Care Home: Little Hayes

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• St Vincents
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• Winton House
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• The Maypole Nursing Centre
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What the care home does well On entering the home people are provided with access to substantial amounts of information, including having access to copies of the `service users guide`, `statement of purpose` and details of forthcoming events, how to raise concerns or complaints and the home`s arrangements for visits. People residing at the home are well supported, by the staff, when accessing health and social care services. Records maintained by the staff record all occasions when medical, nursing or care management referrals have been made and the outcomes of subsequent visits. The home provides service users with access to a varied entertainments programme, details of which are displayed around the home for the service users, who can choose whether or not to participate in the activity. During our visit a musical entertainer was in the home and judging from the number of people watching and participating in the sing-along, the event was well received and enjoyed. The environment is well maintained throughout and offers the people resident at the home a variety of communal locations within which they can relax, socialise or entertain visitors. The home is well run by an experienced manager, who based on her interactions with residents, relatives and staff is a well respected and liked manager. What has improved since the last inspection? Recently an extension to the home has been completed. This offers additional accommodation and communal areas, which can be used by the service users; the rooms added benefit from sea or countryside views and are bright and modern. The manager has appointed a new `deputy manager` to work alongside her, the appointment allowing the manager to delegate some tasks to her deputy and free her up to focus on the day-to-day running of the service. The manager states via the AQAA that in addition to the items mentioned above the home has also: `introduced a new call bell system, which tracks and records response times, new hoisting equipment has been purchased, areas of the home have been redecorated, staff training and development opportunities have been increased and all of the home`s policies and procedures have been reviewed and updated`. The requirements of the last inspection have also all been addressed. What the care home could do better: The manager must ensure that people`s care plans are regularly reviewed and updated and that changes in the care are reflected through the plans produced. The manager must ensure that the home`s medication system is reviewed, ensuring that all medications received into the home are accounted for before being used, that all `as and when required` medicines have a protocol in place describing for staff when these should be used and that the `controlled drugs` cabinet is updated to comply with the `Safe Custody Regulations` (Medicines Act), which were amended in the October of 2007. The manager should ensure the staff are aware of the need to maintain and update their `training passports` on the completion of a course. The manager must review the home`s recruitment and selection procedure to ensure it is both thorough and robust. CARE HOMES FOR OLDER PEOPLE Little Hayes Church Hill Totland Isle Of Wight PO39 0EX Lead Inspector Mark Sims Unannounced Inspection 25th November 2008 10:45 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 Little Hayes DS0000012508.V373518.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. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Hayes Address Church Hill Totland Isle Of Wight PO39 0EX 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) 01983 752378 01983 759785 Mr David Burn Mr Christopher John Negus James Mrs Amanda Jayne Saunders Care Home 34 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places Little Hayes DS0000012508.V373518.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 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 Dementia (DE) Physical disability (PD). The maximum number of service users to be accommodated is 34. 2. Date of last inspection 18th December 2006 Brief Description of the Service: Little Hayes is a Residential Care Home that offers care for thirty-four elderly residents. It is situated on the outskirts of Totland and is within walking distance of both the local amenities and the sea. It is owned by Mr David Burn and Mr Christopher James and is managed by Mrs Amanda Saunders. All the residents are accommodated in single rooms, many with en-suite facilities. A number of the rooms to the front of the building offer views of the sea. The property is a building of some character that sits in its own well-maintained gardens and has recently been extended to provide additional accommodation and communal facilities. The gardens are extensive and the providers hope to landscape the grounds over the next few years, for the benefit of the service users. Weekly Fees Range From: £440.00 to £520.00. Little Hayes DS0000012508.V373518.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 stars. This means the people who use this service experience good quality outcomes. This inspection was, a ‘Key Inspection’, which is part of the regulatory programme that measures services against core National Minimum Standards. The fieldwork visit to the site of the home was conducted over 6 hours, where in addition to any paperwork that required reviewing we (the Commission for Social Care Inspection) met service users, staff and management. The inspection process involved pre fieldwork activity, gathering information from a variety of sources, surveys, the Commission’s database and the Annual Quality Assurance Assessment information provided by the service provider/manager. What the service does well: On entering the home people are provided with access to substantial amounts of information, including having access to copies of the service users guide, statement of purpose and details of forthcoming events, how to raise concerns or complaints and the homes arrangements for visits. People residing at the home are well supported, by the staff, when accessing health and social care services. Records maintained by the staff record all occasions when medical, nursing or care management referrals have been made and the outcomes of subsequent visits. The home provides service users with access to a varied entertainments programme, details of which are displayed around the home for the service users, who can choose whether or not to participate in the activity. During our visit a musical entertainer was in the home and judging from the number of people watching and participating in the sing-along, the event was well received and enjoyed. The environment is well maintained throughout and offers the people resident at the home a variety of communal locations within which they can relax, socialise or entertain visitors. The home is well run by an experienced manager, who based on her interactions with residents, relatives and staff is a well respected and liked manager. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 6 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. Little Hayes DS0000012508.V373518.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 Little Hayes DS0000012508.V373518.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): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives have access to the information needed when choosing a home that will meet their needs. EVIDENCE: The manager states via the AQAA: the pre-admission assessments are undertaken by the manager, deputy manager or care supervisors to ensure the home can cater for the individuals needs, a comprehensive initial assessment is compiled. The home encourages, when possible, the resident or their family view the home prior to admission. The home provides a brochure, statement of purpose, terms and conditions, service users guide and contract of residency. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 9 During the fieldwork visit three service user files were looked at, all three found to contain details of the initial assessment undertaken prior to their admission to the home. The assessment tool provides a good basic insight into the needs of the individual at their point of admission to the home, however, the need to reassess and update assessments, when readmitting a service user, was discussed with the manager and deputy manager. The catalyst for this conversation was a person who had resided at the home for respite/recuperation and after going home had decided to return to the home permanently. However, their assessment information had not been updated and some changes in their needs and wishes had occurred, an example being their wish to handover control of their medications to the staff instead of self-medicating, which they had done during their initial stay. The home, as stated via the AQAA, does have brochures, statement of purpose and service user guide documentation available, whilst we did not confirm that copies of these documents are given to the service users, copies were seen on display within the front entrance of the home, which ensure they are accessible to people. The home does not provide and intermediate care service and therefore this standard (6) was not reviewed during this visit. Little Hayes DS0000012508.V373518.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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: As stated three care plans were reviewed during the fieldwork visit, as with the pre-admission assessment information the plans provide a good basic indication of the needs and wishes of the service users. The plans reviewed during our visit, were being revised and updated, however, this was not always as regularly as advised and the reviews or revisions were not always resulting in peoples changing needs being reflected via the care plan. Examples being: A client who is now using a neck brace, which is mentioned in the running records but not in the care plan, where details of when the brace Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 11 should be used and how to support the resident fit the brace should be document, this persons care plans also indicated that they were last reviewed in September 2008 and their risk assessments in January 2008. Another persons running records indicated that they were requiring or receiving assistance with washing and dressing and mobilising from one carer, however, the moving and handling assessment and the care plan indicate that both activities required the support of two carers. However, generally the plans provide the staff with a reasonable working tool from which they can identify and document the care required and provided to the service users. Peoples health care needs are also being well supported by the manager and her staff team. Peoples running records document their involvement with health and social care professionals both within the home and at clinic appointments, an example being a client who developed a blood blister, which the staff monitored until a change occurred with the blister and they contacted the Community Nurses to visit and assess the area. During the visit a member of the Community Nursing team was seen around the, although we did not have an opportunity to speak with her. Also during our time in the home the manager took a returned call from a General Practitioner, whom she had rung earlier, as she was concerned with the wellbeing of a resident. Following the call the Doctor agreed to undertake a visit to the home and later in the day the resident was prescribed antibiotics, which the manager arranged to be collected and commenced that same day. Whilst checking the homes medication system a number of issues came to light, which were discussed with the manager and the deputy manager, as they will require addressing. Firstly all medications received into the home must be checked and accounted for before being used with the service users. Presently the home have been checking and signing for medications that are received in packets or bottles, however, those received as part of the Monitored Dosage System (MDS) are not being checked and signed for in the same way. Secondly all as and when required (PRN) medicines must have a protocol in place describing for staff when and how they should be used, i.e. the symptoms exhibited by the service user that would tell staff they require a PRN medicine. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 12 The controlled drugs cabinet must be updated to comply with the Safe Custody Regulations (Medicines Act), which were amended in the October of 2007, if the home is to store any controlled medications. It is mentioned within the Brief Description that all accommodation at Little Hayes is single occupancy and that the majority of rooms are en-suite, which affords the residents’ privacy during meetings with health/social care professionals and during the delivery of personal care. The home’s lounges are also available to residents that do not wish to have visitors in their bedroom and can be used to entertain both official and social guests, although these areas are slightly less private. Communal facilities, toilets and bathrooms, were fitted with locks that were of a suitable design given some of the physical and cognitive impairments suffered by the residents and staff were observed knocking on toilet doors before entering. The care planning records also document peoples preferred terms of address, several people using nicknames or second names in preference to their given name. The interactions between the staff and the service users and their visitors was also noted to be very cordial and polite, comments supported by the service users, who when asked described the staff team in glowing terms, caring, friendly, always there when needed. Little Hayes DS0000012508.V373518.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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their life style and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual expectations. EVIDENCE: The manager states via the AQAA that: The home provides various daily activities. Visitors are welcome anytime. Residents are given the choice regarding menus and where to have their meals; families are given the opportunity to have meal with their relatives at no charge. Menus are varied, nutritious and interesting, all dietary needs catered for, birthdays and anniversaries are celebrated with a special cake or party to include residents families. Residents are given the choice on how they wish to spend their time and where. Residents are encouraged to adapt their rooms as they wish i.e. small items of furniture, photos and ornaments. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 14 The home provides service users with access to a varied entertainments programme, details of which are displayed around the home for the service users, who can choose whether or not to participate in the activity. During our visit a musical entertainer was in the home and judging from the number of people watching and participating in the sing-along, the event was well received and enjoyed. On talking to people about their day-to-day activities it was established that people exercise a deal of autonomy over their daily routines, people having preferred times to visit the lounges, some people opting to stay and participate in the organised activities, whilst others prefer to retire to their bedrooms, etc. The overriding impression was, however, that people generally enjoy their lives at Little Hayes and the social stimulation provided. The home’s visiting arrangements, are detailed within the ‘service user guide’ and ‘statement of purpose’ documentation, which the manager states, via the AQAA, she provides to all prospective residents’ or their representatives, copies of these documents were available within the home’s entrance hallway, as mentioned previously, as are details of the homes visiting arrangements. During our visit a number of visitors were observed arriving at the home and being welcomed by the staff prior to meeting up with their next-of-kin. As mentioned above the service provides single occupancy accommodation, which allows visits to be conducted in private, however, should the person not wish to use their bedroom for entertaining there is the option of using the communal area, although these areas do not guarantee previous. Whilst looking around the home in the company of the manager we were able to establish that each room had been personalised by the occupant, with people using furniture, pictures, ornaments and photographs to create an individual feeling within their room. In discussion with the manager it was made clear that all bedrooms are blank canvasses when people visit with a view to moving into the home and that they are encouraged to bring with them any personal items they wish. If the person does not wish to provide or use their own furniture or fittings, etc then the service can provide the basic necessities, i.e. bed, chairs, table, television, etc. The people living at the home are also supported by the service to retain control over those aspects of their lives that they can, i.e choice of rising and retiring time, choice of menu, activities options and where they spend their time, etc. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 15 A visit was made to kitchen during our visit, where we were informed of the homes five star rating, issued by the Environmental Health Office on the 17th November 2008. Whilst in the kitchen the cook demonstrated how the menus operate and explained that there is a four-week rotational menu and that they home was presently on week one. A look at the menu enabled us to determine that there are two main meal options daily, the options on the day of our visit being either fish pie or sausages. The teatime menus also offer two choices per day, the cook explaining that these are normally sandwiches and a hot dish. Homemade cakes are also baked and made available for pudding after the main choices have been completed. The cook on duty stated that she was the second cook, who also undertakes some care duties. She stated that catering cover is normally from 08:00 to 14:30 and that evening staff warm the teatime meals and serve the sandwiches, it was also noted that the night staff complete breakfasts. The cook stated that feedback on meals is sought via face-to-face contact with the service users and that the menus are updated on a bi-annual basis, which reflects changing season vegetables, etc. Little Hayes DS0000012508.V373518.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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse and have their rights protected. EVIDENCE: The manager states via the AQAA: The home has not received any complaints within the last twelve months. All residents, staff and advocates have access to a complaints procedure. Full records are kept of complaints made, immediate response and feedback given on the investigation. Annual reviews of our policies and procedures are carried out to ensure they remain up-to-date and relevant. As mentioned previously details of the homes complaints process were observed on display in the entrance hallway. Details of the homes complaints process is also contained within the statement of purpose and service user guide documentation, copies of these documents are also on display within the hallway. The manager also makes a clear statement, via the AQAA that all new service users or their representatives are given a copy of the service users guide on admission to the home. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 17 The dataset, which forms part of the AQAA documentation, establishes the existence of the home’s complaints and concerns procedure and that this was last reviewed in the June of 2008. The dataset also contains information about the home’s complaints activity over the last twelve months: No of complaints: 0 No of complaints upheld 0. Percentage of complaints responded to within 28 days: N/A. No of complaints pending an outcome: 0. The manager states via the AQAA that: Protection of vulnerable adults promoted. Recruitment procedures undertaken all residents are protected, Protection of Vulnerable Adults (POVA), Criminal Records Bureau (CRB) checks carried out on all perspective employees, staff training on safeguarding vulnerable adults. The dataset indicates that policies on the protection of service users are in place, ‘Safeguarding adults and the prevention of abuse’ and ‘Disclosure of abuse and bad practice’, both policies updated in the June of 2008. The dataset also establishes that over the last twelve months no safeguarding referrals have been made to the Local Authority, a statement support by a review of our database. During the visit the manager produced copies of the homes training records, maintained for each employ, which demonstrated that staff have completed ‘safeguarding’ training, this corroborating the information contained within the AQAA. Little Hayes DS0000012508.V373518.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): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: We undertook a look around the home in the company of the manager. The building is in a good state of repair, well decorated and furnished to a good standard throughout all communal areas. A new extension has now been completed and the rooms created within this area are light, bright and modern, although the corridor leading into the extension is quiet dark. In discussion the manager felt that this was due to not all of the lights being on at the time, although she has stated she will Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 19 monitor the situation, as poor lighting can lead to problems for people with sight impairments. Several residents’ bedrooms within the existing building were visited during our look around, each room was found to provide ample living space, an ensuite facility in some cases and had been furnished according to the occupants’ own design and wishes. The communal facilities are spacious, light and well furnished areas of the home, which offer the service users the opportunity to socialise and entertain. The dining room is large enough to accommodate all of the existing residents in one sitting; however, plans have had to be made within the extension to provide additional dining space to accommodate the additional numbers. The gardens to the front of the property are well established and contain provide areas that are laid to lawn and off road parking. The rear of the premise has yet to be landscaped following the extension, however, this area is mainly laid to lawn. Just off of the homes main corridor is an exit leading to a seating area, which can be used by the residents and their families/visitors. Throughout the tour of the home no offensive odours were detected, with the premises noted to be clean and fresh. Communal toilets and bathrooms were noted to contain liquid soaps, papertowels and bins for the disposal of waste. All chemicals were stored in accordance with the ‘Control Of Substances Hazardous to Health’ (COSHH) regulations. A review of the homes duty rosters established that there is a dedicated domestic team employed at the home and a statement made via the AQAA: staff are trained in infection control, all precautions are taken to prevent cross infection and ensure the home is free from offensive odours underlines the homes commitment to cleanliness. The laundry is located within the main building and the staff are responsible for laundering residents clothing and returning this to the client room. Clothes are labelled to reduce the possibility of lose or the item being returned to the wrong person. Little Hayes DS0000012508.V373518.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): Standards 27, 28, 29 and 30: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and provided in sufficient numbers to support the people who use the service, however a failure to implement a robust recruitment process does not ensure peoples safety and wellbeing. EVIDENCE: The home operates a weekly rotational roster, which meets the needs of both the home and the staff employed. During the fieldwork visit sufficient staff were observed on duty around the home, including three care staff, one of which was a senior, the manager and catering staff. In discussion with a service user it was established that the staff are considered to be friendly and helpful and always available when required. The staff spoken with during our visit were, knowledgeable about the needs of the residents and also about their roles in caring, supporting and maintaining the safety and wellbeing of the service users. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 21 The manager states via the AQAA that: All staff have a training passport with Skills For Care and have undertaken numerous courses this year. A high percentage of staff have completed National Vocational Qualifications (NVQs). A review of the training passports raised some issues, as the information recorded is not up-to-date and therefore not an accurate reflection of the training completed by staff, an example being one carers training passport documenting that the last training she had attended had been Fire Awareness in the June of 2007. However, the records maintained by the management indicate that this same person completed Medications training in October 2008 and Glucometer training in May 2008, this pattern was repeated across the three training passports reviewed. The minutes of the staff meeting, carried out on the 16th August 2008, also document that staff are finalising their distance learning package, from Highbury College, on Dementia Awareness, yet this again is not reflected via the training passports. In discussion with the manager it was suggested that at the next team meeting she consider bring to the staffs attention the need to ensure the training passports remain up-to-date, as presently they are not reflecting their training and development achievements, when clearly from other records training and development opportunities are reasonable. Information taken from the dataset and confirmed with the manager, indicates` that currently the home employs twenty care staff. Thirteen of the twenty staff has completed a National Vocational Qualification (NVQ) at level 2 or above and this provides the home with a rate of 65 of its care staff possessing an NVQ at level 2 or above. The dataset also indicates that three other staff are completing their NVQ, which would increase the percentage of staff holding an NVQ level 2 or equivalent to 80 , if there was no turnover in staff. Information contained within the dataset establishes that a recruitment and selection strategy/procedure exists to support the manager when employing new staff. It also indicates that all of the people who worked in the home over the last twelve months have undergone satisfactory pre-employment checks, a statement supported by additional statements made via the AQAA. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 22 On reviewing the files of four recently recruited staff the Criminal Records Bureau (CRB) and Protection Of Vulnerable Adults (POVA) checks were in place. However, one employee did not have two references on file, whilst a second persons referees did not include their last employer. The files did contain completed application forms, although for two people the employment histories given were not full and photographic identification was missing. However, health declarations, details of observational supervisions and appraisal summaries were available. In discussion the need to review the homes recruitment and selection process was raised, as presently the system is not robust. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: It has been established at previous inspections that the manager is an experienced leader, who has worked in the home for more than twenty years and was prior to taking over as the Registered Manager the deputy manager. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 24 It is also documented, within our reports, that the manager holds both a NVQ level 4 in care and the Registered Managers Award, which ensures she is qualified to undertake the role. The manager states, via the AQAA that: The manager now has the support of a deputy manager and three care supervisors. The deputy manager was good enough to come into the home and support the manager during our visit and two of the care supervisors were meet during the visit, as a supervisor is on duty throughout each shift. In discussion with the deputy manager it was established that in addition to supporting the manager with the day-to-day operation of the home the management team also share the on-call duties, ensuring that each day the staff working at the home can contact a senior person for advice and guidance. The deputy manager and the supervisors also taking on additional delegated duties, i.e. the management of medications or the reviewing of training and development. Generally the indication within this report is that the manager is providing good day-to-day leadership, although she does need to address issues such as the recruitment and selection process and the management of peoples medications. The homes approach to quality assurance is a little inconsistent, with areas like staff supervisions and appraisals, team meetings, the reviewing and updating of policies and procedures and the appointment of a management company, Peninsular, to undertake health and safety and risk assessment audits, as identified via the AQAA, all examples of good practice. However, the failure to ensure the care plans are being appropriately reviewed and updated, the shortfalls within the recruitment and selection process and the medication management issues, all undermine the positive aspects of the systems listed above. It is also unclear how feedback from the service users is used by the management to effect change within the service, as the AQAA makes no reference to changes made to the service, as a direct consequence of service user comments, the minutes of the staff meetings made no reference to comments provided by the residents and neither the statement of purpose or service users guide contain comments obtained from the residents regarding their experiences of living at the home. Four service users monies or in house accounts were reviewed during our visit. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 25 The homes’ management and storage of residents’ monies was considered safe and appropriate, with people’s monies held individually and separate accounts or books maintained of the amounts stored. The books or accounts are regularly audited by the manager who signs too confirm completion of her audit, all transactions have an accompanying receipt, however, not all transactions are being doubled signed. Whilst looking around the home no immediate health and safety concerns were identified, although the manager has undertaken to look at issues of poor lighting in the main corridor leading to the new extension. As mentioned above the home is now contracting with an external management company to undertake its health and safety and risk assessment audits, reports following these visits and accompanying plans to manage concerns are supplied. The manager tells us, via the AQAA and dataset information that health and safety policies and procedures are made available to the staff and that domestic appliances and personal equipment is regularly maintained and serviced. Health and safety training is being made available to staff, the training records providing evidence of the courses attended, whilst the AQAA indicates that infection control training is completed by all staff. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP9 OP29 Regulation Requirement Timescale for action 17/01/09 17/01/09 Regulation The manager must ensure a safe 13 and robust medication system is in operation. Regulation The manager must ensure a 19 thorough and robust recruitment and selection process is in operation. 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. 3. Refer to Standard OP7 OP30 OP33 Good Practice Recommendations The manager should ensure that when a residents needs change this is reflected via the care planning process. The manager should ensure staff keep their training passports and training records up-to-date. The manager should ensure that there is a more consistent approach to quality assurance adopted within the home. Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 28 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 Little Hayes DS0000012508.V373518.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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