Care Home: Farriess Court

What the care home does well People told us they continue to be cared for in a respectful and dignified manner, and comments about the care and support included:"The staff are good, and things are good here, my bedroom is lovely". "Life is good in this home; it`s nice, and quiet. I go out in the morning for a walk and to collect my newspaper". "The staff are very good and caring, they would do anything for us" "The routines are relaxed here, and we have plenty of fun things to do. The food is good and we have choices, I am satisfied". Visitors spoken to told us the visiting times were flexible, and the staff are welcoming. The staff team reported that they work well together and have access to training opportunities to enable them to have the skills and knowledge to fulfil their roles. They said they now feel supported as an acting manager is now in place. There are systems in place to enable people to provide feedback about the service and make suggestions for improvements. What has improved since the last inspection? Our last visit highlighted a number of areas requiring improvement. This visit confirmed that improvements have been made in all of these areas to address or to work towards addressing each of these. The following improvements have been made: The contract or terms and conditions of residency now include the fees payable. This ensures people are aware of the amount they are paying to live in this service. The care plans have been updated to ensure they include people`s preferences and are person centred. This is to ensure staff have access to the required information to deliver individualised care. Each person has had risk assessments completed in order to monitor their mobility, pressure areas, nutrition and falls. This ensures those risks that identified can be minimised. We found that the handling and recording of medicines had improved greatly since the last inspection. Records on medication charts indicated that people received their medicines as prescribed. A system is now in place for the recording and monitoring of complaints. This ensures people feel listened to and the records reflect the complaints and action taken in response to these. All staff have attended training in safeguarding people from harm. This ensures staff members are aware of what to do if they witness any potential abusive situation. The smoking area has been relocated into a room with appropriate ventilation. This means people are no longer at risk of smoke inhalation in the communal areas. The staff team have access to the required mandatory training to ensure they maintain their skills and knowledge in order to fulfil their role and responsibilities. The service now has an acting manager who is in the process of completing her application to register with us. This ensures the service is managed in people`s best interest and the staff team, have leadership and direction in their roles. A system is now in place to consult people and gain their feedback. This ensures they are consulted about their care and the running of the service. A system is in place to ensure all staff members receive regular supervision. This ensures they are supported in their role. What the care home could do better: We have made no requirements following this inspection visit. We have made some good practice recommendations for the service to consider, which if implemented will enhance the service provided to people. CARE HOMES FOR OLDER PEOPLE Farriess Court 103 Boulton Lane Alvaston Derby Derbyshire DE24 0FF Lead Inspector Claire Williams Unannounced Inspection 20th January 2009 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 Farriess Court DS0000065783.V373878.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. Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Farriess Court Address 103 Boulton Lane Alvaston Derby Derbyshire DE24 0FF 01332 755555 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) Mr Allen William Heath Manager post vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories 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: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 26 2nd September 2008 Date of last inspection Brief Description of the Service: Farriess Court Residential Care Home provides care for up to 26 Older People. The Home is situated within its own grounds, and comprises of an older building, with ground floor and first floor facilities that retains many of its original features. In addition to this a modern ground floor extension provides 5 single bedrooms. The Home has a communal dining room and two main sitting rooms. There is a passenger lift for access to the first floor. There is a varied selection of bedrooms, both singles and double that are available. People are permitted to smoke, and a designated smoking room is now available which is fitted with the required ventilation. The Home is located between the areas of Alvaston and Allenton, and has access to several GP surgeries, and is within walking distance, to a small range of shops. The current charges for living at Farriess Court Care Home range from £314 week to £353 a week, dependent on the bedroom provided. People have to pay for toiletries, hairdressing, and transport as these are not covered in the fees. A copy of the Commission’s inspection report is available from within the Home and information is provided to people in the format of a service user guide. Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 5 Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is Two Star. This means the people who use the service experience good quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of a day. This is the third Key inspection visit to this service this year. This visit was undertaken to monitor and ensure improvements had been made to the service provided to people. Some of the previous shortfalls were in relation to the medication practices; therefore a Pharmacist inspector assisted us with the inspection and examined the medication systems and practices in place. In order to prepare for this visit we looked at all of the information that we have received since our last visit which was undertaken on 02/09/08. This includes: Notifications and information received from the service about events that have occurred. We also used the improvement plan we received as evidence of the improvements the provider said they would make. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of two people representing a cross section of the care needs of individuals within the service. Discussions were held with those individuals as able, together with a number of others about the care and services the home provides. Their care planning, and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their deployment, recruitment, induction, training and supervision, and records examined to support the procedures in place. What the service does well: People told us they continue to be cared for in a respectful and dignified manner, and comments about the care and support included: Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 7 The staff are good, and things are good here, my bedroom is lovely”. “Life is good in this home; it’s nice, and quiet. I go out in the morning for a walk and to collect my newspaper”. “The staff are very good and caring, they would do anything for us” “The routines are relaxed here, and we have plenty of fun things to do. The food is good and we have choices, I am satisfied”. Visitors spoken to told us the visiting times were flexible, and the staff are welcoming. The staff team reported that they work well together and have access to training opportunities to enable them to have the skills and knowledge to fulfil their roles. They said they now feel supported as an acting manager is now in place. There are systems in place to enable people to provide feedback about the service and make suggestions for improvements. What has improved since the last inspection? Our last visit highlighted a number of areas requiring improvement. This visit confirmed that improvements have been made in all of these areas to address or to work towards addressing each of these. The following improvements have been made: The contract or terms and conditions of residency now include the fees payable. This ensures people are aware of the amount they are paying to live in this service. The care plans have been updated to ensure they include people’s preferences and are person centred. This is to ensure staff have access to the required information to deliver individualised care. Each person has had risk assessments completed in order to monitor their mobility, pressure areas, nutrition and falls. This ensures those risks that identified can be minimised. We found that the handling and recording of medicines had improved greatly since the last inspection. Records on medication charts indicated that people received their medicines as prescribed. A system is now in place for the recording and monitoring of complaints. This ensures people feel listened to and the records reflect the complaints and action taken in response to these. Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 8 All staff have attended training in safeguarding people from harm. This ensures staff members are aware of what to do if they witness any potential abusive situation. The smoking area has been relocated into a room with appropriate ventilation. This means people are no longer at risk of smoke inhalation in the communal areas. The staff team have access to the required mandatory training to ensure they maintain their skills and knowledge in order to fulfil their role and responsibilities. The service now has an acting manager who is in the process of completing her application to register with us. This ensures the service is managed in people’s best interest and the staff team, have leadership and direction in their roles. A system is now in place to consult people and gain their feedback. This ensures they are consulted about their care and the running of the service. A system is in place to ensure all staff members receive regular supervision. This ensures they are supported in their role. What they could do better: 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. Farriess Court DS0000065783.V373878.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 Farriess Court DS0000065783.V373878.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): National Minimum Standards 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people are provided with the information they need to know about the service and assessments take place prior to admission ensuring that the service can meet their needs. EVIDENCE: People told us they still have access to information about the service, and they confirmed they have received a copy of the Service user guide. These documents need to be updated to ensure they reflect the current management arrangements. The terms and conditions and/or contracts have been revised and include the fees for each person. This enables people to be aware of how much they are paying to live in this service. We were told the service have not had any new admissions since our last visit. Pre-admission assessments are now in place to enable all prospective people to Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 11 be assessed before a decision is made about whether the service is right for them and can meet their needs. The home does not provide intermediate care and there were no residents accommodated at the time of the site visit with diverse cultural or religious needs. The pre -admission documentation is currently being updated to include the six areas of diversity, so that is it inclusive to all people. Farriess Court DS0000065783.V373878.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): National Minimum Standards 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. Each person has a plan of support which covers their personal, health and social care needs, which they had been involved in making. This ensures support is provided based on their preferences. EVIDENCE: In response to the requirement we made following our last visit, all care plans have been reviewed. We looked at two files and both of these contained person centred care plans that covered all of the persons needs. The files reflected people’s preferences, which ensure people receive individualised care which meets their expectations. Each care plan that we sampled contained the required risk assessments that should be undertaken to monitor people’s mobility, pressure areas, nutrition and falls. There was evidence in the files to support that the plan of care is reviewed on a monthly basis. However when their are no changes, the record just states ‘reviewed’ and no further information is recorded. It is good practice to include Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 13 a further explanation about peoples general well being in addition to the information about identified changes to the care plan. There was evidence in the files to support that formal annual reviews are undertaken. The care records that we sampled confirmed that contact with external healthcare services is routinely made. During our visit the dentist was on site and people told us they access their doctors and district nurses, as and when required; this was supported by observations during our visit. All people spoken to told us they continue to receive support which is provided in a safe, respectful and dignified manner, and our observations, which the exception of the administration of some medication, supported this. Discussions with relatives also confirmed this to be the case. People and their relatives spoke positively about the staff team and comments made include; “The staff are good and very caring, they look after us well”. “I like it here, it is good and I am well looked after”. “It is a nice place to live, quite and relaxing”. A pharmacist inspector examined the medication systems and records. The report from the pharmacist inspector is as follows: We found that medicine storage facilities were tidy and not over-stocked. We observed that the lock on the medicine cupboard was not very secure, and there was no lock on the door of the room where medicines are kept. These issues were addressed during our visit. We observed that keys were also kept inside this cupboard, and a member of staff not qualified to handle medicines asked for access to the cupboard three times during the inspection. This issue was addressed and the keys were relocated to ensure the medication was secure and safe. The controlled drugs cabinet complied with the relevant legislation. The medicine fridge was locked and the temperature was recorded each day. However, the thermometer in the fridge was not of the maximum/minimum type, which is good practice. The medication therefore may not be as effective as it should be, as it may have been stored at an incorrect temperature. We found that staff had recently received training on medicines and were putting what they had learned into practice. We watched medicines being given to people at lunch-time, and saw that medication administration records (MARs) were completed correctly. lock all medicines away safely when she left the medicine trolley to give a person their medicine. We found that accurate records of the receipt, administration and disposal of medicines are kept. The quantities of a sample of peoples’ medicines were compared to these Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 14 records and the numbers of tablets in containers were correct. We looked at the home’s medicine policy and found that it needed up-dating. Farriess Court DS0000065783.V373878.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): National Minimum Standards 12- 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People find the lifestyle experienced in the service meets their expectations and preferences. EVIDENCE: All care files that were sampled now contained some information concerning people’s social needs and likes/dislikes. Work has commenced to update each person’s file to include information about their family and about their past and life history. This enables the staff team, to learn more about the person and their background. People told us they continue to have access to activities that meet their expectations. During our visit we observed people visiting the hairdresser, and reading newspapers which they collected from the local shop. People had a sing along, and participated in movement to music. The activities co-ordinator continues to encourage people to participate in various activities, and observations supported that she was very interactive with people and motivated in her role. Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 16 People told us they had enough to do in the service and the following comments were made: “We have plenty of things to do and our activities staff member is great and we have lots of fun”. “I enjoy the singing especially the old songs, as they bring back good memories”. “The routines are flexible here, it is very free and easy and we can do as we like”. “We had a great time at Christmas especially at out Christmas show it was good fun”. We spoke to a visitor who told us they felt welcomed into the service, and could see their friend / relative in private if they wished. They told us they thought the staff were “caring”. People told us their daily routines continue to be flexible, and they could choose what time they rose and went to bed. People who wanted to stay in their bedrooms were able to do so. People told us they liked the food provided and described it as “nice” and “tasty”. They told us they have choices, at each meal time and observations supported this. The cook told us she was aware of people’s dietary requirements. However a record of these and of people’s likes and dislikes is not currently available in the kitchen or in people’s files. A brief visit was made to the kitchen and good standards were maintained and all required documentation was in place. Farriess Court DS0000065783.V373878.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): National Minimum Standards 16, and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems in place ensure people have confidence to raise their concerns, and are safeguarded from harm. EVIDENCE: During our discussions with people they told us they knew how to complain and they said they would not hesitate to raise any issues with the staff team or acting manager. A complaint book is now in place, and the procedure is displayed. The service has received three complaints since our last visit. These were in relation to the following; the food, as it was not seasoned enough on one particular day, a bedroom door no longer being propped open due to fire legislation, and about the laundry. All issues have been responded to and resolved, and all outcomes recorded. A copy of the Multi-agency Safeguarding adult’s procedures could not be located during this visit. However contact was made to Social Services during our visit and we were told a copy was put in the post. It is beneficial for these procedures to be in the service so that the staff and acting manager are aware of the local protocols. These should be followed in accordance with the internal procedures, which when sampled still needed to be updated to link in with the local protocols. Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 18 There was evidence to support that all staff, including the domestics and catering staff have completed safeguarding adults training. When we spoke to staff members they had a good knowledge on what action they should take if they had any suspicions or witnessed any practices of abuse. All staff members were able to describe an understanding of their responsibilities in reporting these. The service or CSCI have not received any safeguarding issues since our last visit. Farriess Court DS0000065783.V373878.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): National Minimum Standards 19 and 26. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The environment was well maintained, and met peoples needs. EVIDENCE: People using the service have access to a smoke room, which has been fitted with the required ventilation. This means that people in communal areas are no longer at risk of inhaling smoke, and that the service meets the new legislation requirements. During this visit when we undertook a tour of the building we identified several hazards. These included: • • • Toiletries and razors, in the bathroom area that were not labelled. Emollient Cream in the bathroom. The outside bin was overflowing with items and bags of rubbish left on the floor. DS0000065783.V373878.R01.S.doc Version 5.2 Page 20 Farriess Court Once identified these items were removed and the building was made safe for people to move about in. The outside bin was tidied and items placed inside the bin. There was evidence in the minutes from the last staff meeting; to confirm that the acting manager had spoke to the staff team, about leaving individuals personal belongings in communal areas. However staff are still continuing to leave items in these areas. A renewal and maintenance programme is in place, and areas are renewed on a priority basis. People who were spoken to told us they continue to enjoy living at this service and comments made include: “I like the building it is very homely” “My bedroom is nice and I really like the front room it is very homely”. People said they liked the communal areas and in particular their bedrooms which they had personalised with their belongings. People said they continue to have access to various aids and equipment in order to assist them in their mobility and to get around the home. Farriess Court DS0000065783.V373878.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): National Minimum Standards 27 to 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a competent staff team, who have been recruited to ensure they are safeguarded from any harm. EVIDENCE: During our visit we observed that there were sufficient staff members on each shift, to meet people’s needs. We were told the staffing levels were flexible and dependent on people’s needs. People and their relatives told us that enough staff are available at all times. Staff members told us they were able to provide a good standard of care and complete all required tasks based on the current levels in place. A training matrix was in place. This and the evidence in peoples file confirmed that staff are now accessing the required mandatory training, and are up to date with any refresher training or this is now planned. This ensures staff members have the required skills and knowledge for their role. We examined the recruitment file for the most recently employed staff member. All of the required information was available except for evidence to support that a Povafirst check had been completed. Evidence was presented by the provider of the completed Povafirst check the following day and placed on file. Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 22 The current application form does not request a full employment to be provided and only requests 3 years. However a full employment history was provided in the staff member’s file. Although we were told that references from care related employers were validated to check their authenticity, there was no evidence to confirm this practice. There was evidence to support that the staff member had completed a service specific induction. She had evidence to demonstrate that she had completed the skills for care induction at a previous service, and a National Vocational qualification to a level 2 standard. There was evidence to support that more than half of the staff team have already completed this award and more staff will be enrolling on this course in the near future. Staff members spoken with told us how much they enjoyed working in this service and how motivated and committed they were to ensure people received a good standard of care. People said their needs are met and confirmed that staff provided a good standard of care and support, comments made include: The staff are kind and caring They do a good job and are very caring Farriess Court DS0000065783.V373878.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): National Minimum Standards 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 Health, safety and welfare of people and staff is promoted and protected in this service. EVIDENCE: The service now has a permanent acting manager, who has many years experience of working with older people and being in a senior role. She told us she was in the process of completing her application, to register with us. She is currently completing her registered manager’s award which will mean that she will be qualified for this position. Staff, people, and relatives spoken to said that they found the acting manager to be experienced, supportive and approachable. The staff members told us the service was well managed now and the service was a “better place to Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 24 work”. Staff told us they now felt valued and everyone worked as part of a team. People also spoke positively and the following comments were made: “The service is much better now we have a new manager she is very good” “She is very nice and easy to talk to”. People have recently completed a quality assurance survey, with the assistance of the activities co-ordinator or their relatives. A report of the findings is currently being completed. This is an improvement from our last visit, when their was no evidence to support that people were consulted. There was evidence to support that staff meetings are now undertaken and will be planned on a regular basis. This enables the staff to be consulted about the service and to raise any issues. There was evidence in peoples files to support the staff now have access to regular supervision, which provides them with ongoing support and direction in their role. There are systems in place for looking after people’s money and when checked these were found to be satisfactory. People told us they can access their money when they choose to. The provider undertakes monthly visits and completes a report of his findings. This is to monitor the standards in the service and ensure it is meeting people’s needs. A report has been completed each month and these were found to be in good detail. Farriess Court DS0000065783.V373878.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 3 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP3 Good Practice Recommendations The Statement of Purpose and Service User Guide should be updated to reflect the current management arrangements. The pre-admission assessments should include areas for obtaining information about people’s behaviour and support needs. This is to ensure an holistic assessment is obtained. Information should be clear in peoples care plan to direct staff on how often to undertake welfare checks. The medicine policy should be revised so that it describes current practice in the home, for staff reference. The policy should be dated and a date set for the policy to be reviewed. The homely remedies list should be signed by a doctor from each GP practice caring for people in the home, to show that named medicines bought from the pharmacy can be given on specified occasions. A record of the DS0000065783.V373878.R01.S.doc Version 5.2 Page 27 3. 4. OP7 OP9 5. OP9 Farriess Court 6. OP9 7. 8. 9. 10. 11. OP15 OP18 OP19 OP27 OP29 12 OP29 13. OP38 quantities of homely remedies in stock in the home should be kept, for audit purposes. The temperature of the medicine fridge should be monitored with a maximum/minimum thermometer to ensure that medicines in the fridge have been at the correct temperature all day and night The menus should reflect the choices available at lunchtime and tea-time. People should be regularly consulted about the food provided and records kept. The internal abuse policy should be reviewed to ensure it covers all areas of abuse and links in with the multiagency procedures. All communal areas should be free from hazards at all times to ensure all areas are safe for people to use. The staff roster should contain staff member’s full names and roles. A full employment history should be requested on the application form. This is to ensure this information is provided, and staff are vetted appropriately in order to safeguard people. References from previous care related employment should be verified and evidence recorded to demonstrate this. This is to ensure the reason the applicant left that employment is valid and recorded. People should have footplates attached to their wheelchair unless they have signed a consent form to state this is not required. Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Farriess Court DS0000065783.V373878.R01.S.doc Version 5.2 Page 29 - 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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