Care Home: Kirkella Mansions Residential Home

Similar services:

• Snydale Care Home
• Abbey The
• Larchfield Manor
• Hawkhills
• Beeches The - North Yorkshire County Council
• Carentan House
• Ravensworth Lodge

What the care home does well People are well assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follows robust practices and procedures. The service handles medication well and staff are satisfactorily trained in medication administration, though this should be updated annually.People experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. They are encouraged to maintain contact with family members and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives. People enjoy good food, which mostly matches their expectations and preferences, but also offers a satisfactory level of nutrition. People are confident their complaints will be listened to and acted upon. People are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service`s policies, procedures and practice under the safeguarding adults systems. People experience a safe, clean and well-maintained environment. A more than sufficient number of care staff work in the home on each shift to meet the needs of people. Staff are satisfactorily trained and qualified to do their jobs. The manager runs the service in the best interests of people, safeguards their financial interests, and maintains their health, safety and welfare. What has improved since the last inspection? The service offers increased safety due to the removal of door wedges and the introduction of door guards. Changes to people`s care plans are now being made if the monthly summary notes changes in their needs or requests. Staff and management have received training in safeguarding adult`s issues. Staff have undertaken annual fire safety training, which is planned to be updated each year. There are temperature readings undertaken on hot water outlets, including peoples` rooms to ensure the risks of scalding are reduced, which are recorded. What the care home could do better: The service could make sure all staff that administers medication receives updated training on an annual basis. CARE HOMES FOR OLDER PEOPLE West Ella House 6 Church Lane Kirkella Hull East Yorkshire HU10 7TG Lead Inspector Janet Lamb Unannounced Key Inspection 6th December 2007 08:50 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 West Ella House DS0000019768.V356681.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. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Ella House Address 6 Church Lane Kirkella Hull East Yorkshire HU10 7TG 01482 659403 01482 653995 jeff@Kirkellamansions.karoo.co.uk 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) Kirkella Mansions Company Limited Maureen Tindall Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2006 Brief Description of the Service: West Ella House is a large grade two listed building that is privately owned by a local care organisation. It is registered to provide care and accommodation for twenty-five older people, including those with dementia. Information about the home is provided to people and others in the home’s statement of purpose and service user guide. Fees paid range from £334.00 to £450.00 per week and there is an additional charge for hairdressing, private chiropody, cosmetics/toiletries and newspapers/magazines. On the day of the inspection there were 23 people being accommodated at the home. Communal accommodation is provided in two lounge areas (one that incorporates a large conservatory) and a dining room. There are also two small lounge areas where people can sit quietly if they choose to do so. Seventeen of the bedrooms are single and eleven of these provide en-suite facilities. The home provides ramps and a passenger lift to ensure that people have access to all areas of the building. The garden is landscaped and provides a safe and easily accessible amenity; it includes seating areas and raised flowerbeds. The home is close to local amenities and has car-parking facilities. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of West Ella House has taken place over a period of time and involved sending an annual quality assurance assessment (AQAA) requesting information to the home in September 2007 concerning people that live there and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information in October 2007 and questionnaires were then issued to a selection of people and their relatives and GPs. They were also sent to other health care professionals with an interest in their care, to social service departments commissioning their care and to the staff working in the home. This information obtained from surveys and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. An Inspector with the Commission and an accompanying expert by experience made a site visit to the home on 6th December 2007 to test these suggestions, and to interview people, staff, visitors and the home manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed, and the accompanying expert by experience viewed some people’s rooms with their permission. Several people were interviewed and chatted to and two staff, the manager and one of the directors were also interviewed. All of the information collected was checked against that obtained through questionnaires and details already known because of previous information gathering and contact with the home. What the service does well: People are well assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follows robust practices and procedures. The service handles medication well and staff are satisfactorily trained in medication administration, though this should be updated annually. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 6 People experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. They are encouraged to maintain contact with family members and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives. People enjoy good food, which mostly matches their expectations and preferences, but also offers a satisfactory level of nutrition. People are confident their complaints will be listened to and acted upon. People are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service’s policies, procedures and practice under the safeguarding adults systems. People experience a safe, clean and well-maintained environment. A more than sufficient number of care staff work in the home on each shift to meet the needs of people. Staff are satisfactorily trained and qualified to do their jobs. The manager runs the service in the best interests of people, safeguards their financial interests, and maintains their health, safety and welfare. What has improved since the last inspection? What they could do better: The service could make sure all staff that administers medication receives updated training on an annual basis. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 7 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. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 only. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People’s individual and diverse needs are well assessed so they are confident needs will be met. They receive sufficient written information in the form of a statement of purpose and a service users guide so they can decide if the home is the right place for them. EVIDENCE: Discussion with three people that live in the home, the provider and the manager and viewing of case files with peoples’ permission reveals placing councils usually assess people prior to their admission into the home wherever possible. The manager also carries out an assessment of need before people become resident in the home. Both of these documents would be held on file and include an assessment of peoples’ different and personal, social and health West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 10 needs. They take into consideration all aspects of the individuals’ lifestyle and their expectations. Of the three people case tracked however, one is only there for a short period of time due to being flooded out of his home, is a relative of the manager and is paying privately, and two are private paying users of the service. Therefore none have had an assessment of needs undertaken by the councils, but two have a detailed assessment carried out by the home. These documents are available for viewing. There is also a letter sent to people once they have been assessed, which states their needs can or cannot be met by the home. A copy of this is held on file. One person said, “I’m only here for a short while, and they are looking after me very well. I don’t think I’ve had an assessment done.” Another said, “We came to look round first and then had a trial stay. Yes someone has asked what we like and what we need in terms of help.” There is a ‘statement of purpose’ and a ‘service user guide’ available for people to view and which provide them with information about the service on offer. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service receive good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have their health and social care needs well documented in care plans, so they are confident all their needs will be met. They have good opportunities to self-medicate or their medication needs are well managed, and they enjoy good levels of privacy and their dignity is well maintained, so their overall quality of life is good. EVIDENCE: People, staff and management spoken to, documents seen in files and information taken from that provided prior to the site visit, reveals people have a care plan, which is generated from the information obtained during assessment and from information provided by relatives, etc. Individual and diverse needs in respect of religion, social activities and physical impairment, are recorded to ensure people have their individual needs met, and according to their preferences. These are made clear in peoples’ care plans and are being kept up-to-date as requested at the last key inspection. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 12 Plans include eleven areas of need from personal care to communication. Action plans and risk assessments are also written in the care plans. There are also copies of local placing authority care plans held on file. Care plans are reviewed six-monthly in the home, and annually with the placing council and other stakeholders, and all dates are maintained and copies of reviews are held. Where possible people or their relatives sign documents. Those people with particular health issues or ailments receive support from the District Nursing Services and visits from their GP and records are held on diary note forms separate to general diary notes, while assistance is given to accompany them to hospital appointments etc. There is a policy and procedure on medication administration, which include self-medication although no one does self-medicate at the moment. A monitored dosage system is stored in a locked cupboard in a designated medical room. The Alliance Pharmacy supplies medicines and one of the senior carers is responsible for ordering, checking and booking them in to the home. She also organises returned medicines and monitors all other staff that have been trained to give out medication, as well as monitors when people need such as their influenza injections etc. There are six staff including the manager and one of the directors that are trained to undertake medication administration. Records show this was done in 2006. Three more of the staff, night carers, have only just completed the training and are awaiting their certificates of completion. Those staff whose training is more than 12 months old should refresh their training and do so each year. Medication systems are robust and follow an audit trail for safety. The medication administration record sheets were seen for three people being case tracked and these are satisfactorily completed and signed according to procedure. Observation of people during the day and conversations with them reveal their privacy and dignity are satisfactorily upheld. They are assisted with personal care only in private and they are spoken to and treated respectfully. West Ella House DS0000019768.V356681.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 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People enjoy flexible routines, good contact with relatives and friends, good opportunities to be self-determining, and satisfying food provision, so they are confident their daily lives and social activities meet their expectations. EVIDENCE: Discussion with people, staff and the manager and viewing of diary notes reveals people lead fairly fulfilling lifestyles of their choosing and according to their abilities. There are a variety of activities to take part in, all of which are usually planned according to the arrangements made by the activities coordinator. This person is currently unavailable for work however, so things within the home have not been happening as regularly as before and not always as planned. However, people still talk of being able to do things and go places, especially with their relatives. One of the directors of the company also takes people out to the local shops or park etc. and these impromptu outings are usually greatly appreciated. There are often ‘sing-along’ or slide shows organised, discussions are held once a month, and people listen to music or watch television. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 14 Visitors to the home are made very welcome and at least four were observed visiting a relative in the home on the day of the site visit. Visitors can either be seen in the lounges or in people’s rooms. There are no concerns about receiving visitors or about taking trips out. There are board games available for those who wish to play them and two people regularly play dominoes. All entertainment is taken up at the will and choice of people living in the home. Pastimes are offered and provided and people either do or do not indulge. Daily diary notes show whether or not they take part in anything or go out etc. Information obtained by the accompanying expert by experience also confirms that there is sufficient for people to do. “Both lounges had large TV screens, but neither were switched on when I visited. There was taped music in the dining area. People were dozing or chatting, and it was also hairdresser day. The handyman was busy putting up Christmas trees in both lounges. Some people might have enjoyed making hanging decorations as an activity. I was told by several people that someone visited about once a month to give a talk with slides, and there was also an occasional sing-a-long. Sometimes a few people were taken for a ride out in a car. A gentleman who preferred music to watching TV said he would really appreciate a tape/CD player in his own room. Several of the more mobile people seemed to enjoy quite an active social life, with friends and relatives collecting them, to attend clubs or fellowships where they were previously members. Other people said they had quite a few visitors. One lady said she felt trapped, and was quite sure she could go out for a walk on her own, if allowed.” This person has higher expectations of what she is able to do and what the home can offer her and sometimes finds it difficult to reconcile these expectations with the reality of her situation. Food provision is according to people’s likes and choices, and the compiled menus that are set by the cook in consultation with people, show a threecourse lunch is provided and a planned alternative is available. One person likes to go shopping for provisions with one of the directors, one relative stated in their questionnaire that special foods are brought in upon request, and one person spoken to on the day of the site visit said he would like to see a little more choice of things to eat. Information obtained by the accompanying expert by experience also reveals meal provision is satisfactory. “I took the three-course lunch with 15 people. There were genuine choices each day of main course and sweet, and the food was well presented on warm plates. The Chicken Kiev I chose was rather dry, and would have benefited from a sauce. Some residents regularly ate in their own rooms, and assured me it always arrived hot, and they were assisted as necessary. In the dining room the staff offered help unobtrusively, and most West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 15 members of staff, including the manager, helped at meal times. Several residents described the meals to me as ‘adequate,’ or ‘not enough choice’. One lady said she used to love cooking in her own home, but couldn’t think of her favourite meal ‘ on the spur of the moment’. One or two people might welcome the opportunity of being consulted on ideas for meals. I understood that hot and cold choices were offered at teatime. I was also assured that it would be ‘monitored’ if a person regularly returned food only partly eaten, although I saw no evidence of this being recorded at the time. There was ample fruit juice drinks offered at lunchtime and during the day. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People make use of informal complaint processes and systems and have all issues dealt with appropriately and they do not need to make formal complaints, so they are confident their concerns are dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: People, staff and management spoken to, information in questionnaires and records viewed reveal people have good opportunities to make their concerns or complaints known before they become major issues and have good systems in place for their protection. There are complaint and protection policies and procedures in place, staff have undertaken safeguarding adults training in July 06 and generally people’s grumbles and complaints are dealt with at the point of there being an initial problem. Records held show there to be no safeguarding referrals in the last twelve months and around fifteen niggles in the ‘grumbles’ book, which were all upheld and resolved within the allotted time. There has been no serious complaint. One communication from a relative of a person that only spent a West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 17 short time in the home before passing away in hospital, did express some concerns about basic care. Information obtained from the home’s records show despite staff trying to encourage diet and fluid intake the person was very reluctant, often refusing, resulting in a general deterioration. There is a good ethos amongst the staff group and lead by the manager, that shows they are open to suggestions for improvement, consider complaints to be a means of helping the service move forward with improvements, and that people’s views should be listened to. Two people’s questionnaires state they do not feel the staff always listen to them and act on what they say, but both are completed by people that are new to care, do not particularly wish to be in care, have strong views and opinions and are very capable of representing themselves verbally, but are physically deteriorating and feel ‘trapped’ in the words of one. In general people feel they should not be ‘bothering’ staff because they are usually busy. On the whole from what people say and from observation of part of the daily routines, the staff and management are very approachable, will assist wherever possible and requested to, and are a caring group of people, competent in dealing with complaints and allegations. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have a well-maintained, safe, clean and comfortable environment in which to live, so they are confident they live in a good home. EVIDENCE: Discussion with people, staff and management and observation of the communal areas of the home reveal the house is suitable for its stated purpose of providing care and accommodation to older people. Handrails are provided in strategic places according to individual need, there is a passenger lift to the upper floor, which was last serviced and tested in July 2007, and the whole house has been professionally assessed for general aids and equipment. The garden to the rear has a ramp and rails for access to those with poorer mobility or that use wheelchairs. Maintenance of the house internally and West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 19 externally is very good. There is a maintenance worker employed to keep on top of many of the minor jobs that need doing and to carry out redecoration etc. On the day of the site visit he was putting up Christmas trees and lights. The laundry meets the requirements of the Water Supply (Water Fittings) Regulations 1999 and provides sluicing and hand washing facilities. Staff have infection control policies to follow and have completed training in infection control. They have access to a file containing information in the form of leaflets and alerts from the National Health Service, as well as on such as hand washing, handling sharps etc. The file also contains ‘Infection Control Guidance For Care Homes.’ In addition, when a person goes to hospital for admission or to accident and emergency, an infection control form goes with them, stating any details of past or current issues the person may have had or still has. The home would like to see this kind of information reciprocated by the discharging hospitals, but unfortunately information from hospitals in the area is poor. The provider intends to seek planning permission to extend the home in the near future. Information obtained by the accompanying expert by experience also reveals the home to be well maintained and comfortable. “The communal rooms were clean, spacious and comfortably furnished, and gave alternative choices of sitting areas, including a large conservatory looking out over the enclosed garden. The bedrooms I saw were also clean and nicely decorated and furnished. Some bedrooms on the ground floor had patio doors opening on to the safe garden area outside.” West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users are cared for by well-recruited, well-trained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy a good service of care. EVIDENCE: Two staff were interviewed and their permission was obtained to view their recruitment and selection, their training and their supervision files. Discussion with the manager, viewing of the weekly roster and using information from the home to determine the Residential Staffing Forum figures shows the home is sufficiently staffed in terms of staffing hours provided per week. Forum figures require 491.06 hours for 13 high, 10 medium and 0 low dependency people, and the general environment, layout of the home causing some difficulty in providing care. The home provides 493 hours each week, and therefore staffing is sufficient. Discussion with staff and the management and information taken from the inspection questionnaire reveals there are now 12 from 14 care workers with or soon to have the required qualification, giving 86 with or soon to have the award. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 21 There is a recruitment and selection policy and procedure for the management to follow and discussion with staff and viewing of files reveal these to be satisfactorily followed. Requirements under regulation 19, schedule 2 are being met. Staff files contain details of their application for the job, security check, employment contract, job description and so on. The two files viewed have security checks that were completed in 2003 and therefore it is recommended they be redone and updated. It is a Criminal Records Bureau recommendation that checks be completed every three years. The files also had references missing, but the manager explained that because the two staff have worked in the home since 1999 and 2000, many of their documents have been archived. References for another staff member were therefore verified as being available in the recruitment file. All staff undertake induction training in line with Skills For Care and do mandatory training in fire safety, moving and handling, food hygiene, emergency first aid, safeguarding adults and medication administration etc., as well as other courses in such as dementia, continence, nutrition and so on. Certificates of completion and attendance line the walls of the home’s corridors. Staff confirm this in their interviews. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 22 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, 37 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People live in a home that is well run and in their best interests, where good systems are in place to determine the quality of the service. Their financial interests are safeguarded and their health, safety and welfare are well promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: Discussion with the manager and staff, and viewing of documentation, safety records and certificates reveals, people and staff benefit from a safe and wellrun home. The manager has the NVQ level 4 in Care and the D31/32 Assessor’s Award. She has many years experience as a manager and constantly strives to West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 23 improve her own knowledge and understanding of the care business for the benefit of improved services to people. She is to complete an intensive management course within the month. There have been no changes to the systems for quality assuring the service provided in the home since the last inspection. These were not assessed on this inspection, but the manager explained the home usually carries out service user, relative and staff surveys to obtain information on how well the service is doing. The home has recently been reviewed by the East Riding of Yorkshire Council to determine whether or not it continues to be awarded the council’s Quality Development Scheme payments, and was successful. The home has also achieved the Investor’s In People Award this year. People have control of their own finances, where possible, and if unable then their relatives do. Some have a small amount of money held in safekeeping for which the home maintains a record of money in and out, with signatures and running balance. Records of peoples’ finances were not seen on the site visit. Records required under standard 37, regulation 17 and schedules 3 and 4 are being maintained. It is the registered providers responsibility to make sure all records specified in regulation 17 are complete and accurate. The manager and staff maintain a safe environment for people and staff by ensuring all equipment is regularly serviced and certificated if necessary, by following all relevant legislation in respect of health and safety responsibilities, and by maintaining appropriate records of safety checks, etc. Areas sampled to determine whether or not standard 38 is met are, fire safety, passenger lift and hoist maintenance, water temperature and legionella testing and safety in the use of cleaning substances. Monthly fire safety and equipment checks are carried out and recorded and monthly emergency lighting checks are done and recorded. The home carries out fire drills as necessary, usually monthly and the record for the whole of 2007 was seen. Staff also complete six-monthly fire training instruction with a competent external trainer. Staff confirm their training and competence in interview. There is a fire risk assessment in place, but it does not appear to have been reviewed formally since 2004. This needs to be audited and reviewed if not done so since then. During the site visit an engineer form Image 2000 visited to undertake an annual safety check on the fire systems and the emergency call bells. Pickering’s Lifts last maintained the home’s passenger lift and hoist in June 2007. Certificates were not seen, but maintenance reports were. West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 24 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 3 3 West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The registered provider should make sure all staff that administers medication receives updated training on an annual basis, so that people are confident their safety is being protected by competent staff. The registered provider should make sure the fire risk assessment document is reviewed each year and recorded as having been reviewed, so that people are confident the fire risks are accurately and regularly assessed. 2 OP38 West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 West Ella House DS0000019768.V356681.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!