Care Home: Limegrove

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What the care home does well The needs of prospective residents have been assessed in detail before they moved in, including social and leisure needs, to ensure that these could be met in the home. People living at the home can be confident that their healthcare needs will be well met and they are safeguarded by the home`s procedures and practices of medication administration. A selection of social and leisure activities are offered to people living at the home and they are supported to take part in these. Encouragement is provided to help those living at the home to maintain contact with their families and friends, and visitors to the home are made welcome. A selection of well balanced and appetising meals are offered to residents and these are served in attractive and comfortable dining rooms. Residents and those involved in their support, can be confident that their complaints will be listened to and acted on. Staff have received training in safeguarding adults and were aware of their responsibilities in the protection of those living in the home. People living at the home benefit from a safe, well-maintained and comfortable environment, which is attractively decorated and furnished, is kept clean and very freshly aired. The home`s recruitment policies and practices protect people living at the home, and residents are supported by a full team of staff who are well trained. It is clear from the good outcomes experienced by people living in the home, that it is being effectively managed and run in the best interests of those living there. What has improved since the last inspection? Contracts or statements of terms and conditions have been provided to people who have moved into the home, to advise them of the conditions of residence. These contained most, but not all, of the required information. Although the complaints procedure has not been changed, it was clear that it is meeting the needs of people living in the home, as they know who they can speak to if they are unhappy or dissatisfied. Staff, including ancilliary staff, have received training in safeguarding adults, to ensure that they are aware of the types of abuse that may occur, and what they should do to keep residents safe. What the care home could do better: The contracts or statement of terms and conditions for living at the home must advise residents of the fees that they must pay, or that others must pay on their behalf. It is recommended that the new service user plans are used as soon as possible, to ensure that staff are clearly informed of the needs of the people living at the home, and of the care and support required to meet those needs. Although medication in the home was accounted for, it is good practice to maintain records that enable a clear audit trail to be followed. This will ensure that medication can be fully monitored to safeguard residents. CARE HOMES FOR OLDER PEOPLE Limegrove St Martin`s Close East Horsley Surrey KT24 6SU Lead Inspector Sandra Holland Unannounced Inspection 13th February 2008 10:15 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 Limegrove DS0000033691.V357993.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. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Limegrove Address St Martin`s Close East Horsley Surrey KT24 6SU 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) 01483 280690 01483 280834 maureen.burns@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust Mrs Maureen Burns Care Home 54 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only (PC) 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) Physical disability (PD) Dementia (DE) The maximum number of service users to be accommodated is 54. 2. Date of last inspection 11th September 2006 Brief Description of the Service: Limegrove is a large purpose built home for older people located in the village of East Horsley. The home is registered to provide personal care and support for up to 54 service users. The home is divided into five self-contained units each with their own lounge, dining room, kitchenette, toilets and assisted bathrooms. All residents bedrooms are for single occupancy with an en-suite facility. A meeting room is available and is used for some resident activities. Other activities are carried out on the individual units. The home has spacious, well-maintained gardens and is located close to the local village, with its shops and church. There is parking to the front and rear of the property. The fees at this service range from £ 457.52 per week to £ 728.00 per week. Limegrove DS0000033691.V357993.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 Commission has since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced “Key Inspection”. The inspector arrived at the service at 11.00 and was in the service for seven and a quarter hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. Mrs. Sandra Holland, Regulation Inspector carried out the inspection and Mrs. Maureen Burns, Registered Manager was present representing the service. A tour of the home was carried out and most areas were seen. A number of records and documents were sampled including medication administration records, individuals’ care plans, staff recruitment and training records. Twelve residents, two visitors and ten members of staff were spoken with during the course of the inspection visit, and some were spoken with at length. An annual quality assurance assessment (AQAA) was supplied to the home and this was completed and returned. Information supplied in the AQAA will be referred to in this report. Information supplied in the AQAA indicated that equality and diversity is promoted by assessing each individual’s needs and choices, before they move into the home, and by recording these in person centered plans. The home aims to recognise and respond to the individual’s rights of choice, privacy, dignity and individuality, which are reflected in their care plan. The people living in the home prefer to be known as residents and that is the term that will used in this report. The inspector would like to thank residents and staff for their time, hospitality and assistance. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Contracts or statements of terms and conditions have been provided to people who have moved into the home, to advise them of the conditions of residence. These contained most, but not all, of the required information. Although the complaints procedure has not been changed, it was clear that it is meeting the needs of people living in the home, as they know who they can speak to if they are unhappy or dissatisfied. Staff, including ancilliary staff, have received training in safeguarding adults, to ensure that they are aware of the types of abuse that may occur, and what they should do to keep residents safe. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 7 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. Limegrove DS0000033691.V357993.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 Limegrove DS0000033691.V357993.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 and 6. People who use the service experience good outcomes in this area. People living at the home have been provided with a contract detailing the terms and conditions for living there, but some of these did not specify the amount of fees that the resident, or others, must pay. The needs of prospective residents have been assessed in detail before they moved in, including social and leisure needs, to ensure that these could be met in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who have moved into the home since the last inspection have been provided with, and signed, a contract with the home, so that they are aware of the terms and conditions for living there. It was noted these did not specify the information regarding the fees payable. The manager advised that in some Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 10 cases, residents receive financial support from a local authority and their residence at the home is funded under a contract with the authority. It is required that this information is supplied to residents before they move in, or on the day they move in, to ensure that they are fully aware of the terms they are agreeing to live under, regardless of who is providing the funding. A detailed assessment had been carried out of the needs of prospective residents, as this enables the home to know if they can meet the resident’s needs. These were seen to include reference to risks to the safety and welfare of residents, such as the risks of falls. It was positive to note that the assessments also recorded the social and leisure interests of prospective residents, as this would enable the home to know if it could meet these needs. Most residents had visited the home for an assessment day, although the manager advised that residents are also visited at their own home or previous place of residence. The manager advised that intermediate care is not provided at the home, so Standard 6 does not apply and has not been assessed. Limegrove DS0000033691.V357993.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 experience good outcomes in this area. The new service user plans should be brought into use, so that people living at the home can be assured that staff are provided with detailed information about their needs, and with clear guidance as to how their needs should be met. Residents’ healthcare needs are well met and they are safeguarded by the home’s procedures and practices of medication administration. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff advised that new service user plans have recently been introduced by the Anchor organisation, which runs Limegrove. To ensure the needs of residents are met, these have been designed to increase the amount of information held and improve the way that it is laid out. This should ensure that staff are fully aware of all the needs of people living at the home, and what care and support staff need to provide. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 12 It was observed that staff are in the process of transferring information from the older style of service user plan into the new ones, although the new ones have not yet been brought into use. The manager stated that she has developed an action plan, and intends to have the new style plans fully in use by the end of next month (March 2008). It is recommended that this timescale is followed, as it has been recognised that the older style plans contain limited information and do not guide staff to meeting residents’ needs very effectively. From speaking to residents and staff, and from the records seen, it was clear that the healthcare needs of residents are well met. A number of healthcare professionals are involved in the support of residents, including specialist nurses, general practitioners (GP’s) and community psychiatric nurses (CPN’s). The procedures and practices of medication administration appeared to be effectively managed, and the required records are maintained to safeguard people living in the home. Medication was seen to be appropriately stored in locked provisions, and a lockable fridge was available for medication requiring chilled storage. Access to medication is restricted to the management team and staff who have received medication training. The amounts of a number of medications were randomly sampled, were checked against the records held, and these were seen to accurately match. It was noted that for a number of medications, the amount held had not been carried forward onto new medication administration record (MAR) charts, so it was not easy to follow an audit trail. It is recommended that all stocks of medication held are carried forward, as this enables an audit trail to be clearly followed. This will further safeguard residents and their medication, and assists with monitoring stock. Staff were observed to treat residents with respect, and to speak residents in a relaxed and friendly, but appropriate manner. Resident’s privacy was seen to be promoted, with staff taking care to knock on resident’s bedroom doors before entering and waiting for a response before entering. Staff also offered support with personal care in a tactful and discreet way, to maintain the dignity of those living in the home. Limegrove DS0000033691.V357993.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 outcomes in this area. People living at the home are offered a selection of social and leisure activities and are supported to take part in these. They are also encouraged to maintain contact with their families and friends, and visitors to the home are made welcome. A selection of well balanced and appetising meals are offered to residents and these are served in attractive and comfortable dining rooms. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information supplied in the AQAA indicated that an activities co-ordinator had been employed and that it was planned to employ a second co-ordinator, so that they could focus on person centred activities. The manager stated at the time of the inspection however, that the activities co-ordinator had left and the vacancy was currently being advertised. Staff and team leaders are responsible for arranging and carrying out activities until a new co-ordinator is appointed, the manager advised. This was seen to be the case on the day of inspection, as the deputy manager and staff on duty were busily preparing for a St Valentine’s dance to be held that evening. A Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 14 church service had also taken place on one of the units during the afternoon of the inspection. It was positive to see the number of photos of Christmas events on the notice board in the entrance hall. Staff advised that some social activities are held on individual units, whilst others take part in the large activities room on the first floor. This room is well equipped with tables and chairs to enable groups of residents to take part in activities together, as well as musical facilities. Individual residents spoke of their leisure interests and some were happy to show the activities they enjoyed and how they spend their time. Trips out of the home are also arranged and these include visits to places of interest and local garden centres, the AQAA indicated. From speaking to residents and visitors, it was clear that people living in the home are helped to maintain contact with their families and friends. A number of residents advised that they have their own telephone to enable them to keep in touch with others outside the home. Visitors advised that they are made very welcome in the home and can visit at any time. Residents are supported to follow their own faith, the AQAA indicated, and some residents attend local churches, whilst others like to be visited in the home by their minister. Residents advised that they were encouraged to make their own choices and decisions in as many aspects of their lives as possible. Residents said they could get up and go to bed as they wished, and could take part in the activities or spend time in their room, as they preferred. A choice of meals is offered to residents at each mealtime, as meals do not have to be ordered in advance. A number of residents were spoken to as they finished their meal, and all said how much they enjoyed it, that it was hot when served and that they appreciated the choices. It was noted that staff were available to assist residents with their meals if required, but were seen to encourage residents to be independent wherever possible. Each unit has its own dining room and these were furnished in a homely style with tables seating up to four residents. Tables were attractively set with colourful tablecloths and napkins, and with glasses and flowers. Staff advised that meals are served in alternative forms, such as pureed, if necessary to meet residents’ needs, and specialist food supplements had been obtained for those residents requiring them. Information supplied in the AQAA indicated that various diets can be provided to meet individual’s needs and choices, and currently vegetarian and diabetic diets are being catered for. Limegrove DS0000033691.V357993.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 and 18. People who use the service experience good outcomes in this area. A small number of complaints have been received and these have been dealt with appropriately. Residents and those involved in their support, can be confident that their complaints will be listened to and acted on. Staff have received training in safeguarding adults and were aware of their responsibilities in the protection of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made following the last inspection, that the home’s corporate complaints procedure must be reviewed and must be suited to the needs of residents. This was because the main part of the procedure requests anyone wishing to make a complaint, to write to the Anchor organisation’s office. As many of the residents in the home are either very frail, experiencing dementia or have a physical disability, this may present as a barrier to them making their views known. Although the complaints procedure has not been changed, it is accepted that the current complaints procedure is meeting the needs of residents. Residents and visitors said they know who they can speak to if they are unhappy or dissatisfied, and no information has been passed to CSCI about any complaint made to the home. Staff and residents advised that as the manager and the Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 16 senior staff team are available in the home on a day-to-day basis, any areas of dissatisfaction or unhappiness can be discussed promptly. These are then dealt with immediately to prevent them developing, wherever possible, into formal complaints. The manager was able to advise of the formal complaints that have been received in the past year, and of the actions taken in response. The manager stated that some of the complaints had been upheld, and that she had written to some people who had made a complaint, and held a meeting with others, to advise of the outcomes and any actions taken. It was positive to note that there did not appear to be any recurring issues in the complaints. The management team were observed to interact with residents and visitors in a friendly, informal manner, whilst maintaining respect. Visitors advised that there was an open atmosphere in the home, and they could speak to the management team if they had any concerns, but had not needed to do so. It was positive to hear that the home receives many letters and cards of thanks and commendation from appreciative residents, their families and friends, and a number of these were seen. The manager stated that in the event of any concerns being raised about suspicions or allegations of abuse, the home would follow the Surrey MultiAgency Safeguarding Adults procedure. An up to date copy of the procedure is kept in the home for staff to refer to if needed. The home has made referrals under this procedure in the past and all appropriate actions were taken. A number of staff were spoken with and they advised that they understood about the types of abuse, and said they would report any concerns to the manager or person in charge. From the staff training records it was noted that most of the staff working in the home had received training in safeguarding adults and almost all staff had received training in Rights and Responsibilities. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 17 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 outcomes in this area. People living at the home benefit from a safe, well-maintained and comfortable environment. It is attractively decorated and furnished, is kept clean and very freshly aired. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The entrance hall of the home presents as a welcoming space and is furnished in a very homely style with a fireplace, sofa and armchairs. A table has been set up near the main notice board and both provide a range of useful information to residents and visitors. A selection of greetings cards were available for sale on a stand in the entrance hall, which is very useful for those residents who do not wish to go out or are less able to. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 18 The home is registered to provide accommodation and care for up to fifty-four people, but residents live in smaller, family style units. Each of these has its own lounge, dining room and kitchen areas, and it was noted that each unit was decorated and furnished in different colours and some had a different layout. Kitchen and laundry facilities are provided specifically for residents to use, enabling them to maintain their independence in these areas, if they wish to. All areas of the home were very attractively decorated, comfortably furnished in a homely style and appeared well maintained. All residents’ bedrooms are single rooms and all have en-suite toilets and basins. Information in the AQAA stated that it is planned to install showers in five of the en-suite facilities. Residents who were spoken with said they were happy with their bedrooms and had been able to bring their own things in when they moved into the home, to make their rooms more personal. Many residents had brought their own photos, pictures and ornaments to personalise their rooms. All areas of the home that were seen were clean, very well presented and appeared hygienic. Staff advised that they are provided with personal protective equipment, including gloves and aprons to maintain hygiene and prevent infection, and these were seen in use. Hand-washing facilities were equipped with liquid soap and paper towels and were provided in all appropriate places. It was very positive to note that the home was freshly aired throughout, which gave no indication of the high personal care and support needs of some residents. Information in the AQAA indicated that the majority staff have received training in infection control, to ensure they understand current good practice in maintaining effective hygiene standards, and the actions to take to prevent infection or to prevent the spread of infection. A poster on the table in the entrance hall provided helpful guidance about the importance of thorough hand-washing & how to carry this out effectively, to maintain hygiene. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 19 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 outcomes in this area. People living at the home are protected by the home’s recruitment policies and practices, and are supported by a full team of staff who are well trained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information supplied in the AQAA indicated that residents are supported and cared for, by a full team of staff. The team consists of care staff, catering staff, housekeeping staff, laundry staff, a maintenance person, a receptionist and administrators. A number of staff from a variety of roles were spoken with during the course of the inspection visit. It was positive to hear that they enjoyed working at the home and appreciated the training opportunities that are provided. A number of care staff have achieved a National Vocational Qualification (NVQ) to level 2 or higher, and further care staff are working towards this qualification, so the home is on target to achieve the recommended 50 of care staff trained to this level. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 20 The manager advised that there is an on-going recruitment programme, and residents are protected by the home’s recruitment policies and practices. The files of a number of recently recruited staff were seen and the specified records and documents had been obtained. These included two written references, a check of the POVA Register and a Criminal Records Bureau (CRB) disclosure. These had been obtained to ensure that staff are fit to work in the home. A general staff training plan is maintained, in addition to individual staff training records. These confirmed that staff receive training required by law (mandatory training), including fire safety, first aid and food hygiene, and other training to develop their knowledge and skills, such as dementia care and continence promotion. It was positive to note that staff receive training that is appropriate to their role, and staff advised that they are provided with opportunities to develop and progress their roles within the home. Records of the induction received by staff were also seen. These recorded that staff had been advised of their role and responsibilities, and of the policies and procedures that they work under. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35 and 38. People who use the service experience good outcomes in this area. It is clear from the good outcomes experienced by people living in the home, that it is being effectively managed and run in the best interests of those living there. The procedures for managing residents’ monies that are held for safekeeping, ensure that residents are safeguarded from financial abuse. The health and safety of all those living and working in the home is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 22 From speaking to residents, visitors and staff, and from all the information gathered, it was clear that the home is being effectively managed and is providing good outcomes for the people living there, as assessed during this key inspection. The home is managed in an open and accessible way, by a manager who has many years experience in care and is fit to be in charge. The manager is ably supported by a management team, made up of a deputy manager, a team of senior care staff and a chef manager. The manager stated that the views of residents and those involved in their support, are obtained to ensure the home is run in the best interests of those living there. This is achieved in a number of ways, including surveys, resident meetings and by the day-to-day contact between residents and the management team. Quality assurance surveys have recently been supplied to residents’ relatives and friends, the manager advised. A number of responses have been returned, but the results are still to be analysed. The manager stated that surveys are due to be supplied to residents shortly, to ask their views on the standards of staffing, catering and housekeeping. Staff advised that the chef maintains regular contact with residents to obtain their feedback on the meals provided. Residents’ meetings are held regularly the manager advised. These provide people living in the home and their supporters, an opportunity to air their views, and to make a contribution to the way that the home is run. The administrator advised that monies can be held for safekeeping if required by residents. To ensure these are safeguarded, only administrative or senior staff have access to these and two signatures are recorded for each transaction. Staff advised that a new computer based recording system has been introduced since the last inspection, and detailed written and computer records were seen. The amounts recorded were noted to accurately match. Residents are also provided with a lockable facility in their bedrooms, in which to store any valuables. Information provided in the AQAA confirmed that maintenance and service checks are carried out on systems and equipment in the home. This is to ensure that these work effectively and protect the health, safety and welfare of all those who live and work there. It was positive that no hazards were noted during the tour of the home. Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 23 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 2 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 3 3 X 3 X X 3 Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation Requirement Timescale for action 16/05/08 5A (2 & 3) Each person who became a resident after 1st September 2006, must be supplied with a statement specifying the fees payable by, or in respect of the resident, for the provision of any of the following services – (i) accommodation, including the provision of food; (ii) nursing; and (iii) personal care. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP7 Good Practice Recommendations It is good practice to maintain medication records that enable a clear audit trail to be followed. It is recommended that the new service user plans are used as soon as possible, to ensure that staff are clearly informed of the needs of the people living at the home, and of the care and support required to meet those needs. DS0000033691.V357993.R01.S.doc Version 5.2 Page 25 Limegrove Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Limegrove DS0000033691.V357993.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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