Care Home: Hannah Levy House Trust

What the care home does well The manager of the home carries out a comprehensive assessment of a person’s needs before offering a placement at the home. Residents and relatives are fully informed of the services and facilities provided by the home. Health care needs of residents were being met through the homes care planning arrangements with consideration of minimising any risks of harm to residents. Residents are treated with respect and dignity. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.2 Generally medication was being administered safely and medicines stored correctly. The home provides both communal and individual activities to meet residents’ leisure and recreational needs. The home has close links with the local Jewish community and residents’ spiritual needs are met. Residents are able to maintain links to friends and family with there being no restrictions on visiting. The home provides a kosher diet that is closely supervised. There was satisfaction with the standard of food being provided at the home. The home has fully compliant complaints’ procedures and residents told us that they had confidence that their complaints would be investigated thoroughly. All of the staff have received training in adult protection and the home has full procedures relating to the protection of vulnerable adults. The home provides a comfortable and safe environment for residents and is well maintained. The home employs sufficient members of staff to meet the needs of residents. Staff training is provided that makes sure the staff are competent to perform their duties. New staff are recruited in line with regulatory requirements. Generally we found that the home was being well managed, with good record keeping, supervision of staff and run in the interests of the residents. What has improved since the last inspection? The home has complied with the requirement made at the last key inspection concerning implementation of risk assessments for the use of bed rails. Care plans and risk assessments are now being reviewed regularly as required at the last inspection. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.2 There is better management and rationale of the administration of ‘as required’ medications, as required at the last inspection. What the care home could do better: In some instances, details within the care plans could be more specific to better inform staff on how to support residents. Where hand entries have to be made to the medication administration of records a second member of staff should check and sign that the entries have been made correctly. Where creams are prescribed by doctors to maintain residents’ skin integrity, a record should be maintained of these having been administered as prescribed. The management of the home should consider additional steps that could be taken to make the physical environment more suitable for residents with memory loss. In order to maintain good infection control standards, paper towels should be provided in all communal bathrooms and staff should ensure that tablets of soap and cotton towels used by residents should be returned to their rooms after use. The home must ensure that a visual inspection of the fire fighting equipment is carried out and recorded each month. Any money is deposited by residents for safe keeping with the home must not be deposited into the home’s bank account. Key inspection report CARE HOMES FOR OLDER PEOPLE Hannah Levy House Trust 15 Poole Road Bournemouth Dorset BH2 5QR Lead Inspector Martin Bayne Unannounced Inspection 14th September 2009 09:00 DS0000003944.V377700.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hannah Levy House Trust Address 15 Poole Road Bournemouth Dorset BH2 5QR 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) 01202 765361 01202 751007 hlhtrust@btconnect.com Hannah Levy House Trust Manager post vacant Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Hannah Levy House Trust DS0000003944.V377700.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 providing personal care only-Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category- Code OP The maximum number of service users who can be accommodated is 34. 4th September 2008 Date of last inspection Brief Description of the Service: Hannah Levy House Trust has charitable status and has been set up to provide care, including personal care, to those members of the Jewish Faith who need such assistance. The home has a Board of Trustees that has regular contact with the home. Hannah Levy House Trust is situated half a mile from the centre of Westbourne, with its local shops, library and other amenities. The home is on a bus route providing easy access to Bournemouth town centre and the Travel Interchange. There is plenty of on site parking as well as parking on the roads surrounding the home. Hannah Levy House Trust is registered to accommodate a maximum of 35 older people and provides both permanent and respite care as well as day care. All rooms are for single occupancy although some are large enough to be used as doubles should this be requested by residents. Hannah Levy House Trust provides twenty-four hour personal care, all meals, laundry and domestic services. Residents are encouraged to participate in a wide range of activities, including outings to local places of interest. The fees for the home, as confirmed to the Commission for Social Care Inspection (CSCI) at the time of inspection, are set at £545 per week and include chiropody. Additional charges are made for hairdressing, dry cleaning, toiletries and newspapers. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.2 Page 5 Hannah Levy House Trust DS0000003944.V377700.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 star. This means the people who use this service experience good quality outcomes. We, the Commission, carried out a key inspection of Hannah Levy Trust House between 9:50am and 3:20pm. The inspection was carried out by two inspectors, but throughout the report the term ‘we’ is used, to show that the report is the view of the Care Quality Commission. The aim of the inspection was to evaluate the home against key National Minimum Standards for older persons, and to follow up on 3 requirements and 2 recommendations made at the last key inspection of the home in September 2008. We were assisted throughout the inspection by the home’s manager, the deputy and also by the responsible individual for the organisation. We had the opportunity to speak to about half of the residents who were living at the home at this time. We chose a sample of three residents’ personal care files and used these to track the paperwork and records that the home is required to keep up to date under the Care Homes Regulations 2001. We also walked around the building and looked at some resident’s personal accommodation as well as the communal areas provided for residents. Additional information that helped form to the judgements contained within this report was obtained from the Annual Quality Assurance Assessment document (AQAA) completed by the home. What the service does well: The manager of the home carries out a comprehensive assessment of a person’s needs before offering a placement at the home. Residents and relatives are fully informed of the services and facilities provided by the home. Health care needs of residents were being met through the homes care planning arrangements with consideration of minimising any risks of harm to residents. Residents are treated with respect and dignity. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.2 Page 7 Generally medication was being administered safely and medicines stored correctly. The home provides both communal and individual activities to meet residents’ leisure and recreational needs. The home has close links with the local Jewish community and residents’ spiritual needs are met. Residents are able to maintain links to friends and family with there being no restrictions on visiting. The home provides a kosher diet that is closely supervised. There was satisfaction with the standard of food being provided at the home. The home has fully compliant complaints’ procedures and residents told us that they had confidence that their complaints would be investigated thoroughly. All of the staff have received training in adult protection and the home has full procedures relating to the protection of vulnerable adults. The home provides a comfortable and safe environment for residents and is well maintained. The home employs sufficient members of staff to meet the needs of residents. Staff training is provided that makes sure the staff are competent to perform their duties. New staff are recruited in line with regulatory requirements. Generally we found that the home was being well managed, with good record keeping, supervision of staff and run in the interests of the residents. What has improved since the last inspection? The home has complied with the requirement made at the last key inspection concerning implementation of risk assessments for the use of bed rails. Care plans and risk assessments are now being reviewed regularly as required at the last inspection. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.2 Page 8 There is better management and rationale of the administration of ‘as required’ medications, as required at the last inspection. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.2 Page 9 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 10 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 Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from having their needs assessed before being offered a placement at the home. This procedure makes sure that the home only admits those people whose needs it can meet. EVIDENCE: Prospective residents and their relatives are provided with full information about the services and facilities of the home by having access to the homes Statement of Purpose, Service User Guide and brochure. We were told that both relatives and prospective residents are encouraged to visit the home to assist them in choosing a suitable placement. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 12 We looked at the pre-admission assessments for two residents, one of whom had only moved into the home on the day of our visit. We saw that the manager carried out a pre-admission assessment of need with this being recorded. The pre-admission assessments included a social history of the person referred that had been completed by family members, a short dementia test consisting of several orientation questions, as well as covering all of the topics that are detailed within the National Minimum Standards for older persons. We were also told through the AQAA, that should a person go into hospital, their needs are re-assessed before they return to the home to ensure that the home is still able to meet the person’s needs. The above procedures make sure that the home can meet the needs of the people that it admits for residential care. We saw that once the decision had been made to admit a person to the home, letters are sent out confirming that the person’s needs can be met and an offer of a placement made. The home does not provide an intermediate care service. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from their care needs being met through systems of risk assessment and care planning. They also benefit from being treated with respect and dignity and from having their medication administered safely by trained staff. EVIDENCE: We looked at the personal care files for two residents. We saw that once a person has been admitted to the home the assessment process is continued and care plans developed. We saw that the care plans provided a detailed social history of the person concerned, their preferences as to daily routines and instructions to staff on how to meet personal care needs. We recommend however that care plans be more specific. In the case of one person where Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 14 there were concerns about hydration due to the nature of their illness, the care plan stated that the resident should be offered ‘regular’ drinks, when it would be more helpful to define at what interval drinks should be offered. In the case of another person the care plan stated that barrier cream should be applied to an area when red, when again it would be more helpful to state which area of skin was identified as being red. In the case of one person the care plan referred to the person being ‘more verbal and aggressive’ but did not go on to describe what staff should do in these circumstances. We saw that the care plans were being regularly reviewed and that residents and relatives had been involved in their development. We saw that risk assessments had also been completed and used to inform the care plans. These included the malnutrition universal screening tool (MUST tool), skin-care assessments, moving and handling assessments and a risk assessment for the use of bed rails. At the last inspection a requirement was made concerning the use of bed rails, as at that time relatives and health professionals had not been included in that assessment process. We found that this inspection that this requirement had been complied with. From looking at care plans, daily recording notes and from speaking with residents we found that residents’ health needs were being met at the home. We saw that appropriate referrals are made from district nursing support and GP visits. In the case of one person they had been appropriately referred to the community mental health team. We also saw that other health care needs relating to chiropody, hearing and eye care needs were being met. During the inspection we observed to people sitting in wheelchairs on slings used for hoisting. We recommend that the homes seek professional advice to ensure that it is okay for people to sit in the hoist slings for long periods of time. All of the residents we spoke with told us that the staff were kind and courteous and that their privacy and dignity was maintained. During the inspection we observed staff providing personal care and assistance to residents in a courteous and dignified manner. We looked at how medication was managed and administered within the home. Medications are stored in the team leader’s office where there are the facilities of locked medication cabinets, a medication trolley and a small locked fridge that is used to store medications requiring refrigeration. The home also has a controlled drugs cabinet that meets new regulatory requirements. We saw that medications were being stored correctly and safely with one senior member of staff on duty having delegated responsibility of the keys and security of medications for each shift. We were told that the home had recently updated the home’s policy and procedure for administering medication with the assistance of a pharmacist from PCT. Guidance had also been sought and Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 15 taken regarding the use of ‘as required’ medications, thus meeting the requirement made at the last key inspection. We looked at the medication administration records for all of the residents. We saw good practice of the photograph of each resident provided on the front of their medication administration records, together with a list of any known allergies suffered by that person. We also saw that at the front of the records was a sample of staff signatures of those members of staff trained to administer medication in the home. We found that the medication administration records were being completed in full with no gaps within the records. We made two recommendations however, that could improve medication administration. We saw that generally where hand entries had to be made to the medication administration records, a second member of staff checks and signs that the entry has been made correctly, but not in all cases. We recommend that all hand entries that have to be made to the records are checked and signed by a second member of staff to make sure that the entry has been transcribed correctly. We found that where creams had been prescribed these were not being recorded as having been given. We recommend that as these creams are prescribed medications to maintain skin integrity, a record should be completed that they had been administered as prescribed. We discussed this with the manager and it was agreed that a recording sheet would be kept in residents’ rooms so that when they receive personal care, the staff are able to sign that the creams have been administered as prescribed. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from their recreational and leisure needs being met, through being able to maintain contact with friends and family and through being provided a good standard of food. EVIDENCE: On the residents’ notice board in the dining room we saw a list of communal activities planned for the week ahead. These included weekly gentle exercise sessions, music therapy sessions carried out by qualified music therapist, reminiscence shows also carried out by another qualified therapist, as well as arts and crafts sessions. We also saw that the occasional outing was arranged, with residents being taken out in the home’s minibus. On the morning of our visit residents were taking part in a gentle exercise session. The home maintains an activities book and records activities carried out with residents. From this we saw that some residents were taken out for walks and others Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 17 provided with individual activities, especially where they chose not to participate in communal activities. Residents are also able to order a daily paper. The returned AQAA informed us that entertainment is now provided on residents’ birthdays instead of just a tea party. Residents told us that they could have visitors at any time and were encouraged to maintain links with friends and family. The home maintains very close ties with the Jewish community and both an Orthodox and Reform Rabbi visit the home regularly to support residents’ spiritual needs. All of the residents we spoke with told us that the food provided was of a good standard. The home provides a kosher diet under strict supervision and the home’s Service User Guide informs prospective residents of this. Lunch is provided in two sittings. The first sitting is at 11:30am and caters for residents who have difficulty with eating or who require assistance from staff. We were told that the system was put in place to maintain the dignity of these residents. The second setting is at 12:30pm for residents who do not need assistance. We observed some of the lunchtime sessions and saw that residents were able to eat their food in an unhurried and dignified manner with patient assistance from staff. We also saw that some residents could have their meals within their rooms and we observed a staff member appropriately assisting one resident who was being cared for in bed. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well-publicised complaints procedure and through the staff being provided with training in the protection of vulnerable adults. EVIDENCE: The home maintains a complaints’ logbook where complaints and outcomes of complaints are recorded. We saw that since the key inspection a year ago one formal complaint had been registered by a member of staff. The home’s complaints procedure had not been followed through in full as the complainant had not been responded to by letter. We were told that this matter had been dealt with verbally by the manager and that the staff member had not wished to have a formal letter of the outcome of the complaint. It was agreed that this information would be added into the complaints logbook to conclude this complaint. The residents we spoke with told us that they knew how to complain and that they had confidence that their complaints would be dealt with fairly. Details of the complaints procedure are provided within the home’s Service User Guide. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 19 We saw that all of the staff are provided with training in the protection of vulnerable adults with the last training session being provided in September and a further course planned for October 2009. We saw that the home has all relevant policies and procedures relating to the protection of vulnerable adults. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Hannah Levy House Trust provides a homely, comfortable and safe environment for residents. EVIDENCE: As part of the inspection we carried out a tour of the premises. In general we found the home to be clean, free from any unpleasant odours, in reasonable decorative order with furniture and fittings in a good state of repair. We saw that equipment necessary for the care and support of residents was provided, such as hoists and assisted bathing facilities. Residents also have access to a pleasant enclosed and well maintained garden and a small quiet ‘reminiscence’ Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 21 lounge. We saw that residents were able to bring their own possessions and furniture to personalise their rooms. We were told that wardrobes were assessed as to their likelihood of being able to be toppled and that where this risk was identified, the wardrobe would be screwed to the wall. We saw that radiators in residents’ bedrooms had been covered or were of a low surface temperature type to protect residents from getting burnt. We saw that risk assessments had been carried out to the uncovered radiators in the corridors and that these had been assessed as posing a low risk to residents. Thermostatic mixer valves have been fitted to hot water outlets of the baths, to protect residents from scalding water. At the last inspection a recommendation was made that more thought be given to making the environment more suitable for residents with memory loss. At this inspection we were told that about a third of the residents suffer from a degree of memory loss. We saw that those residents with memory loss had their names put on the doors of their bedrooms. We discussed further steps that could be taken to make the environment more suitable for these residents and the management should consider putting photographs of residents with memory loss on their doors to assist them in finding their bedrooms. We also discussed the possibility of having bathrooms and toilet doors painted a different colour so that they can be easily identified. The recommendation therefore remains in place that additional steps are considered to make the environment more suitable for residents with memory loss. Residents are provided with ensuite WC facilities within their bedrooms. The home also has sufficient communal bathrooms and assisted bathing facilities. We saw that liquid soap was provided in communal bathrooms as well as a foot operated lidded bins to maintain infection control standards. These standards were being compromised as we saw tablets of soap and some cotton towels in some of the communal bathrooms. We were told that these items had been left in bathrooms by residents. In order to maintain good infection control standards we recommend that within communal bathrooms paper towels are provided and that staff ensure the tablets of soap and cotton towels are returned to residents’ bedrooms after use. We saw that staff are provided with gloves and protective clothing as part of their infection control standards. The home also has a sluice facility for cleaning of commodes. We looked at the laundry facilities and saw that the home has commercial machines sufficient to meet the laundry needs of the home. We also saw that the walls of the laundry room were tiled and that the floor surface was impermeable so that the area can be cleaned appropriately. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from the home providing sufficient staffing levels to meet the needs of residents and through the staff being well-trained and recruited in accordance with regulations. EVIDENCE: We were told that between 7am and 1:30pm there were six care staff on duty. Between 1:30pm and 8pm, five care staff and during the night-time period two awake members of staff and one member of staff who carries out a sleep-in duty. One of the awake night staff members is a team leader but there is also an on-call rota if further assistance is required. We saw that the home provided good sleeping facilities for the staff member who carries out the sleep-in duty. We were provided with copies of duty rosters that reflected the above staffing. We also saw that from the records, one could determine who had worked particular shifts in the past. The home also employs ancillary staff such as domestic staff, kitchen staff and maintenance staff. The residents we spoke with told us that the staffing levels were sufficient to meet their needs. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 23 We looked at three staff recruitment files of staff members who had been employed to the staff team since the last key inspection. We found that all the recruitment checks as detailed within Schedule 2 of the Care Homes Regulations 2001 had been complied with. These included proof of identity, a recent photograph, a check against the register of adults deemed unsuitable to work with vulnerable adults, a criminal record bureau check, the taking up of two appropriate references and the staff member signing a health declaration. We also saw that staff members did not start work in the home until all these checks had been undertaken. The returned AQAA informed us that the home had now achieved a level above 50 of the staff team trained to NVQ level 2 or above. We looked at the training provided to the staff team and were provided with a training matrix. From this we saw that the staff had received core mandatory training and that where any gaps in training were identified and courses arranged accordingly. We also saw that some specialist training such as caring for people with dementia, catheter care had been undertaken by some of the staff. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and run in the interests of residents. EVIDENCE: The manager of the home has being employed for over a year and has achieved the Registered Managers Award and NVQ level 4 in management. She also has the NVQ assessor’s award. An application to become Registered Manager of the home has been submitted to the Care Quality Commission. The manager is supported by a deputy manager and team leaders. The home Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 25 is a registered charity and there is much involvement by the trustees and the responsible individual for the organisation. On the day of our visit one of the trustees and the responsible individual were visiting the home. We saw that there are monthly meetings held with the manager and the trustees about the performance of the home. In general we found that the home was well managed and run in the interests of the residents. The home safe keeps sums of money held on behalf of residents. We looked at the records and balances of money held for three residents. Good records were maintained detailing money deposited, withdrawn and the balance of money held. The balance of money held tallied with the records in all cases. In the case of one person however, money was being sent by a relative to the home and was then being deposited into the home’s account and later withdrawn in small amounts when required by the resident concerned. We discussed this with the manager, as this is contrary to the standards. We require and it was agreed that this money would no longer be deposited into the home’s bank account. The return to AQAA informed us that servicing of equipment was taking place in the home as required. We saw that the home had a current employer’s liability insurance certificate. We looked at the home’s fire logbook and saw that all the tests and inspections of the fire safety system were being carried out as required with the exception of the visual inspection of the fire fighting equipment where we identified gaps in the inspection taking place. We require that the fire fighting equipment inspection takes place and is recorded each month. We saw that the home carries out regular surveys each year involving relatives and residents as part of their quality assurance programme. At the last inspection the recommendation was made concerning staff supervision. We found that this inspection from the sample of staff records that we saw that staff supervision stations were taking place to the required timescale. Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 26 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X X X X 2 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 1 x x 2 Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP35 Regulation 20 (1) Requirement It is required that money held on behalf of residents for safekeeping is not deposited into the bank account for the home. It is required that a visual inspection of the fire fighting equipment takes place each month and is recorded. Timescale for action 01/10/09 2. OP38 23 (4) (c) 01/10/09 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 OP7 OP8 Good Practice Recommendations We recommend that care plans be more specific. We recommend that you liaise with health professionals as to whether it is okay for residents to sit on hoist slings for long periods of time. We recommend that: • When hand entries have to be made to the DS0000003944.V377700.R01.S.doc Version 5.3 Page 28 3. OP9 Hannah Levy House Trust • medication administration records, a second person checks and signs that the entries have been entered correctly. Where creams are prescribed for residents by their doctors, records are maintained to evidence that the creams have been administered as prescribed. 4. OP19 We recommend that the home considers additional steps that could be taken to make the physical environment more suitable for the residents with memory loss. We recommend that within communal bathrooms paper towels and liquid soap be provided and that staff make sure that tablets of soap and cotton towels are returned to residents’ bedrooms after use. 5. OP26 Hannah Levy House Trust DS0000003944.V377700.R01.S.doc Version 5.3 Page 29 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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