Care Home: Herons Park Nursing Home

What the care home does well Herons Park provides a safe purpose built environment for people to live in. There is an informal, relaxed and friendly atmosphere in all areas of the home, and staff were observed talking and laughing with the residents. We were told by relatives and residents that they had been provided with sufficient information about the home to assist them make an informed choice prior to moving in. The manager encourages people to visit the home before making up their minds. All people are assessed before moving into the home to ensure that the home can meet their health and physical needs safely. Residents told us that they have their health and personal care needs provided in a polite and courteous way, and their preferences about their care is respected. The staff told us that the home is committed to them receiving training, and that they have the skills and knowledge to meet the care needs of the residents. The residents and staff told us that the activities and the organiser are excellent, and provide a varied program for all the residents. The home has a thorough recruitment procedure in place so that only people suitable to work with vulnerable people are employed. People living at the home receive a well-balanced and varied diet that meets their nutritional and dietary needs The home is managed in the interests of the people who live there. The health and safety of the people who use the service are protected by the policies and procedures in the home. What has improved since the last inspection? The assessments procedure has been updated providing staff with more information to assist them in caring for the person, and also assists staff in their record keeping in accordance with the nurses` professional accountability. The home has updated their Statement of Purpose and Service User`s Guide, which is now available in alternative formats and is easier for people enquiring or using the service to understand. Care plans have been reviewed and people using the service have been involved with the update, this assists in providing care records, which are person centred for the individual person. Management of complaint records have been reviewed, so that people using the service can be confident that their concerns are listened to and addressed. CARE HOMES FOR OLDER PEOPLE Herons Park Nursing Home Heronswood Road Spennells Wood Kidderminster Worcestershire DY10 4EJ Lead Inspector Chris Potter Unannounced Inspection 09:15 20 October 2008 th 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 DS0000004116.V372111.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. DS0000004116.V372111.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Herons Park Nursing Home Address Heronswood Road Spennells Wood Kidderminster Worcestershire DY10 4EX 01562 825814 01562 753656 heronspark@btconnect.com www.royalbay.co.uk www.royalbay.co.uk Regency Old Homes Plc 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) Ms Sandra Jayne Packwood Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58), Physical disability over 65 years of age of places (58) DS0000004116.V372111.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Pre-admission assessments will specifically address mental health needs of potential service users and the home will not admit any person identified as having dementia illness. The home may accommodate 7 named current service users who have dementia illnesses. When the service users plans are reviewed (ie at least monthly) an assessment will be made as to whether or not there are any dementia needs and, if so, whether they are being met appropriately in the home and how. Commission for Social Care Inspection will be notified of any resident service user who develops a dementia illness after their admission. 14th February 2008 2. 3. 4. Date of last inspection Brief Description of the Service: Herons Park Nursing Home provides nursing and personal care for a maximum of fifty-eight people of either sex, over the age of sixty-five years who have needs associated with old age and physical disabilities. The home has a registration variation enabling it to accommodate named service users with a dementia-type illness. It does not offer a service to new people with dementia illnesses. This home is situated on the outskirts of Kidderminster close to local amenities and the public transport system. The home provides parking for several cars within the homes grounds. Herons Park is a purpose built home offering accommodation to people in both shared and single bedrooms all with en suite facilities. Accommodation is on two floors with a lift to assist people using the service to access all areas of the home. The home provides a range of aids and equipment to assist them in meeting the needs of people using the service. Communal areas are available with lounges and dining facilities on both floors so people have a choice of where they wish to spend their day. The home has a small garden overlooking the adjacent park and an enclosed courtyard garden which are accessible for people in wheelchairs. A varied range of activities are provided for the people living at the home and the home has its own transport for residents wishing to maintain links with the local community. DS0000004116.V372111.R01.S.doc Version 5.2 Page 5 Regency Old Homes Plc, for whom Mr Russell Wilson is the responsible individual and Managing Director of Royal Bay Care Homes ltd own the home. The registered manager is Mrs Sandra Packwood. The email address for the home is heronspark@btconnect.com Information regarding the home is available in the Statement of Purpose, The Service User’s Guide and Inspection reports. These documents are available on request from the home. The fees for the home are between £550 and £650, this was correct at the time of the inspection for more up to date information please contact the home direct. Additional charges are made for chiropody, hairdressing and newspapers. DS0000004116.V372111.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 3 stars. This means the people who use the service experience excellent outcomes. We, the commission, undertook an unannounced inspection of this service, which means that the home did not know we were coming. This was a key inspection – which is an inspection where we look at a wide range of areas. Before the inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the service for completion. The AQAA is a selfassessment and a dataset that each registered provider has to complete each year and send to us within agreed timescales. The document tells us about how providers of services are meeting outcomes for people who use the service and is an opportunity for them to share with us what aspects of the service they believe they are doing well. Some of the provider’s comments have been included within this inspection report. Information was gathered from speaking to and observing people who lived at the home. Three people were “case tracked”, and this involved discovering their experiences of living at the home by meeting and observing them, looking at medication and care files, and reviewing areas of the home relevant to these people in order to focus on outcomes. Case tracking helps us understand the experiences of people who use the service. Surveys were sent out and received from residents (eight) and staff (seven). We looked at some parts of the accommodation and interviewed some staff. What the service does well: Herons Park provides a safe purpose built environment for people to live in. There is an informal, relaxed and friendly atmosphere in all areas of the home, and staff were observed talking and laughing with the residents. We were told by relatives and residents that they had been provided with sufficient information about the home to assist them make an informed choice prior to moving in. The manager encourages people to visit the home before making up their minds. All people are assessed before moving into the home to ensure that the home can meet their health and physical needs safely. Residents told us that they have their health and personal care needs provided in a polite and courteous way, and their preferences about their care is respected. DS0000004116.V372111.R01.S.doc Version 5.2 Page 7 The staff told us that the home is committed to them receiving training, and that they have the skills and knowledge to meet the care needs of the residents. The residents and staff told us that the activities and the organiser are excellent, and provide a varied program for all the residents. The home has a thorough recruitment procedure in place so that only people suitable to work with vulnerable people are employed. People living at the home receive a well-balanced and varied diet that meets their nutritional and dietary needs The home is managed in the interests of the people who live there. The health and safety of the people who use the service are protected by the policies and procedures in the home. What has improved since the last inspection? What they could do better: The service has made significant improvements since the last key inspection. With their pro-active approach, they have met and exceeded the national minimum standards as a result no requirements or recommendations have been made following this inspection. Please contact the provider for advice of actions taken in response to this DS0000004116.V372111.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. DS0000004116.V372111.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 DS0000004116.V372111.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): Standard 1 and 3. The home do not provide intermediate care therefore standard 6 was not assessed. Quality in this outcome area is good. People have enough information to assist them before moving in, so that they know what the home provides, and what they can expect when they move in to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides written information in the form of a Service User Guide to help people decide whether they wish to live at Herons Park Nursing Home. A resident told us that they had received the information and came on a trial visit prior to moving into the home. We saw copies of the Service User’s Guide in the reception area of the home, and in the residents’ bedrooms. The home has the ability to have the documents translated and made available in other formats including large print, Braille and audio. The service has updated the DS0000004116.V372111.R01.S.doc Version 5.2 Page 11 Statement of Purpose and Service User Guide since the last inspection in February 2008 so the requirement given at the last inspection has been removed. We looked at the records for three people who use the service, and these showed that the manager and deputy had been out to visit them before they arrived at the home. They had completed an assessment of the individuals’ care needs. This assessment gives staff the information they need so that they can provide the support and care that people need, as soon as they move in. The manager told us that the assessment form had been updated to include additional information about where the assessment was carried out and who was present for the assessment. We received eight surveys from people using the service who confirmed that they had received enough information about the service. An example read; “(I) had plenty of information and they were very helpful and pleasant” A resident told us that they had been assessed prior to admission, and visited for a trial session before making up their mind about the home. We were told that they had settled well, and were pleased with the choice of home. We spoke to staff and they were able to demonstrate the residents’ care needs. They also stated that they were provided with sufficient information about new residents to enable them to meet their care needs. The Annual Quality Assurance Assessment completed by the manager provided us with the appropriate information to show how the home is meeting these standards. DS0000004116.V372111.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): Standard 7,8,9 and 10 Quality in this outcome area is good The health and personal care people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at three people’s care records and these showed that each person had an individual plan of care. They showed that personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person’s records. For example a diabetic person’s care plan stated to monitor their blood glucose levels three times a day, and the records were in place of the results showing this was being followed. We spoke to the resident who confirmed that the staff were monitoring their diabetes and the blood glucose results had been better following admission into Herons Park. The manager told us that people are encouraged to be involved with the planning and reviewing of their own care, and we saw in the records that either DS0000004116.V372111.R01.S.doc Version 5.2 Page 13 the person or their relatives had signed to say that they agreed with the care plan. Following the previous inspection in February 2008 the home was required to make improvements to the way they assessed and planned the care. The home has made these improvements, and has therefore met this requirement. We received surveys from eight people using the service, and these stated that the home always seeks medical advice when necessary - “The medical support has been very good”. We saw the records that the GP’s and specialists had been contacted whenever someone’s health had given them cause for concern. The tissue viability specialist was complimentary about the homes success with healing pressure sores and leg ulcers. A good range of specialist equipment is available to assist the staff in meeting the health and personal care needs of the residents. Profile beds are provided for all the residents, which have a standard mattress to provide additional protection for the person from developing damage to the skin caused through pressure. Staff told us that the home had sufficient pressure relieving equipment to care for the residents prone to skin pressure damage. The home has good procedures in place for the management of medication. Medication is stored safely, and accurate record keeping enables the home to know which medications have been given and at what times. We looked at three peoples’ medication records and they had been completed by the nurse who administered the medication. The manager completes a monthly audit of the medication system and these records were looked at and support that the nurses are adhering to the homes medication policy. Residents’ privacy was seen to be maintained by the staff, they were knocking on doors before entering. Residents and relatives confirmed that all staff respect their privacy and dignity. The surveys returned confirmed that the residents were pleased with the care provision. All residents appeared contented and were seen enjoying the activities, and laughing with the staff. There was a friendly relaxed atmosphere throughout the home, and all staff were polite and courteous. Staff told us that they were provided with sufficient information about the residents’ care needs to enable them to look after them. They also confirmed that they were given time to look at the residents’ care records for additional information about any health need. DS0000004116.V372111.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): 12, 13, 14 and 15 Quality in this outcome area is excellent. People using the service have the opportunities to be involved and stimulated by a wide range of interesting activities and access the gardens. The dietary needs of the residents are well catered for with a balanced diet and a varied selection of foods. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a full time person designated for the social activities for the residents. The service understands and actively promotes the importance of respecting the human rights of people using the service, with fairness, equality, dignity, respect and autonomy - all being seen as central to the care and support being provided. All residents and staff recognised the value and the benefits of having varied activities and flexible lifestyle. All the residents referred to the activities organiser by her first name, and were most respectful of her position, and how approachable she is. For example: “this is an DS0000004116.V372111.R01.S.doc Version 5.2 Page 15 excellent and a very valuable part of the home. There is variety and it is fun” “Judy, the activities co-ordinator is excellent and very enthusiastic.” The staff confirmed that they take an active part in the activities, so that they can continue with them when the activities person is not there. The activities person has also completed a qualification in care to assist them in understanding and helping the residents with suitable social activities. A social record is maintained for each individual resident showing what they have participated in. To assist with the planning of a varied program of activities they hold regular meetings with the residents and the minutes from these are maintained. Two Church services are held each month for the residents who wish to participate. A newsletter is produced on alternate months to update the residents and relatives of forthcoming events. A link with the local schools has also been developed so that they come and sing for the residents on special occasions. The home has a small library area with a range of books that are changed by the local library at regular intervals. Some of the residents prefer to go the local library weekly to renew their books, and participate in the weekly coffee morning at the same time. The service has its own transport, which assists residents with their choices. The home has two sensory gardens and an enclosed patio area for the residents to use when the weather permits. Various photographs are displayed around the home showing the residents and some of the activities they have participated in. Residents told us that they when they move into the home, they are asked questions about what time they prefer to get up, go to bed, whether they prefer male or female carers. The home then respects their wishes, and if they decide to stay up late, the carers respect this. The information on surveys received before the inspection and comments received from visitors during the inspection were all complimentary about the home. All said that the staff were friendly and made them feel welcome when they visited. Relatives were seen coming and going during the day and made welcome by the staff. The home provides varied well balanced meals for the residents and caters for cultural and dietary needs. The residents told us that the chef had asked them about their dietary likes and dislikes and had used this information to develop a weekly menu. The menu is displayed in the reception area of the home for all to see. We saw the lunch being served in both dining rooms, in a relaxed manner. The food appeared appetising, and the people told us that they were enjoying their meal. Lunch on the day of the inspection was sausages and mash or cauliflower cheese. With five choices of dessert, this assists in ensuring that DS0000004116.V372111.R01.S.doc Version 5.2 Page 16 the residents receive their five portions of fruit and vegetables daily. People requiring assistance with their meal were being assisted in a sensitive manner. The comments received about the food included: “Toast could be hotter” “the food choice is good and appropriate for older people” and “the meals are very nice” The Annual Quality Assurance Assessment completed by the manager provided us with their planned intentions for the next 12 months to improve the service which included more planned activities for the weekends. DS0000004116.V372111.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): Standards 16 and 18 Quality in this outcome area is good. People who use the service are able to express their concerns, and have access to a robust and effective complaints procedure. People are protected from abuse, and have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents told us they were confident that any concerns would be listened to and looked into. Residents named the manager, deputy manager and the activities organiser as people that they would talk to if they had any concerns. The complaints policy is displayed in the reception area of the home and in the Service User Guide a copy of which is in the residents’ bedrooms. Since the last inspection we have received one complaint about the service which is a contractual issue about the fees. The service investigated the complaint using their complaints policy and the complaint was not upheld. The complaints register was seen and was up to date with the complaints, this was a requirement at the last inspection, and therefore this requirement has been met. DS0000004116.V372111.R01.S.doc Version 5.2 Page 18 Training records showed that staff attend regular training on the protection of vulnerable adults. Staff spoken to confirmed that they had received training and would have no hesitation in reporting poor practise. The Annual Quality Assurance Assessment completed by the manager provided us with information in how they have met these standards improved in the last 12 months. One improvement listed was they have enlisted the help of Wyre Forest advocacy for the residents who have no relatives and lack capacity. DS0000004116.V372111.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): Standards 19 and 26 Quality in this outcome area is excellent. The physical design and layout of the home enables residents to live in a safe, well maintained and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Herons Park nursing home provides a choice of single or shared accommodation for people who choose the service. It has twenty-eight single bedrooms, ten double bedrooms all with en-suite facilities. The accommodation is on two levels with a passenger lift to assist residents with mobility problems to access all areas of the home. The home provides two large lounges, two dining rooms and quiet sitting areas for the residents to sit DS0000004116.V372111.R01.S.doc Version 5.2 Page 20 in. Since the last inspection the service has provided new chairs in the ground floor lounge, which all have pressure relieving protection built in so additional cushions are not required. Large flat screen televisions are situated in the lounges with “Sky” satellite television, so the residents have more choice of what to watch. The manager told us that they are awaiting new carpets to complete this area. The gardens continue to be developed so that the residents can use them if they wish, and they provide a pleasant outlook from the home. Residents have the facility of using pendant alarms to summon assistance when they go outside in the gardens. We looked at parts of the home, and saw residents’ bedrooms were personalised by the individual with ornaments, photographs and pictures. The shared rooms had dividing curtains and all toiletries were clearly separated for each individual, minimising any risk of cross infection. The home has hygienic hand gel placed in prominent places around the home for the staff and visitors to use to further assist in reducing cross infection to the residents. The home is in good decorative order throughout and all areas of the home were clean and tidy. The home have a good maintenance program in place and monitor the hot water temperatures weekly. Checks are made of the window restrictors to ensure that they are working correctly. All beds in the home are of a specialist profile type, which assists the staff in meeting the residents’ health and personal care. The staff told us that the majority of residents prefer baths, but they are finding that more people now request a shower. The home has eight specialist baths and is in the process of converting some to showers to offer residents a choice of bath or shower on each unit. Residents confirmed that the staff respond quickly when they activate the nurse call system for assistance. The staff told us that the home was always clean, and that they all worked as a team and respected everyone’s job in looking after the home. Staff when asked could not think of any improvements to the home to assist them in looking after the residents. The Annual Quality Assurance Assessment completed by the manager provided us with their plans for improvement over the next twelve months which included to continue with the refurbishment of the shower rooms and bathrooms. DS0000004116.V372111.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): Standards 27,28,29 and 30 Quality in this outcome area is excellent. Herons Park provides people who use the service with staff who are trained, skilled and in sufficient numbers to meet their care needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection, the home was accommodating 46 residents. The duty rotas showed that the home was planning staffing levels proportionate for the number and needs of the residents. The manager told us that they have not used agency staff in the last twelve months, and that staff work additional hours to cover any shortfalls. Residents stated that they felt the staffing levels were good and they never had to wait for long periods when requesting assistance. Staff spoken to also expressed that the staffing levels were sufficient for them in meeting the health and social care needs of the residents. “Because of the staffing levels we have time to spend with the residents and do activities, and so get to know them really well”. “We always have enough staff on duty”, “staff all get on well, we work as a team” “the trained staff are very supportive”. DS0000004116.V372111.R01.S.doc Version 5.2 Page 22 Staff told us that they liked the new uniforms and name badge, which they had just been provided with. All grades of staff wear a uniform and named identity badge including the Director of the company. On walking around the home a staff presence was noted in all areas. In addition to the nurses and care staff, the home provides domestic, catering, laundry, maintenance, gardening and administration staff. Comments from the residents, relatives and surveys were complimentary. “The staff are very good, and respond quickly both day and night when we ring for assistance”. Three staff files were reviewed during the inspection. The home was following their recruitment procedure and completing the appropriate checks on the applicants. Since the last inspection the service has updated their application form to show the applicants continuous employment history, this recommendation is now removed. We looked at the staff training records and saw that the service have prioritised staff training. The requirement from the last inspection report is now met so removed from the report. In addition to annual training updates, eight carers are in the process of completing a course on dementia at a local college. Residents told us that they felt that the staff were suitably qualified to meet their care needs. The staff told us how the service facilitates and provides them with paid time to attend the courses. The national vocational qualification in care assessor comes to the home, and stated, “ I have worked in various homes and The Herons is a lot better than most and positively promotes the training”. The Annual Quality Assurance Assessment completed by the manager provided us with the information that the home has 65 of staff with an NVQ level2 or above and a further 16 are working towards the qualification. The residents are being encouraged to attend interviews for new staff and give their opinion on suitability. DS0000004116.V372111.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): Standards 31, 33, 35 and 38 Quality in this outcome area is excellent. People living at Herons Park can be confident that the management and administration of the home is based on openness and respect, and has effective quality assurance systems developed by a competent manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last key inspection in February, the manager set about addressing the requirements and the recommendations, and some were actioned prior to the report being finalised which is commended. The management team are pro active and enthusiastic in providing a good quality person centred service for people using the home. The Managing Director is based at the home and is DS0000004116.V372111.R01.S.doc Version 5.2 Page 24 approachable and supportive with plans for improving the service. He also knows all the residents and staff, and is appreciative of all the hard work carried out by the staff team in improving the standards of care for the residents. This enthusiasm is cascaded down to all the staff working at the home. Staff who had worked at the home for many years told us that all the improvements have further enhanced the service being provided for the residents and the staff. The manager is a first level registered nurse and completed the registered manager’s qualification. All staff and residents stated that she was helpful and supportive. Comments included, “Sandra is lovely” and “Sandra is a very good manager”. The manager and the deputy manager complete monthly audits in medication, wound care, infection control and accidents to assist in monitoring the home’s performance and ensures staff are following correct procedures. The accident records were looked at during the visit and, for the number of residents, the monthly results were low. The accident forms were being completed and people identified at risk of falls had an appropriate risk assessment in place advising staff on how to minimise the risk of falls. Feedback is encouraged from the residents, relatives and professionals using the service. The compliments from the local GPs covering the home have been complimentary. The questionnaire for the residents has recently been updated to make it easier so more residents can complete it. The system for monies held in the home for the residents were checked. It is an individualised system and records all money received, and any outgoings for which a receipt is maintained. Limited staff have access to the residents’ monies, and two staff check money going out. The home employs a maintenance operative who has a well organised system for ensuring that the safety checks are completed. All records requested were available and up to date. The Annual Quality Assurance Assessment completed by the manager provided us with detailed information, and gave a good reflection of the home and how the service is progressing. It advised us that all staff receive annual appraisals to assist in identifying their learning needs. All policies and procedures are reviewed annually and a new health and safety policy has been implemented. DS0000004116.V372111.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 4 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 4 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 x x 4 DS0000004116.V372111.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. Refer to Standard Good Practice Recommendations DS0000004116.V372111.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000004116.V372111.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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