There is also a spacious and comfortable lounge for service users to enjoy. Faith House is located in Severn Beach, near to the sea wall and overlooking the Severn Estuary. The train station is approximately 100 yards away, where journeys into the centre of Bristol can be taken. There are also a number of local shops and a Post Office within a short walk. The home is located near to the M5 and M4 motorways, and the nearby Cribbs Causeway shopping complex provides a wider range of larger shops. There are several daytime clubs in the nearby locality that service users can attend if they wish as well as the local church. The owner, Mrs Stevens works full time at the home, supported by her staff team and her husband. Faith House DS0000066329.V359995.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 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection which took place over nine hours and was undertaken to review the requirements made at the last inspection and to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. At the last inspection three requirements were made, it was pleasing to note that the home had made efforts to ensure that the requirements were met. At this inspection an unsafe practice in relation to safe administration of medications was dealt with immediately to prevent further occurrence. The service users were noted relaxed and staff were noted interacting with the service users in a dignified and respectful manner. We met with the manager and provider Mrs Toni Stevens. Whilst touring the building, we spoke with six service users; three staff members and a number of records were viewed. What the service does well: Generally the home was found clean, warm, well lit and free from unpleasant odours. The atmosphere of the home was noted to be relaxed; individuals living in the home looked well cared for in their homely environment. Staff were interacting with service users in an informal, respectful, personalised and dignified manner. Prospective service users have detailed needs assessment, using different tools, before admission to the Home to ensure that the home is able to meet the individual’s need. The deputy manager stated that the Home ensures that a Service Users Guide is sent or given to the prospective service user or their relatives when they make enquires to enable them to make an informed choice about moving to the Home. Individuals spoken with at this visit confirmed this information. Evidence from the visitors book shows that families, friends, relatives and other visitors are encouraged to visit the home to ensure that regular contact is maintained. Service users we spoke with stated that they were satisfied with Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 6 the care provided for them, staff are kind and that their relatives are able to visit the home at any time without restrictions. There are ongoing training courses to enable staff to meet individual service users needs and to ensure that staff were aware of how to protect individuals from harm and abuse. Individuals living in the home are enabled to complain through a robust complaints procedure and the home would ensure that all complaints are thoroughly investigated and all required action (if any) implemented. What has improved since the last inspection? What they could do better: To minimise accidents to identified individuals, accidents must be followed up and the risk assessments and care plans completed/reviewed. Individuals living in the home would receive appropriate care if care plans were in place for all identified needs. Prospective service users and their families would receive accurate information if the Statement of Purpose and the Service Users guide were updated. To ensure that staff are aware of actions to be taken in actual fire emergency it could be better if they regularly attended fire drills. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 7 Staff would be able to protect the service users from harm and abuse if they undertake training on the protection of vulnerable adults from abuse. Furthermore, service users would be adequately protected if staff undertake training on First Aid and Control of Substances Hazardous to Health (COSHH). 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. Faith House DS0000066329.V359995.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 Faith House DS0000066329.V359995.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): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensures that service users are assessed before admission to ensure that their needs will be met. However a review of the Statement of Purpose and Service Users Guide is needed to provide accurate information to prospective service users and their relatives. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide. However these two documents have not been updated. This is to provide accurate and required information to prospective service users and their relatives when they visit the home or make enquiries to enable them to make an informed choice about moving into the home. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 10 The registered manager stated that these documents would be reviewed and copies sent to the Commission for Social Care Inspection. Updated copies of the above documents were received at the Commission before the report was completed. At a discussion with a recently admitted service user, the individual stated that the relatives came to look round and were satisfied with the home. The registered manager told us that the individual was assessed when he visited the home before admission. There is evidence in the care file to confirm that this happened. The registered manager also stated in the Annual Quality Assurance Assessment document that new service users are encouraged to come for a period of 1-2 weeks respite and another 4-6weeks trial period to enable them to decide whether to stay. Terms and conditions of their stay at Faith House were noted in files viewed. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers care and support to service users throughout their lives and towards the end. It protects service users by appropriate risk assessments and care plan review. Medication administration practices were satisfactory and protect individuals living in the home. EVIDENCE: We looked at six care files at this visit. Records showed that one recently admitted individual had pre-admission assessment. There was evidence of personalised care plans, which described how these needs are to be met, and the care plans were recently reviewed. The service users that we spoke with confirmed that their privacy was never compromised when staff assisted them with personal care. One individual stated that they were satisfied with their care. “I am very comfortable here. Everyone is very kind”. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 12 Staff were noted knocking at the service users’ doors and waiting for an answer before going in to assist service users with personal care demonstrating that individuals living in the home are treated with respect and that their privacy is maintained. However we looked at one care file of an individual with a recent fall. We noted that the person had a risk assessment put in place to help to minimise these falls however, this was not reviewed so that staff can support and protect this individual from possible injury. We discussed this with the registered manager and it was agreed that the risk assessment must be put in place along with the care plan review in order to protect this person. One care file of a service user with a terminal illness contained records of referral and visits from the hospice nurse. Also noted on the care file were doctor’s visits to review the pain control and any other issues affecting comfort of the service user. On the care file were risk assessments, manual handling risk assessments, nutritional risk assessment and weight monitoring records. These were regularly reviewed. Whilst we noted that there was a care plan identifying that the individual was on pain control medication there was no care plan to support staff with monitoring the pain. We discussed this with the manager and it was agreed that the care plan must be put in place to ensure that the individual is adequately protected and comfortable. There was evidence of visits from the Doctor, optician, chiropodist and other health professionals on the care files reviewed. Medication administration was reviewed and was noted satisfactory. However records seen show that Controlled drugs were recorded in a way that could potentially cause drug error. This was discussed with the manager and the problem was remedied immediately. There was evidence in the care files viewed of details of service users’ wishes in the event of death. One staff member that we spoke with showed awareness of policies and procedure regarding dealing with a dying individual and at the time of death. The staff member was aware of the importance of keeping information about service users’ confidential. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to maintain contact with families and friends and local community and are provided with varied activities and nutritious meals. EVIDENCE: From discussions with individuals living in the home and from information contained within the feedback forms we sent to the home it appears that service users find the everyday life experience within the home is in line with what they expect and prefer and that it satisfies their social, religious and recreational interests. Service users were really kind about the support and attention they receive from the home. The manager said that service users are treated as part of a big family. For example, all service users are invited to two garden parties by service user’s family in their home this year. A record of all activities that each person had undertaken is recorded in the care file. These activities include the arts club organised by one staff member. The paintings seen were very good. The home manager stated that the arts club had a beneficial effect on one individual with a mild mental health illness, as the person tends to concentrate better when doing the paintings. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 14 Service users confirmed that they enjoyed participating in these sessions and also enjoyed it when there was a church service at the home. Service users also said they enjoyed the library service and going for walks in the local area. From discussion with staff members it was clear that activities undertaken are dependent on individuals choice as to whether they participate or not. The manager told that an aromatherapist comes in to offer professional massage to service users and that those suffering with arthritis have benefited the most. One comment card from a relative stated “There is no unnecessary rules and various interests are encouraged and fostered. Extra help and care is available if required but individuals living in the home are allowed to do their own thing if possible”. Lunch being served during the visit was chicken casserole, broccoli, cabbage and roast potatoes with assorted pudding. The inspector had lunch with the service users and found the meal tasty and nutritious. Service users told the inspector that the food was always ‘delicious and tasty’ with alternatives offered. The manager showed us the revised menu that was due to be implemented and would offer service users more choices at both lunch and evening meals. This shows that the home has complied with the requirement made at the last inspection in regards to menu choices. The kitchen was found clean and staff have attended basic food hygiene training to ensure that the residents are adequately protected. The visitors’ book showed that the relatives and representatives regularly visit the service users. Service users spoken with stated that they had regular visitors. One service user spoken with stated “ My family visit regularly and sometimes they take me out for lunch”. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are confident that their complaints would be listened to and taken seriously. Individuals living at the home are protected from potential abuse due to understanding in this area. EVIDENCE: The complaints logbook for the home was viewed; it was found that a reported complaint by a person in relation to care of their relative had been dealt with effectively to the satisfaction of those involved. A copy of the home’s complaints procedure was on prominent display at the home. Information on how individuals are able to raise issues or make a complaint was seen in individual contracts, with information including the arrangements for contacting the Commission for Social Care Inspection if the individuals were not happy with the outcome of a complaint investigated by Faith House. Comments from service users during the inspection included ‘I feel very happy here I have no complaints”. All of the service users spoken with during the visit were positive about the care they receive and stated that they were happy with no complaints or concerns raised to us. Individuals living at the home told us that the relationships with the registered manager and staff are well established. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 16 One comment card that we received from a relative states, “ The standard of the home from all aspects are very high. The staff all act in a professional way and are caring and conscientious, therefore I can see no reason to complain”. There is no evidence that any staff at the home is on the protection of vulnerable adults list. There was evidence that the complaint received by the home was recorded and that the outcome was satisfactory. Training records seen at the home showed that new staff have not attended protection of vulnerable adult awareness training and there have been no updates for staff members that have been working at the home for long periods. This is to ensure that staff are familiar with action to be taking if incidents of abuse occur. The registered manager stated that they are making arrangements to ensure that the identified staff members attend this training as soon as possible. A requirement has been issued to ensure that this takes place. Staff members were aware of their responsibility in relation to reporting incidents of abuse if it occurs in order to protect the service users. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 25 26 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 suitable, safe and well-maintained environment where service users are happy to live. EVIDENCE: Faith House is a privately owned care home providing accommodation for eight elderly people. The property is a bungalow with first floor extension. On the ground floor there are six single bedrooms, four of which have en-suite facilities. There are a further two en-suite bedrooms on the first floor as well as a staff sleeping-in room. There is also a spacious and comfortable lounge for service users to enjoy. Faith House is located in Severn Beach, near to the sea wall and overlooking the Severn Estuary. The train station is approximately 100 yards away, where journeys into the centre of Bristol can be taken. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 18 There are also a number of local shops and a Post Office within a short walk. The home is located near to the M5 and M4 motorways, and the nearby Cribbs Causeway shopping complex provides a wider range of larger shops. There are several daytime clubs in the nearby locality that service users can attend if they wish as well as the local church. The home is well managed and safe and the quality of furnishings and fittings in the home is good, providing a warm comfortable and homely environment to ensure that individuals’ needs are met. The manager also stated that there has been on-going refurbishment since the last inspection. These included complete refurbishment of the lounge, six bedrooms and replacement of all the carpet in the hallway. The kitchen has been replaced and a new hot cupboard and dishwasher have been installed along with timed lighting at the front and sides of the home, for extra security. There is a high standard of décor and furnishings in the lounge and dining areas, which were also spacious. Service users were observed sitting in the communal areas of the home and looked very relaxed and settled in their environment. Lighting within the home is domestic in style and of a good standard, emergency lighting is provided throughout the home, we saw that this is checked on a monthly basis. A hand test of the water temperature found the temperature was at a safe level, the temperature in the home was warm and comfortable. No areas of health or safety concern for those living at the home were seen at this visit. The home was clean, tidy and odour free throughout. Domestic staff are employed at the home and were carrying out their duties during the inspection. Infection control at the home is well managed with staff being provided with protective clothing and appropriate products to undertake their duties. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 19 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): 27,28,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment process demonstrates safeguards are in place and ensures staff competency with adequate numbers and skill mix along with training to protect service users. EVIDENCE: The home has a robust recruitment procedure to ensure that suitable staff are recruited to meet service users’ needs. Records of two recently recruited staff members contained required information to include personal details, previous employment details, two satisfactory references, Criminal Record Bureau (CRB) disclosures and relevant qualifications. On the day of inspection there were two care assistants from 8am to 3pm. Two care assistants from 3pm to 10pm and one care assistant from 10pm to 8am on sleep-in duty. Mr and Mrs Stevens live on the premises and are able to attend the service users in emergency. There was one domestic staff on duty on the day. Staff spoken with stated that they attended various training courses to include food hygiene, manual handling, fire safety, health and safety and medication. The manager stated that they are making efforts to ensure that training update on the Protection of Vulnerable Adult is arranged at the home and in particular for a newly employed staff member. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 20 Furthermore. It was agreed that to ensure that the service users are adequately protected First Aid training must be provided for staff to ensure that they are aware of actions to be taken in an emergency situation if and when they occur. One staff member spoken with stated that she had been employed for one year, she stated that the induction period was very valuable, she stated that she worked with another staff member for six weeks before she felt confident to assist service users with personal care independently The manager stated that of four care staff; two care staff are undertaking National Vocational Qualification (NVQ) at level 2. A requirement had been issued for the staff member working as domestic to undertake courses on Control of Substances Hazardous to Health (COSHH) training and Infection Control to ensure that the service users are well protected. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 21 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): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and is run in the best interest of those living at the home. The health, safety and welfare of service users at the home are promoted and protected. EVIDENCE: Faith House is a residential care home in Severn Beech, with registered providers Mr. and Mrs. Stevens; Mrs. Toni Stevens is also the registered manager for the above service. The home was established many years ago and the principles of care are based on Christian values. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 22 The registered manager Mrs Stevens has acquired skills and experience over the years to enable her to support the staff to provide good standards of care for the individuals living in the home. Mrs Stevens told us in the Annual Quality Assurance Assessment that the home provides a high standard of care within a comfortable environment that incorporates the wishes of service users and families as much as possible. The home also ensures that equal opportunities is offered to all service users and practiced by staff. Service users are encouraged to practice their religion and this is respected at all times. Staff spoken with stated that the manager is approachable and would listen to concerns raised. Staff are more involved in decision-making “she would have dinner with us and make us feel valued”. One staff member told us “she is the best manager I have worked for”. One comment card received from a staff member states “ we have regular staff meetings to have update on any general care or changes needed for individual service users. Any other changes needed for individual service users are updated via staff communication and managerial intervention”. One resident stated that the manager is “approachable and comes round to see us ”. Another resident stated, “The new owners are very good, they have made a lot of changes and they are very good to us. They are a lovely couple”. One comment card received from a relative states, “ The home is well managed in a very friendly and homely way. Service users and staff being as a big family”. All service users that we spoke with told us that they were very happy with the care and the services that the home provided for them. We looked at the policies and procedures in place at the home, these are appropriate to the service provided and the manager stated that all of the documents would be reviewed as required. We also viewed the fire logbook for the home. The home was completing the appropriate checks on the fire equipment and the recording of training, fire drills and the testing of equipment were satisfactory. We noted that the fire risk assessment was undertaken on 20/3/07 and updated in March 2008. The fire panel was in working order. In regards to how the home measures the quality of it services the manager stated the home has an open door policy to enable service users, relatives, friends and other visitors to approach the management at any time to talk about any issues, confidential or otherwise. Other tools include, service users Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 23 and relatives verbal satisfaction, personal care audit, menu audit, Social Services reviews and regular staff meetings. Individual’s records and home records are secure, up to date, in good order and are kept secure. Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 24 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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 13 Requirement Ensure that accidents to service users are followed up and risk assessments and care plans completed/reviewed to protect them. Ensure that appropriate care plans are in place for an individual’s identified needs. Ensure that the Statement of Purpose and the Service Users guide are updated to provide accurate information to prospective service users and their relatives. Staff must attended fire drills so that they are aware of actions to be taken in actual fire emergency. Ensure that staff undertake training on First Aid and Control of Substances Hazardous to Health (COSHH) to ensure that the service users are protected. Timescale for action 13/04/08 2. OP7 15 31/03/08 3. OP1 6 13/05/08 4 OP38 13 13/04/08 5 OP30 18 13/05/08 Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 26 6 OP30 18 Ensure that staff members undertake training on the Protection of Vulnerable Adults from abuse in order to adequately protect the service users. 30/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Faith House DS0000066329.V359995.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!