Care Home: Foxleigh Grove Nursing Home

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What the care home does well Potential service users know that their needs will be fully assessed prior to being admitted to the home. They and their representatives have all the information they need to help them choose to live in the home. A trial period gives them the opportunity to see if it is suitable for them long term and their contract lets them know what services are included. The home is able to meet a diverse range of needs, although they do not have any service users currently with any specific cultural needs they have demonstrated that these could be met. Service users receive care as identified in their individual care plan. They are treated with respect and their dignity is upheld. A robust medication procedure supports staff to give service users their medication safely. A relative surveyed said `I find everyone very helpful and caring. They always have time to answer my questions and are very kind and gentle with my relative`, Service users benefit from an excellent choice of activities and outings and enjoy a stimulating lifestyle. They are provided with a healthy and appetising diet. Service users were positive about activities provided, `Activities are good, I like art classes, music and the outings are excellent.` A relative surveyed said `Foxleigh Grove is a very friendly place to visit.` Service users and their relatives know that their concerns will be dealt with. There have been no complaints received since 2003. Service users live in an attractive, well-maintained and homely environment that has been adapted to enable them to live as independently as possible. The owners take pride in keeping the home well furnished, nicely decorated and well maintained. The home is kept clean, hygienic and free of unpleasant odours. A relative surveyed said `The laundry is extremely efficient...things that go in the morning are usually clean and dry by the afternoon`. Service users are supported by staff who are trained to meet their needs. A robust recruitment procedure protects service users by making sure that suitable staff are employed. There is a very stable staff team with some nurses and health care assistants having worked in the home for many years. Staff spoken to were positive about working in the home and morale is good. Service users live in a well run and managed home. Up to date health and safety systems protect service users. The views of service users and others are sought to help develop the service. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? Since the last inspection some carpets have been replaced, doorways upstairs in the new wing have been repainted, some new curtains have been purchased, there is a new flat roof on the reception area and a cinema room has been created. CARE HOMES FOR OLDER PEOPLE Foxleigh Grove Nursing Home Forest Green Road Holyport Maidenhead Berkshire SL6 3LQ Lead Inspector Jill Chapman Unannounced Inspection 12th August 2008 10:05 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 Foxleigh Grove Nursing Home DS0000010985.V369202.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. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Foxleigh Grove Nursing Home Address Forest Green Road Holyport Maidenhead Berkshire SL6 3LQ 01628 673332 01628 635992 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 Robert Anthony Aram Mr Mark Andrew Robert Aram, Miss Gillian Jane Aram, Mr Simon Michael James Aram, Mrs Gina Sanderson Aram Mrs Elizabeth Moxon Mrs Adrianne Plant Care Home 39 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (39), Physical disability (5) Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The room known as `Goring` situated on the first floor of the home may only be used by service users if a documented risk assessment of their mobility capabilities has been undertaken and placed on record. 23rd August 2006 Date of last inspection Brief Description of the Service: Foxleigh Grove is a care home with nursing. It provides nursing care to older people who do not suffer from a diagnosis of dementia and younger people with physical disabilities. Mr Mark Aram is the General Manager and one of the Registered Individuals. There are two Care Managers, Mrs Plant and Mrs Moxon; they share the responsibilities of the Registered Manager position. In addition, they are responsible for the clinical care provided at the home. Accommodation is provided over two floors that are serviced by a passenger lift. The majority of the rooms available are for single occupancy. The property is situated in the village of Holyport on the outskirts of Maidenhead. It has extensive gardens and fields. The train station is approximately 2 miles away and a bus service runs near to the care home. The home has its own transport which residents use for appointments and visits to local amenities. The current fees for this service range from £ 850-£1050 per week. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10:05 am and was in the service for six hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector spoke to Mrs Moxon one of the registered managers, Mrs Aram one of the owners, a registered nurse, three health care assistants, a handyman/kitchen assistant and the chef. A tour of the building was undertaken and records relating to care, staffing and health and safety were sampled. The inspector met most of the service users and spoke with some individually and others in a group at a lunchtime meal. An Annual Service review was carried out in March 2008 and showed that the home continued to provide good outcomes for service users. Surveys were carried out at this time and some of the feedback is quoted in this report. What the service does well: Potential service users know that their needs will be fully assessed prior to being admitted to the home. They and their representatives have all the Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 6 information they need to help them choose to live in the home. A trial period gives them the opportunity to see if it is suitable for them long term and their contract lets them know what services are included. The home is able to meet a diverse range of needs, although they do not have any service users currently with any specific cultural needs they have demonstrated that these could be met. Service users receive care as identified in their individual care plan. They are treated with respect and their dignity is upheld. A robust medication procedure supports staff to give service users their medication safely. A relative surveyed said ‘I find everyone very helpful and caring. They always have time to answer my questions and are very kind and gentle with my relative’, Service users benefit from an excellent choice of activities and outings and enjoy a stimulating lifestyle. They are provided with a healthy and appetising diet. Service users were positive about activities provided, ‘Activities are good, I like art classes, music and the outings are excellent.’ A relative surveyed said ‘Foxleigh Grove is a very friendly place to visit.’ Service users and their relatives know that their concerns will be dealt with. There have been no complaints received since 2003. Service users live in an attractive, well-maintained and homely environment that has been adapted to enable them to live as independently as possible. The owners take pride in keeping the home well furnished, nicely decorated and well maintained. The home is kept clean, hygienic and free of unpleasant odours. A relative surveyed said ‘The laundry is extremely efficient…things that go in the morning are usually clean and dry by the afternoon’. Service users are supported by staff who are trained to meet their needs. A robust recruitment procedure protects service users by making sure that suitable staff are employed. There is a very stable staff team with some nurses and health care assistants having worked in the home for many years. Staff spoken to were positive about working in the home and morale is good. Service users live in a well run and managed home. Up to date health and safety systems protect service users. The views of service users and others are sought to help develop the service. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Staff are trained to recognise potential abuse and to protect service users but additional training would make sure they are up to date. Interim health and safety measures are needed to make sure that service users are fully safe until refurbishment is completed. Managers could improve the monitoring of health and safety issues around the building and of delegated health and safety checks and records. Please contact the provider for advice of actions taken in response to this Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 8 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. Foxleigh Grove Nursing Home DS0000010985.V369202.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 Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5. The people who use the service experience good quality outcomes in this area. Potential service users know that their needs will be fully assessed prior to being admitted to the home. They and their representatives have all the information they need to help them choose to live in the home. A trial period gives them the opportunity to see if it is suitable for them long term and their contract lets them know what services are included. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA (Annual Quality Assurance Assessment) states that the home has a Statement of Purpose and Service Users Guide and copies of previous inspection reports to give potential service users and their relatives to help Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 11 them decide if the home is suitable for their needs. Surveys received at the time of the Annual Service Review carried out in March 2008 confirmed that service users and their relatives received enough information about the home. The AQAA and surveys confirmed that service users receive a copy of their terms and conditions. The home has an admissions procedure that includes carrying out a pre placement assessment to make sure that the home can meet the needs of potential service users. The manager showed a sample of a completed assessment. It showed that it covers a variety of needs including religious and cultural needs. The manager said that when possible both registered care managers carry out the assessment of the prospective service user to give the best possible view of the service users’ needs. The AQAA states that inappropriate referrals are declined and that the home does not take emergency admissions. Service users and/or their relatives are encouraged to visit the home prior to admission and all placements are on a trail basis to make sure that the home is suitable for the service users needs. Standard 6 does not apply to this home because it does provide intermediate care. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, &10. The people who use the service experience good quality outcomes in this area. Service users receive care as identified in their individual care plan. They are treated with respect and their dignity is upheld. A robust medication procedure supports staff to give service users their medication safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are developed from the assessment of need. These were sampled and were found to be clearly written with good information to show staff how to meet identified needs. The manager confirmed that these are reviewed monthly but more frequently if needs change. Health care assistants confirmed that they have input into care plan reviews via discussion with the registered nurses. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 13 Risks are identified as part of the care planning process and individual risk assessments were seen on files sampled. The manager agreed to develop individual bathing risk assessments to show that the risks of falling in the bath, scalding and drowning have been assessed. Service users confirmed that their health care needs are met, they are supported to access the services of chiropodists, opticians and dentists. They said that the GP visits the home weekly and when required. Records show that service users views are sought on health care needs and end of life care. The homes medication procedure was seen and shows that appropriate arrangements are in place for the safe storage, administration and recording of medication. There is a contract in place for the disposal of unused medication. Medication is give by trained nurses and the manager confirmed that they are given induction training in the homes medication procedure and practice. This is not currently documented but the manager agreed to develop a medication induction checklist to record future in house training. A previous recommendation about the storage of controlled drugs has been carried out. Care plans refer to the need to treat service users with respect and to preserve their dignity. Observation of the lunchtime routine showed that staff carry this out and relate to service users in a friendly and supportive manner. A relative surveyed said ‘I find everyone very helpful and caring. They always have time to answer my questions and are very kind and gentle with my relative’, Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The people who use the service experience excellent quality outcomes in this area. Service users benefit from an excellent choice of activities and outings and enjoy a stimulating lifestyle. They are provided with a healthy and appetising diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an extensive range of leisure opportunities for service users. Two activity co-ordinators organise a variety of in house activities and outings. A monthly activity timetable is given to service users and a copy can be e mailed to their relatives for information. The timetables for July and August show that in house activities such as games, quizzes, memory games, manicures, arts and crafts. birthday teas, indoor bowls, netball, sewing circle, flower arranging, visiting pianist and ‘Gentlemen’s group’. A cinema room has been developed to enable service Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 15 users see a film on a large screen and a different film is shown weekly twice a day on Mondays and Fridays. Holy communion is held monthly in the home. The home has its own minibus for smaller groups and a local voluntary transport organisation is used for larger groups. Outings include garden centres, meals out and theatre trips. Some service users have enjoyed outings to Buckingham Palace and the London Eye. Service users were positive about activities provided, ‘Activities are good, I like art classes, music and the outings are excellent.’ Discussion with service users confirmed that daily routines are flexible to their preferences and capacities. Residents can choose between spending time in their rooms or in communal lounges. Some like to go to bed early and others like to stay up and watch TV. Some prefer to eat in their rooms and others in the dining room. The home welcomes visitors and some service users go out with relatives and friends. A relative surveyed said ‘Foxleigh Grove is a very friendly place to visit.’ Service users can bring some items of furniture into their bedrooms and rooms seen were personalised with service users own photos, pictures and ornaments. The manager confirmed that service users and their families are encouraged to manage their own finances when able to. Service users can have a lockable facility in their own rooms in which to store valuables. There was positive feedback from service users about the quality and quantity of food on offer. They confirmed that there is always a choice and this was seen at a lunchtime meal. Breakfasts are mostly taken in service users rooms although some service users choose to eat in the dining room. The home employs two chefs who provide a four-week rotational menu. Menus seen show that a variety of healthy and appetising meals are provided. The chef keeps records that show that food is stored and cooked at the right temperature and that he confirmed staff who handle food receive food hygiene training. The inspector joined service users for a lunchtime meal; it was well cooked, hot and appetising. It was seen that staff were sensitive and patient in assisting service users who need help at mealtimes. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 16 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. The people who use the service experience good quality outcomes in this area. Service users and their relatives know that their concerns will be dealt with. Staff are trained to recognise potential abuse and to protect service users and additional training would make sure they are up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The commission not received any information about complaints against the service. There is a complaints procedure in place and staff and service users were aware of what to do if someone has a concern. No formal complaints received since 2003 and the current complaints record has no entries, advice was given to put the start date of the record and the manager agreed to do this. The AQAA confirmed that the home regularly consults with relatives and service users through informal and formal contacts. A relative surveyed said ‘I find everyone very helpful and caring. They always have time to answer my questions and are very kind and gentle with my relative’, Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 17 The home has not needed to make any safeguarding adults referrals and CSCI has not received any information about any safeguarding referrals relating to this home. Staff spoken with said they would report any safeguarding concerns to their managers The AQAA states that staff are all trained in Protection of Vulnerable Adults (POVA) and that Criminal Records Bureau checks, POVA list checks and references are carried out before staff are appointed. In discussion with the manager she confirmed that managers and nurses receive external POVA training and that they cascade this training to health care assistants in 1-1 supervision. There is an outdated copy of the local safeguarding procedures but an up to date copy not be found. The manager agreed to source an up to date copy, to check that managers have been trained to POVA level 2 standard and to see if the local authority or other accredited trainers offer POVA training that health care assistants can access. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 18 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): The people who use the service experience adequate quality outcomes in this area. Service users live in an attractive, well-maintained and homely environment that has been adapted to enable them to live as independently as possible. The home is kept clean, hygienic and free of unpleasant odours. Interim health and safety measures are needed to make sure that service users are fully safe until refurbishment is completed. Managers could improve the monitoring of health and safety issues around the building and of delegated health and safety checks and records This judgement has been made using available evidence including a visit to this service. EVIDENCE: Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 19 The home is well maintained and cared for, has an attractive appearance and a homely feel. There is an ongoing programme of redecoration and refurbishment. There is a maintenance logbook to identify and action repairs and a deep cleaning policy for vacated rooms. A new telephone system is planned that will give direct dialling to service users rooms. The owners take pride in keeping the home well furnished, nicely decorated and well maintained. Some new furniture was being delivered on the inspection day. Bedrooms seen were attractively furnished and decorated. Service users spoken with were happy with their accommodation and said they enjoyed spending time in the large gardens. They spoke of the birds and wildlife they see on a daily. A service user surveyed said ‘It is a charming and tasteful home’. The owner confirmed that the older part of the home is in the process of being refurbished and upgraded. There are plans to widen doorways and improve the lighting. There were some health and safety issues identified which will be dealt with by the refurbishment but need to be made safe in the interim. It was found that the hot water in two bedroom sinks was excessively hot and could potentially scald service users. The owner confirmed that these sinks will be fitted with thermostatic control valves as part of the refurbishment and that the plumber will be called to make the hot water temperatures safe in the meantime. Maintenance staff test bath hot water outlets on a weekly basis but currently do not carry out checks to the sinks accessible to service users. The manager and owner agreed that these would be included in the weekly checks. Some hallway carpets in the older part of the home are due for replacement and there are some frayed edges on steps that are a potential trip hazard. Some have already been made safe but the manager and owner agreed that the rest would be made safe until the carpet is replaced. A bathroom in the older part of the house needs refurbishment and a bath seat needs replacing. The owner confirmed that a replacement bath seat is available and would be put in place. The development of a health and safety checklist to be carried out at least monthly could be considered to help identify any potential hazards in the building. Regular monitoring of delegated health and safety checks and records would identify any shortfalls. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 20 There is equipment to assist in the care of service users with mobility problems. These include slide sheets, overhead and other types of hoists, adapted bath and toilet seats. The owner confirmed that each service user has his or her own hoist sling. The home is kept clean and hygienic and there are no unpleasant odours. There is a team of domestic staff, a maintenance man and gardener. Staff receive infection control training and there are systems in place for dealing with soiled linen and other clinical waste. There is a well equipped laundry and cleaning materials and other hazardous substances are kept secure. A relative surveyed said ‘The laundry is extremely efficient…things that go in the morning are usually clean and dry by the afternoon’ Foxleigh Grove Nursing Home DS0000010985.V369202.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 & 30. The people who use the service experience good quality outcomes in this area. Service users are supported by staff who are trained to meet their needs. A robust recruitment procedure protects service users by making sure that suitable staff are employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Nursing and care staff deployment was confirmed with the manager. From speaking to staff and surveys received it was found that deployment meets the current needs of the service users. There is often more than one qualified nurse on duty as well as one of the registered managers. The home has minimal use of agency staff with permanent staff covering vacant shifts most of the time. There is a very stable staff team with some nurses and health care assistants having worked in the home for many years. Staff spoken to were positive about working in the home and morale is good. There is an ongoing programme of National Vocational Qualification NVQ training. One of the registered managers is a qualified NVQ assessor. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 22 The home has a recruitment policy that includes carrying out checks and references to make sure staff are suitable. Staff records were sampled and discussion with staff shows this is carried out. Care staff spoken with confirmed that they are given an in house induction and complete the Common Induction Workbook. From training records seen and speaking with staff it shows that they receive core training that includes health and safety, fire safety, manual handling and infection control. Some health care assistants are due to start nurse training and were positive about the experience gained working in the home. Foxleigh Grove Nursing Home DS0000010985.V369202.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, 36 & 38 The people who use the service experience good quality outcomes in this area. Service users live in a well run and managed home. The views of service users and others are sought to help develop the service. Up to date health and safety systems protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 24 There is a qualified management team with a clear management structure. The Responsible (registered) Individual is in daily charge of the home and the care managers, who are both qualified nurses, share the Registered Managers role and have completed the Registered Managers Award. This arrangement works well for the individuals concerned and the home. One of the other owners was on site during the inspection and it was clear that the owners are directly involved in the running of the home and have different roles and responsibilities. The home has a Quality Assurance system to seek the views of service users and others. The manager showed that surveys recently sent out are starting to be returned. The manager confirmed that the home do not act as appointees for any service users. The general manager has can arrange for the safekeeping of service users personal money if needed. There was evidence that a system of supervision and appraisal is in place. Staff spoken with confirmed the frequency and records are kept of dates of supervisions. The home operates in accordance with the health and safety policy and procedures. Records show that equipment is regularly maintained and serviced and the manager confirmed that the owners are very efficient in this. Health and safety records were sampled and were mostly satisfactory. It was found that the record of checks to the fire alarm system did not identify which call point was tested each week and the manager agreed to put this in place. Foxleigh Grove Nursing Home DS0000010985.V369202.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 2 3 X 3 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 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 3 X 3 X 3 3 X 3 Foxleigh Grove Nursing Home DS0000010985.V369202.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 Refer to Standard YA24 Good Practice Recommendations The development of a health and safety checklist to be carried out at least monthly could be considered to help identify any potential hazards in the building. Regular monitoring of delegated health and safety checks and records would identify any shortfalls. Foxleigh Grove Nursing Home DS0000010985.V369202.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Foxleigh Grove Nursing Home DS0000010985.V369202.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. 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