Care Home: Horncastle House

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What the care home does well The home is situated in an attractive location and offers a homely environment for residents to live in. There is a rolling programme of maintenance and residents have a choice of comfortable communal and private spaces to spend their time. Mealtimes offer residents a choice of balanced freshly prepared meals which can either be served in the dining area or bedrooms depending on what residents prefer.Horncastle House provides a range of fulfilling activities with a dedicated activities co-ordinator employed to work in the home four afternoons each week. Residents spoke highly of the activities on offer and the attendance to the bingo session on the day of the inspection was observed to be high. Residents receive the support they need by a team of trained and experienced staff. The home is managed effectively with systems in palace to monitor quality and gain feedback from a range of stakeholders. What has improved since the last inspection? A number of environmental improvements have been made since the last inspection, which has created a more homely and pleasant feel. A new person centred (individualised) approach to developing plans of care has been introduced that look at the holistic support needs of residents. What the care home could do better: Shortfalls in the way some key daily information is recorded was identified. It is important that all staff take responsibility for ensuring charts that record what people have eaten and drank and how often the people in bed are supported to change positions are routinely completed. These documents are vital to ensure that people receive the level of care they need to be comfortable and healthy. Registered nurses need to be more proactive in following correct medication procedures, particularly where residents are on medicines that are supplied outside the normal ordering system. CARE HOMES FOR OLDER PEOPLE Horncastle House Plawhatch Sharpethorne East Grinstead West Sussex RH19 4JH Lead Inspector Lucy Green Key Unannounced Inspection 29thJanuary 2008 09:00 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 Horncastle House DS0000024159.V358085.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. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Horncastle House Address Plawhatch Sharpethorne East Grinstead West Sussex RH19 4JH 01342 810219 01342 811247 horncastlehouse@sussexhealthcare.org 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) Dr Shafik Hussien Sachedina Mr Shiraz Boghani Mrs Linda Rose Mountford Care Home 43 Category(ies) of Dementia (43), Old age, not falling within any registration, with number other category (43), Physical disability (4) of places Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia - (DE) Physical Disability (PD)(4) The maximum number of service users to be accommodated is 43. 2. Date of last inspection 20th September 2006 Brief Description of the Service: Horncastle House is part of the Sussex Health Care Group and is privately owned by Dr Sachedina and Mr Boghani. Horncastle House is registered to provide nursing care and accommodation for up to forty-three older people, who may also have a dementia type illness. The home also has four registered places to support people who are diagnosed with a physical disability. The Registered Manager confirmed that as bedrooms are all now offered for single use, the home is able to provide accommodation for thirty-six people. Horncastle House is a large detached property located in the village of Sharpethorne, near East Grinstead. The home is surrounded by large and attractive grounds. The accommodation is arranged over two floors, which are served by a passenger lift. Communal areas comprise of a lounge, activities room and a large dining area. More detailed information about the services provided at Horncastle House, including the range of fees can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are available in the home. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 5 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. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. The Registered Manager of Horncastle House confirmed that the people who live in the home identify themselves as ‘residents’. For the purpose of this report, those living at Horncastle House are therefore referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, feedback from representatives and an unannounced site visit which lasted seven and a half hours on Tuesday 29th January 2008 between the hours of 9am and 4:30pm. A second Inspector visited the home for four and a half hours to support the Lead Inspector. The site visit included a partial tour of the premises and an examination of medication, care and staffing records. Both Inspectors observed the lunchtime meal being served. At the time of inspection, twenty-six residents were living at Horncastle House. Throughout the inspection process, the Inspectors met with all of the residents and spoke with thirteen of them individually. The Inspectors also observed the support residents received in communal areas The Inspectors spent time with the Registered Manager and spoke with five staff members including one Registered Nurse, two carers and a member of domestic staff. What the service does well: The home is situated in an attractive location and offers a homely environment for residents to live in. There is a rolling programme of maintenance and residents have a choice of comfortable communal and private spaces to spend their time. Mealtimes offer residents a choice of balanced freshly prepared meals which can either be served in the dining area or bedrooms depending on what residents prefer. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 6 Horncastle House provides a range of fulfilling activities with a dedicated activities co-ordinator employed to work in the home four afternoons each week. Residents spoke highly of the activities on offer and the attendance to the bingo session on the day of the inspection was observed to be high. Residents receive the support they need by a team of trained and experienced staff. The home is managed effectively with systems in palace to monitor quality and gain feedback from a range of stakeholders. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 7 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 Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 8 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): 3&6 People who use 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. Prospective residents are protected by an assessment process that ensures their needs are identified and confirmed they can be met before they move into the home. Horncastle House does not provide intermediate care. EVIDENCE: The Inspector viewed the pre-admission assessments in place for five people who have been admitted to Horncastle House in the last twelve months. There was documentary evidence that a representative from the home, usually the Registered Manager, had conducted a comprehensive assessment on all of these individuals prior to them moving into the home. In addition to the home’s own assessment, necessary information had also been obtained from other relevant professionals, including assessments Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 9 undertaken by the Primary Care Trust and Social Services and where appropriate, hospital discharge forms. The Registered Manager confirmed that prospective residents and/or their representatives are encouraged to visit the home prior to admission to assess the suitability of the placement. All residents whose care was looked at as part of this inspection confirmed that the admission process had been tailored to meet their needs and that either they or a relative had visited the home before they moved in. There is no provision for intermediate care at Horncastle House and therefore Standard 6 is not applicable. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 10 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): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff practice reflects a good understanding of residents’ personal and healthcare needs which ensures that needs are met. The documentation in place for some people does not fully reflect the level of care provided and there is a risk that care may not be consistently provided in accordance with the care plan. Registered Nurses need to pay greater attention to the way they manage medication to ensure residents are fully protected. EVIDENCE: Care plans viewed generally provided clear guidance for staff on how to meet the assessed needs of individuals. Some care plans were noted to have some pre-populated information. These show how to meet the needs of the individual, however do not read as being personalised. The Registered Manager confirmed that care plans are in the process of being changed to reflect person centred care. For those residents who had a care plan on the new system, there was a detailed record of their needs which looked at their required support from a holistic and person centred approach. Discussion with Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 11 five residents confirmed that the information recorded about them was accurate. All care plans viewed had been reviewed on at least a monthly basis by the key worker (key worker is a named person delegated responsibility for overseeing an individual’s care records). At six monthly intervals there was evidence of a formal review involving the resident and/or their representative. Advanced care plans were in place in each of the care plans viewed which provided detailed and sensitive information about how the resident and their representative wished care to be delivered at the end of their lives. Specific areas of care were looked at for seven residents. There was guidance for staff to follow specific to these needs. It was noted that monitoring charts were not always being used effectively. There were significant time gaps noted in fluid balance charts and turning charts were not evidencing that guidelines within a care plan were being followed. (Turning charts - used for people who have limited movement and are at risk of developing pressure areas. Fluid balance charts – used to monitor the fluid intake and/or output of an individual). The Registered Manager e-mailed the Inspectors the day following the site visit to advise that she has emphasised to staff the importance of recording and charting all procedures in the care plans when attending to residents. As the home has confirmed that the required action has been taken to rectify this issue in a timely way, no requirement or recommendation has been made on this occasion. Forms in use for the documentation of wounds were not being completed consistently for all residents. Nurses must ensure that all section of the wound assessment form is completed. No requirement or recommendation has been made in relation to this, as the overall outcome for wound care practices within the home is good and the practical care provided is effective. This area will however be closely monitored at the next inspection. The home has access to a tissue viability/practice nurse when the need arises. The home has access to pressure relieving equipment when needed. Pressure relieving mattresses were observed to be in use for residents at risk of developing pressure areas. There were risk assessments in place for the use of bed rails, however some rails were noted not to be covered, to further protect residents from injury. If bed rail covers are not used, this must be identified with the reason why on the risk assessment. No requirement or recommendation has been made in relation to this as the Registered Manager confirmed that she will address this with immediate effect. The home receives medication on a weekly basis from a supplying pharmacist. The Medication Administration Records (MAR) charts observed demonstrated that medication is generally being signed for at the time of administration. Prescribed creams were not being signed for on the MAR charts, however a Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 12 nurse confirmed that these are signed for within an individuals care plan. It was confirmed that there are policies and procedures in place for all aspects of dealing with medication. Registered nurses administer medication and a nurse spoken with confirmed that they receive updated training for this procedure. Residents are provided with an opportunity to self medicate if they wish and a risk assessment identifies that it is safe for them to control their own medications, which is subject to ongoing review. One resident is currently responsible for administering their own medication and this resident showed one of the Inspectors her lockable cupboard and explained how she manages her medicines safely. One resident, who has retained her own GP, has their medicines delivered and administered in a different system from other residents. Staff were found to be hand writing the directions on the MAR chart for this individual. The dosage written on the MAR chart and the actual GP prescriptions were different for two medicines. The Inspector viewed the previous three months of MAR charts that identified that the same error was reoccurring. It was discussed with a registered nurse and the Registered Manager that this is poor practice for registered nurses. They must be aware of their Code of Conduct and responsibilities as prescribed by the Nursing and Midwifery Council (NMC), their registration authority. A requirement was going to be made in respect of this, however the Registered Manager confirmed in writing the day after the site visit of the action she has already taken to address the shortfalls. A new policy and procedure has been implemented for the entering of new medication on the MAR charts and a memo has been written to all trained staff making them aware of the new procedures. This will be again be monitored through the inspection process. A sample of controlled drugs were checked and demonstrated that clear records were being maintained for these. It was discussed with the Registered Manager that she seeks advice to ensure the storage of the controlled drugs complies with the standards set in the Misuse of Drugs (Safe Custody) Regulations 1973, particularly in respect of the upstairs storage. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 13 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 & 15 People who use 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 are supported to retain choice and control over their lives and benefit from the opportunities to participate in activities if they wish to. Residents receive a choice of balanced and freshly prepared meals. EVIDENCE: The daily running of the home was observed to provide residents with the flexibility and choice about how and where to spend their time. On the Inspector’s arrival at the home it was evident that routines are respected by staff and residents are supported to get up at a time that suits them. Breakfast is served in bedrooms at a time agreed with the residents – this arrangement was reported by residents to work well and they confirmed that they had choice regarding what they have. Menus for lunch and tea are displayed in the dining room and on notice boards around the home. The serving of the lunchtime meal was observed with a choice of either cod with parsley sauce and vegetables or minced beef with Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 14 mash potatoes and dumplings, each followed by dessert. The meal looked appetising and well presented and the food was served on a trolley to enable residents to see the choice they were making. Discussion with staff, residents and a viewing of the menu, identified that residents also receive a choice of meals at teatime. Residents spoken with were complimentary of the food provided at Horncastle House. One resident told the Inspector “the food is very good here” and another resident commented “the food is good and you always get a choice of two things”. The dining room is arranged into two areas, one area is for residents who can eat independently and the other for residents requiring a level of support at mealtimes. Tables in both areas are arranged in small groups and residents were observed to be interacting positively with the people they sat with. Those residents requiring support were assisted with dignity and respect. Horncastle House offers a range of activities for residents to participate in and on the day of inspection, the hairdresser visited in the morning and an activity and physiotherapy session was arranged for the afternoon. The home employs an Activities Co-ordinator who works in the home four afternoons each week. On the day of the inspection, this individual was observed providing a bingo session which was attended by at least ten residents. Other in-house activities include; quizzes, word association activities, aromatherapy and arts and crafts. The home has links with a visiting library and there was a selection of books in the lounge for residents to borrow. Discussion with the activities co-ordinator revealed that the activities are always well attended and that residents use the afternoon sessions to get to know other residents and develop friendships. The activities co-ordinator also stated that whilst the home has arranged a number of outings for residents, these activities tend to be declined on the day. Feedback from the residents spoken with was positive about the activities provided by the home. One resident told the Inspector “you won’t catch me this afternoon, I’ll be playing bingo” and another reported “I love the activities, she [activities co-ordinator] is marvellous”. Residents are encouraged and supported to maintain contact with their family and friends. The home operates an open door policy and residents are able to spend time with their guests in their rooms or in one of the lounges. Visitors were observed being welcomed into the home during the inspection and the visitors’ book evidenced that there are lots of regular visitors to Horncastle House. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 15 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 People who use 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 an open culture where they are able to express their views and feel valued and protected from harm. EVIDENCE: Horncastle House has a complaints policy which is accessible to both residents and visitors to the home. Neither the home nor the CSCI have received any formal complaints about the services provided at Horncastle House since the last inspection. A complaints book is located in the reception area and residents or visitors are encouraged to record any comments. The residents spoken with all confirmed that they knew how to complain and stated that if they had any concerns they would speak to the Registered Manager or one of the nurses. The staff spoken with were knowledgeable about the vulnerability of residents and the systems in place to protect them. Staff have received training in the protection of vulnerable adults and prevention of abuse. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use 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 continue to benefit from the clean, accessible and homely environment provided at Horncastle House. EVIDENCE: A partial tour of the environment was undertaken that demonstrated that the environment is comfortable for residents and there is ongoing maintenance within the service to improve these standards. Resident accommodation is provided in thirty-six single bedrooms, with the exception of two, all have ensuite facilities. Rooms are well presented and residents confirmed that they had been able to personalise their bedrooms with their own belongings. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 17 The home was generally found to be clean, tidy and well maintained. A cleaner and the Registered Manager were made aware that attention is needed to ensure that the underneath of bath hoists seats are regularly cleaned. The floor to the medical rooms must also be kept clean. The Registered Manager confirmed via telephone to one of the Inspectors that they have ordered a new bath hoist seat for one of the bathrooms. A nurse spoken with confirmed that there were enough suitable assisted bathing facilities provided to meet the needs of the residents. A nurse confirmed that there is a sluice machine located on both floors of the home to assist in infection control. The Inspectors observed that the size of the lounge room and activities room would pose restrictions if all residents wished to used these areas at the same time. The Registered Manager confirmed that this has not been an issue to date, but would be considered at the assessment stage of prospective residents if this ever became an issue. The cupboard containing cleaning materials was observed to be locked ensuring residents are safeguarded in accordance with Control of Substances Hazardous to Health Regulations (COSHH). One radiator was noted to be unguarded and very hot to touch. The home was proactive and confirmed in writing to the Inspectors the day following the site visit that a radiator guard is now in place. The Registered Manager confirmed that all other radiators are guarded, window openings above ground floor restricted and hot water outlets fitted with a device to prevent scalding. In line with the recent change to registration to accommodate people with a dementia type illness, the home has fitted a system of keypads and alarms to external doors. The home is also planning to make a secure garden area available for the summer to enable those residents who require more support the freedom to wander outside if they wish. It was a requirement of registration that home use appropriate signage around the home to assist with orientation for persons with dementia. Consequently, signs have been placed on toilet, bathroom and bedroom doors. The Registered Manager confirmed that the use of colour coding areas and pictorial signs would be considered if the needs of the residents indicated this would be beneficial. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 18 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 People who use 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 being supported by an experienced and committed team of staff and are protected by the robust recruitment procedures. EVIDENCE: The calm and relaxed atmosphere in the home on the day of the inspection, indicated that staffing levels are currently sufficient to meet the needs of the residents. Any requests from residents were responded to promptly and call bells were answered efficiently. Discussion with the Registered Manager and a review of past and present rotas highlighted that the home is currently staffed during the day by a minimum of two nurses and four carers in the morning, one nurse and four carers in the afternoon. At night the home employs one nurse and two carers, which would increase to three carers if the number of residents accommodated exceeded thirty. The Registered Manager or her Deputy Manager work in a supernumerary capacity. There are additional domestic and catering staff to meet the needs of the home. The feedback received from all residents spoken with confirmed that staffing levels were sufficient and the three staff interviewed re-iterated the same Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 19 view. The Registered Manager confirmed that staffing levels were always under review and that if the needs of the residents changed, staffing levels would be adjusted. The interaction between residents and staff was observed to be positive and all of the residents spoken with were positive about staff support. One resident expressed “the staff are very competent” and another commented “the staff are ever so good and they don’t mind what they do for you”. Staff training is ongoing and the Registered Manager stated in the Annual Quality Assurance Assessment (AQAA) that eight of the eighteen care staff have completed National Vocational Qualifications (NVQ) to at least Level 2 in Care. The Registered Manager also confirmed that all new staff complete an induction and that the new programme is in line with Skills for Care. The registered manager has a list of registered nurses Personal Identification Numbers (PIN) numbers and ensures that they all have up to date registration with the NMC. There are no Registered Mental Nurses (RMN’s) working at the home. The Registered Manager confirmed that they would not be admitting clients who have challenging behavioural needs and whose nursing needs will outweigh any dementia related needs. Should the need arise they will have access to RMN’s that are currently employed by Sussex Health Care at other homes. The necessity of having RMN’s working at the home will continue to be reviewed. Mental health needs are monitored and support is accessed through a GP referral if needed. In line with a requirement of the recent change to registration, all staff have completed in-house training in dementia care and the nurses are all completing a distance learning course in this subject over a four month period. Records viewed demonstrated that some of the recent training provided/arranged are communication and record keeping, nutrition, diabetes, and chewing and swallowing etc. The head office of the organisation maintains the training schedule. The Registered Manager confirmed that all staff are up to date with mandatory training. Additional training is provided to registered nurses relevant to their roles. Staff have designated roles within the home of which they take responsibility for, eg: fire, infection control, COSHH and wound care etc. A nurse spoken with confirmed that they are provided with enough training opportunities. A review of the recruitment files for four newly employed staff provided evidence of a robust system of recruitment being in place – with the exception of one gap in employment history that the Registered Manager has agreed to follow up on, the correct documentation and checks are in situ. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 20 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 & 38 People who use 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 commitment of a skilled and experienced Registered Manager who ensures that the home is well managed and run in the interests and safety of the people who live there. EVIDENCE: The Registered Manager is skilled and experienced and has current registration with the NMC. She has completed the Registered Manager’s Award (RMA). Both residents and staff spoken with were complimentary about the management of the home. Staff described the Registered Manager as “approachable” and “supportive”. Throughout the inspection it was observed Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 21 that the Registered Manager had a good relationship with both residents and staff. The home has developed a number of systems to self-audit and review the services provided. Monthly monitoring visits of the home are conducted on behalf of the Provider in line with Regulation 26. The Registered Manager confirmed that satisfaction questionnaires are sent out randomly to residents and relatives each month. Regular staff and residents’ meetings are conducted and relatives’ meetings are held on annual basis. The Registered Manager informed the Inspectors that the home has no involvement in residents’ finances. The Registered Manager confirmed that the home has a number of systems in place to ensure the health and safety of the home is monitored and maintained, both in the AQAA and on the day of the inspection. The Inspector viewed a limited number of records pertaining to the maintenance of equipment and routine testing which were found to be satisfactorily completed. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 22 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 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 X X 3 Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? 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 OP9 Good Practice Recommendations That hand written prescriptions on MAR charts are double signed by two staff who are trained in medication procedures. This will safeguard staff and residents from errors being made. Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Horncastle House DS0000024159.V358085.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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