Care Home: Figham House

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What the care home does well People in the home are provided with a warm, safe and comfortable place to live that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free. The home is welcoming and has a relaxed atmosphere. People living there said they are happy with their bedrooms and can bring in their own possessions, making it feel more like home. People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. What has improved since the last inspection? In June 2008 the home was re-registered with the Commission for Social Care Inspection, due to the business being bought by new owners. This means that we look upon the home as a new service and this is the first visit since its reregistration. What the care home could do better: The home has worked hard to meet the standards within this report. We have made a small number of recommendations around good working practices and these will be followed up at the next visit to the home. We would like to thank everyone who completed a survey or spoke to us during this visit. Your comments are very important to us and ensure this report includes the views of people who use the service or work within it. CARE HOMES FOR OLDER PEOPLE Figham House Figham Road Beverley East Yorkshire HU17 0PH Lead Inspector Eileen Engelmann Key Unannounced Inspection 22nd September 2008 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 Figham House DS0000071972.V372570.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. Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Figham House Address Figham Road Beverley East Yorkshire HU17 0PH 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) 01482 872926 kath@fighamhouse.co.uk Burlington Care Limited Care Home 54 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places Figham House DS0000071972.V372570.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 with nursing - Code N, to service users of the following gender: either, whose primary care needs on admission to the home are within the following categories: Dementia - Code DE, Physical disability - Code PD Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated: 54 2. Date of last inspection New Service Brief Description of the Service: Figham House is a large Victorian building on the outskirts of Beverley. There is easy access into the centre of Beverley and public transport to Hull and outlying villages. The home is registered to provide both nursing and personal care for up to fifty-four older people, some of who may have a dementia or a physical disability. Accommodation is provided over two floors accessed by a passenger lift or staircase. A new extension has been built with fourteen bedrooms, two bathrooms, a large dining room with comfortable seating areas at one end and a further sitting room with patio doors leading onto an enclosed courtyard. The home now has five shared and forty-four single bedrooms all with en-suite facilities; and five bathrooms, four of which have specialised baths and the fifth is a walk-in shower. One additional bathroom has been lost due to changes to the laundry and plans are in place to create another shower room elsewhere in the home. Communal areas consist of the new dining room and sitting room, and three separate sitting rooms in the original part of the building. A separate room has been designated a hair salon. The home has a car park with spaces for visitors and staff. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 5 manager of the home, and copies are on display in the entrance hall of the home. Information given by the manager on 22 September 2008 indicates the home charges fees from £350.00 to £575.00 per week, plus the nursing band fee where applicable. The level of fee is dependent on the type of care required and the different room facilities chosen by the individual. People will pay additional costs for optional extras such as staff escorts to appointments, hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these is available from the manager. Figham House DS0000071972.V372570.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 this service is 2* stars. This means that the people who use this service experience good quality outcomes. In June 2008 the home was re-registered with the Commission for Social Care Inspection, due to the business being sold to new owners. This means that we look upon the home as a new service and this is the first visit since its reregistration. The home does not have a registered manager at the moment and for the purposes of this report the acting manager is referred to as the manager throughout the text. Information has been gathered from a number of different sources over the past 3 months since the service was registered with the Commission for Social Care Inspection, this has been analysed and used with information from this visit to reach the outcomes of this report. This unannounced visit was carried out with the manager, staff and people using the service. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files, and records relating to the service. Informal chats with a number of people living in the home took place during this visit; their comments have been included in this report. Questionnaires were sent out to a selection of people living in the home and staff. Their written response to these was adequate. We received 4 from staff (29 ) and 7 from people using the service (50 ). The manager completed an Annual Quality Assurance Assessment and returned this to us within the given timescale. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 7 People in the home are provided with a warm, safe and comfortable place to live that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free. The home is welcoming and has a relaxed atmosphere. People living there said they are happy with their bedrooms and can bring in their own possessions, making it feel more like home. People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. What has improved since the last inspection? 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. Figham House DS0000071972.V372570.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 Figham House DS0000071972.V372570.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): 2, 3, 4 and 6. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People wanting to use the service undergo a needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met. EVIDENCE: The homes statement of purpose and service user guide, are available in a large print and audio version if requested. People’s survey responses indicated they received sufficient information to make an informed choice about the service before accepting the placement offer. Four people’s care and records were looked at as part of this visit, they each have been provided with a statement of terms and conditions/contract on admission and these are signed by the person or their representative. These documents give clear information about fees and extra charges, which are reviewed and kept up to date. Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 10 Each person has his or her own individual file and the funding authority or the home, before a placement is offered to the individual, completes a need assessment. The four files looked at during this visit were for funded individuals; one person was living in the home at the time of its purchase and re-registration by the current owners and the other three people have come into the home recently. The home develops a care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the person and their family. Those people living at the home who receive nursing care undergo an assessment by a registered nurse from the local Primary Care Trust, to determine the level of nursing input required by each individual. Discussion with the manager indicated she goes out to assess individuals who have expressed an interest in coming into the home, and each person is given information about the service and life in the home. Staff members on duty were knowledgeable about the needs of each person they looked after and had a good understanding of the care given on a daily basis. Information from the people’s surveys showed that they were satisfied with the care they receive and have a good relationship with the staff. Two relatives said ‘the staff are extremely helpful’ and ‘the needs of our relative are always met’. Information from the Annual Quality Assurance Assessment and discussion with the manager and people living in the home indicates that all of the people using the service are of White/British nationality. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. The home is able to offer a limited choice of staff gender to people who express preferences about care delivery, as they employ 3 male care staff. The information about people’s preferences should be recorded onto the care plans. Information from the training files and training matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, or they are booked onto training in 2008. The home is registered with us to accept placements for people with dementia and the manager is aware of the need to introduce more robust staff training around dementia and challenging behaviour to ensure the staff are able to meet people’s needs. Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 11 The home does not have any intermediate care beds and therefore standard six does not apply to this Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, personal and social care needs of the people living in the home are clearly documented and are being met by the service and staff. The medication at the home is well managed promoting good health. EVIDENCE: Information given to us in people’s surveys, and during discussions on this visit with people and relatives, indicates that individuals are satisfied with the care they receive and enjoy life in the home. Six people said that ‘staff listen to us and take action when needed’, whilst one person felt that ‘the staff are too busy and do not have the time to talk or deal with anything’. Three individuals also told us that ‘staff are quick to answer the buzzer’ and one person said ‘I have never been made to feel a nuisance when asking staff anything’. The care plans are in the process of being changed to another format and therefore are not as ordered as they usually are. The care of four people was Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 13 looked at in depth during this visit and included checking of their personal care plans. On the whole the care plans detailed the needs and abilities of individuals and set out the actions required by staff to ensure peoples wishes and choices are respected and their care needs met. The plans looked at have been evaluated on a monthly basis and any changes to the care being given is documented and implemented by the staff. Information about the person’s social interests, likes and dislikes, spiritual needs and wishes regarding death and dying are included within the individuals care plan. People and relatives are able to input to their plan and changes to their care is discussed with the individual where possible. One area that staff should consider taking more time over is the risk assessments that underpin certain care objectives. One person who was admitted into the home in August 2008 did not have their risk assessments for daily living completed and one person who smoked did not have an associated risk assessment in place. The manager said that these would be done straight away. People said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the people using the service indicate they are satisfied with the level of medical support given to them. Entries in the care plans specify where individuals have dietary needs, including PEG feeds, supplement drinks and specialist diets. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. The nurses within the home carry out specialist tasks such as PEG tubes/feeding regimes and wound dressings. Pressure areas are monitored carefully and proactive measures include risk assessments and special mattresses/beds and seat cushions. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. All of the people spoken to prefer to have staff administer their medication. Checks of the medication records showed these are up to date and accurate, including those for controlled drugs and refrigerated items. However, we recommend that where staff are hand writing medication onto the sheets (transcribing), there should be two staff signing the entry to indicate they have both witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 14 Relatives commented that they are kept informed of their relative’s wellbeing by the staff; they are regularly consulted (where appropriate) on their care and feel involved in their lives. Overall there is a good level of satisfaction with the care being given to the people living in the home. Chats with people revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Observation of the service showed there is good interaction between the staff and people; with friendly and supportive help being given to assist individuals in their daily lives. Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with choice and diversity in the activities and meals provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: The home employs an activity co-ordinator to deliver a programme of events on a Monday, Wednesday and Friday, between 10am and 4pm. At the moment there is a range of group activities and one to one sessions taking place, which reflect the interests of the people living in the home and also their gender. The manager told us that the home has introduced new rooms for television viewing, an activities room and a quiet room. The manager said that there are regular church visitors (twice a month) within the home and a Church of England service every fortnight. People can also go to the local church services and religious celebrations as requested. The home Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 16 provides special meals and cakes for birthdays and helps people celebrate all major Christian festivals such as Easter, Harvest Festival and Christmas. Discussion with the people living in the home indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. People spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. There is some information and advice on advocacy and this is available in the service user guide. There are meetings where the viewpoints and opinions of those living in the home can be expressed and the management team will listen and take action were needed. Visitors said they are kept informed of any important issues affecting their friend/relative and felt that staff did a good job of supporting people to live the lives they choose. The staff training matrix given to us on 22 September 2008 shows that some staff have attended training on the Mental Capacity Act, but there is no evidence that staff have received additional training around current legislation in equality, diversity and disability matters. The registered person should make sure that staff have sufficient knowledge about human rights legislation, so they understand individual rights within the care home and out in the community. Observation of the midday meal showed it to be well prepared and presented, and the kitchen staff had made an effort to provide soft diets in an attractive way. Staff were organised when serving the meal and a number of individuals were seen to offer assistance to people who need help with eating and drinking. People and relatives are pleased with the quality and quantity of the meals served, saying ‘the food is very good and there is always a choice given’. In the past there have been some dissatisfaction with the menus so the home has asked for feedback on the options available through a relative’s working group, with the management team listening and acting on the comments. Figham House DS0000071972.V372570.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. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a satisfactory complaints system with some evidence that people feel that their views are listened to and acted upon. Visitors and people using the service are confident about reporting any concerns and the manager acts quickly on any issues raised. EVIDENCE: Checks of the complaints records in the home showed that the manager has dealt with two concerns since the new owners took over, these were investigated and a written response given to the complainant. The home has a complaints policy and procedure that is found within the statement of purpose and service user guide. It is also on display within the home. The policy and procedure is available in a large print format and an audio version. People’s survey responses showed individuals have a clear understanding about how to make their views and opinions heard and those people spoken to said ‘the manager comes round every day to see us and will discuss any problems at this time’. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of people’s money and financial affairs. Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 18 The staff on duty displayed a good understanding of the safeguarding of adults procedure. They are confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. The staff training matrix given to us on 22 September 2008 shows there is an ongoing training programme for staff to attend safeguarding of adults awareness training, and sessions were held in December 2007, January 2008 and June 2008. The staffing matrix also showed four members of staff attended dementia care training in June 2008. The provider told us that he has obtained training DVD’s for dementia care and challenging behaviour and these would be available to staff from October 2008. Figham House DS0000071972.V372570.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): 19, 22 and 26. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of environment within the home is good, providing people with a comfortable and homely place to live. EVIDENCE: Walking around the home it is clear that the environment is spacious, welcoming and decorated/furnished to a high standard. People have access to a number of communal facilities including a television lounge, a quiet room, and a large lounge and dining area leading onto a secure courtyard area provided with seating and plants. At the moment people have access to four bathrooms and a shower room, with plans in place to create another walk in shower room from additional space in the home. Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 20 People in the home are very satisfied with their bedrooms saying ‘ the staff keep them lovely and clean’. All bedrooms have en-suite toilets and wash hand basins and there is a mix of single (44) and double (5) rooms. Bedrooms are fitted with door locks and have lockable drawers for people to keep personal possessions/valuables in. The home is built on two floors, and people can access the upper level using the passenger lift or stairs. There is a ramp to the front entrance to enable people with mobility problems easy access to and from the home and walkways inside are kept clear of any obstacles. Doorways to bedrooms, communal space and toilet/bathing facilities are wide enough for wheelchairs, and corridors are spacious and have enough room for people in wheelchairs or with walking frames to pass by comfortably. Discussion with the staff and manager indicates that there is a wide range of equipment provided to help with the moving and handling of the people using the service and to encourage their independence within the home. This includes mobile hoists and specialist baths/hoists, lifting belts, slide sheets, turntables, standing hoists and handrails. The laundry facility was not ideal so the new owners have used a bathroom next to the laundry to extend the facility and create a more spacious and workable environment. The provider assured us that additional bathing facilities would be created to replace the lost bathroom. Discussions during this visit indicate that people using the service are satisfied with the laundry service provided by the home. Infection control policies and procedures are in place, and staff have access to good supplies of aprons and gloves for use in personal care. The staffing matrix supplied to us on 22 September 2008 indicates that infection control training took place in February and June 2008. Figham House DS0000071972.V372570.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 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff induction, training and recruitment practices are good, resulting in an enthusiastic workforce that works positively with people to improve their whole quality of life. EVIDENCE: Checks of the staffing rotas and observation of the service showed that the home employs eight staff from overseas. Discussion with the manager indicated that the home is an equal opportunities employer and individuals with disabilities are part of the staffing group. Staff members told us that they work as a team and this includes covering shifts when others are on leave or sick. Staff feel that their induction and training helps them meet the needs of people who use the service. We spoke to two people who use the service during this visit, and they were satisfied with the care they receive and said that they did not have to wait too long for staff to come when they needed assistance. Individuals told us that ‘staff are friendly, helpful and supportive’. At the time of this visit there were 46 people in the home and the staffing levels were as follows: Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 22 Morning 7am – 3pm Two nurses and seven care assistants Afternoon 2.30pm – 10pm One nurse on duty and six care assistants Night 10pm – 7am One nurse and three care assistants. Information from annual quality assurance assessment about the number of staffing hours provided, and information gathered during the visit about the dependency levels of the people using the service, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the minimum hours asked for in the recommended guidelines. Over 50 of care staff at the home have an NVQ 2 or above in care and the home has a mandatory staff-training programme in place. Discussion with the manager indicates that the majority of the staff are up to date with this or are booked onto refresher training for 2008. Nurses are supported in maintaining their own professional portfolio of practice in order to keep their Personal Identification Number (PIN) from the Nursing and Midwifery Council (NMC) up to date. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of five staff files showed that police (CRB) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Nurses at the home undergo regular registration audits with the Nursing and Midwifery Council to ensure they are able to practice. Five staff files were looked at and they contained evidence of a variety of training events attended over the past year including safeguarding of adults, moving and handling, fire management, infection control, dementia care, bereavement, mental capacity act, palliative care and medication training. The new provider has introduced training DVD’s for challenging behaviour, dementia care, health and safety, moving and handling and food hygiene. Figham House DS0000071972.V372570.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 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of audits and consultations, which includes seeking the views of people using the service, staff and relatives. EVIDENCE: The acting manager is in the process of applying to be registered with the Commission for Social Care Inspection and this should be completed by December 2008. The acting manager is a registered nurse and has completed her Registered Managers Award. She has extensive experience of managing other nursing homes and keeps her skills and knowledge up to date with regular training sessions pertinent to her role. Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 24 The home has achieved the Local Council’s Quality Assurance Award (QDS parts I and II). Policies and procedures within the home have been reviewed and updated to meet current legislation and good practice advice from the Department of Health, local/health authorities and specialist/professional organisations. The manager and senior staff complete in-house audits of the home and its service on a monthly basis, and the registered individual does spot checks and completes the regulation 26 visits. Feedback is sought from the people living in the home and relatives through regular satisfaction questionnaires, and the manager has produced a development report as part of this process to highlight where the service is going and/or indicate how the management team is addressing any shortfalls in the service. Checks of the finance systems within the home found that handwritten records are kept for people’s personal allowances; the administrator on a daily basis up dates these. Information from the Annual Quality Assurance Assessment indicates the majority of people have their families looking after their financial affairs, and checks of the system show their relatives top up the person’s individual allowance account on a regular basis. People who have asked the home to look after their personal allowances are able to access their money on request, and receipts are kept for any transactions. All monies are kept safe and secure within the home and only the administrator or manager has access to the funds. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, bed rails and daily activities of living. Figham House DS0000071972.V372570.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 X 3 3 3 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 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Figham House DS0000071972.V372570.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. 3. Refer to Standard OP7 OP7 OP9 Good Practice Recommendations The manager should ensure each person’s care plan includes the individual’s preference regarding staff gender for giving personal care. The manager should ensure that staff are completing the risk assessments for daily living on a consistent basis. The manager should make sure that where staff are hand writing medication onto the sheets (transcribing), there are two staff signing the entry to indicate they have both witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. The registered person should make sure that staff have sufficient knowledge about equality, diversity, disability matters and human rights legislation, so they understand individual rights within the care home and out in the community. DS0000071972.V372570.R01.S.doc Version 5.2 Page 27 4. OP14 Figham House 5. OP31 The manager should register with the Commission for Social Care Inspection by the end of December 2008. Figham House DS0000071972.V372570.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Figham House DS0000071972.V372570.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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