Care Home: Londesborough Court Care Home

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What the care home does well People are only offered a place at the home following a thorough assessment of their needs, and if it is then considered that their assessed needs can be met. Residents are encouraged and supported to live their chosen lifestyle and to take part in appropriate activities. The home is well maintained, clean and hygienic; health and safety practices are good. Staff work well as a team and tell us that they feel well supported by each other and by managers. Staff take part in training programmes that equip them to meet the needs of residents accommodated at the home.The quality assurance system gives residents and others the opportunity to affect the way that the home is operated. What has improved since the last inspection? The registered providers or their representative visit the home on a monthly basis to undertake a `spot` inspection; these records are retained at the home and are available for inspection. There have been no further reports of incidents when staff have `potted up` medication. Most staff that have not achieved the National Vocational Qualification (NVQ) Level 2 in Care are working towards this award. What the care home could do better: Recording in daily records should reflect the areas identified as care needs in individual care plans and should be a full record of the care provided to residents. More attention should be paid to recording on medication administration records being accurate at all times. When medication is prescribed part of the way through the month and information added to medication administration records, these entries should be signed by two staff. The safety and security of medication would be further enhanced if alternative storage arrangements were provided. When recruiting staff, Protection of Vulnerable Adults (POVA) first checks should only be used in exceptional circumstances, not as a matter of routine. The results of any quality surveys should be published and a copy of the published results should be sent to the CSCI. Obtaining individual receipts from the hairdresser and the chiropodist would ensure that Data Protection regulations are not breached. CARE HOMES FOR OLDER PEOPLE Londesborough Court Care Home Londesborough Road Market Weighton East Yorkshire YO43 3AZ Lead Inspector Diane Wilkinson Key Unannounced Inspection 12th March 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Londesborough Court Care Home DS0000019691.V360742.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. Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Londesborough Court Care Home Address Londesborough Road Market Weighton East Yorkshire YO43 3AZ 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) 01430 873954 F/P01430 873954 court@amserve.com Londesborough Court Limited Ms Megan Kennedy Care Home 30 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (30), Old age, not falling within any other of places category (30) Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2006 Brief Description of the Service: Londesborough Court is a privately owned care home that is registered to accommodate and care for thirty older people, including those with dementia. The company owns another care home in a nearby town. Information about the home is provided to service users and others in the home’s statement of purpose and service user’s guide. The property is a large detached house that has been extended to provide additional bedroom and communal accommodation, and that is set in its own grounds. Private accommodation is provided in a variety of single and shared rooms, most of which have en-suite facilities. Some bedrooms are on the first floor and there is a passenger lift to enable residents and visitors to have easy access. There are various communal rooms available, including a dining room, a lounge and a conservatory. The home is close to local amenities such as shops, banks, cafes, public houses and transport facilities, and there is a car park available for visitors and staff. Fees paid range from £375.25 to £446.50 per week and there is an additional charge for hairdressing, private chiropody, toiletries and newspapers. . Londesborough Court Care Home DS0000019691.V360742.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. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 28th June 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.00 am and ended at 4.00 pm. On the day of the site visit the inspector spoke on a one to one basis with one resident and one relative, as well as three members of staff and the manager. Inspection of the premises and close examination of a range of documentation, including four care plans, were also undertaken. The registered provider and manager submitted information about the service in advance of the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA) form. Survey forms were sent to the home for distribution to residents and staff; three were completed by residents (some with the assistance of a relative) and seven were completed by staff. Comments from discussions with residents and others were mainly positive, for example, ‘I like to spend my time in the lounge doing word puzzles and crossword puzzles, reading the newspaper and watching TV’ and ‘the meals are good’. Other anonymised comments are included throughout the report. What the service does well: People are only offered a place at the home following a thorough assessment of their needs, and if it is then considered that their assessed needs can be met. Residents are encouraged and supported to live their chosen lifestyle and to take part in appropriate activities. The home is well maintained, clean and hygienic; health and safety practices are good. Staff work well as a team and tell us that they feel well supported by each other and by managers. Staff take part in training programmes that equip them to meet the needs of residents accommodated at the home. Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 6 The quality assurance system gives residents and others the opportunity to affect the way that the home is operated. 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. Londesborough Court Care Home DS0000019691.V360742.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 Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: We examined the care records for a newly admitted resident. These included an admission form and various assessments, including biographical, physical and dependency levels. The registered manager confirmed that people are visited by staff at their current place of residency prior to their admission and that this is when the initial assessment of needs commences. There is evidence that people are only offered a place at the home if it is believed that their current assessed needs can be met, and in some instances, a period of respite care is arranged to assist people in making a decision about permanent care. Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 9 We observed that assessment information was thorough and included a risk assessment for moving and handling. This information, along with a community care assessment undertaken by care management (where people are funded by a local authority), had been used to develop an individual plan of care for the resident. There is evidence that family members and health/social care professionals are consulted as part of the initial assessment of needs. Londesborough Court Care Home DS0000019691.V360742.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): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning documentation evidences that health care needs are met in a way that respects a person’s privacy and dignity. EVIDENCE: We examined three care plans in addition to the care plan for a newly admitted resident. These contained an individual care plan that was based on the needs assessment undertaken by the home as well as information gathered from care management and family members. Care plans include risk assessments for moving and handling as well as those for more specific risks to the individual resident, such as taking part in gardening, becoming aggressive in certain situations and being let out of the building by visitors. Risk assessments include advice on how to minimise these incidents occurring, and how to deal with these situations should they occur. Care plans record a person’s need for assistance with personal care and continence care. We saw records on the day of the site visit that evidence that Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 11 care plans, assessments and risk assessments are reviewed and updated on a regular basis. The AQAA form records that care plans are evaluated at regular intervals; we observed on the day of the site visit that annual reviews are organised by the local authority for the people that they fund and that the home organise a care plan review for residents who are self funding. When asked what the service does well, a member of staff recorded in a survey, ‘the service caters to the individual’s needs and desires’. Daily diary entries are brief; we recommend that these records should make reference to the particular care needs that have been identified in individual care plans. Daily records would then be useful when monitoring and reviewing care plans. Care plans include a thorough record of a person’s medical history, and biographical assessments include a personal history, information on food likes and dislikes, preferred times to get up and go to bed and hobbies and interests. There is a record of a person’s nutritional requirements, such as a diabetic diet and any allergies; people are also weighed on a regular basis as part of nutritional screening. There is a record of any visits from or contacts with health care professionals, including the reason for the visit. Relatives told us that they are kept informed about issues concerning their relative. On the day of this site visit we observed the administration of medication by a senior carer; this was carried out in a satisfactory manner. There is evidence that staff that administer medication have undertaken accredited training, and there are sample signatures held with medication records to enable signatures on medication administration records to be checked for authenticity. Following discussion with staff on the day of the site visit, we are satisfied that the practice of ‘potting up’ medication does not take place at the home. We observed that there were some gaps in recording on medication administration records, particularly when residents have refused ‘as required’ medication. It is recommended that a record be made when residents refuse medication to indicate that this has been offered to them. There was another recording error on the medication administration records; after further checks, it was clear that this was a ‘one-off’ and the manager assured us that she would discuss this with staff to ensure that this error did not occur again. We also recommend that, when hand written entries are made to medication administration records part of the way through the month, these entries are signed by two members of staff as an additional safety measure. The AQAA records that the manager now undertakes spot checks of the medication system to ensure that procedures are adhered to by staff. Controlled drugs are stored in a satisfactory manner, although it would be preferable for controlled and other drugs to be stored in an area of the home that does not encroach on the resident’s communal accommodation, and that was not visible to visitors and others, to promote both safety and security. Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 12 Controlled drugs are recorded separately and there is a record of medication received, medication administered and medication remaining, with all entries being signed by two members of staff. We observed on the day of the site visit that residents are spoken to sensitively with regard to personal care, and that staff respect a person’s privacy by knocking on bedroom doors and by closing doors when people were using the toilet and bathroom. A relative told us that they had always heard staff speaking nicely and with respect to residents. We observed that resident’s are treated as individuals, with consideration given to their personal relationships and particular lifestyle choices. Londesborough Court Care Home DS0000019691.V360742.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 available evidence including a visit to this service. Residents are encouraged and supported to maintain their chosen lifestyle and to continue with their hobbies and interests, and visitors to the home are always made welcome. Residents told us that the meals are good. EVIDENCE: Care plans include information about a person’s life history and previous lifestyle, including details of family and friends, hobbies and interests. Care plans record information about a person’s preferred time to get up and go to bed and about likes and dislikes regarding their diet. Residents confirmed that they can get up and go to bed as a time chosen by them, and that this can vary from day to day, depending on their preference. The AQAA completed by the manager records, ‘We have completely open visiting arrangements and encourage Service Users to maintain contact with their family and friends’. Visitors told us that they are able to visit the home at any time, and are always made welcome; this was observed on the day of Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 14 the site visit. There are various areas of the home where residents can sit; we observed on the day of the site visit that there was a radio playing in one lounge and the TV was on in another. In addition to this, there is a small room available for use when people have visitors, and the wide corridor area has seating where some people prefer to sit, as it overlooks the garden. We saw on the day of the site visit that the dining room was used also used when people had visitors. Care plans evidence that care staff facilitate activities such as chair exercise, music sessions and playing board games. A carer was seen to be assisting a resident on a one to one basis with exercises to improve mobility in their arm; this was done in the dining room to promote privacy. Another resident played a mouth organ to entertain themselves and others when everyone was gathering in the dining room for lunch. One resident recorded in a survey, ‘I spend most of my time in the lounge doing word puzzles and crossword puzzles, reading newspapers and watching TV. I prefer to keep myself to myself’. We were told that staff accompany some people who like to go out for a walk. Some residents have had a telephone installed in their own room; this assists them to remain in contact with family and friends. The AQAA records, ‘We provide activities on a one to one basis as well as group activities’. Daily records are quite brief and it would be helpful if they included more information, such as food/fluid intake, any visitors seen, any activities that the person has taken part in, what time they got up and what time they went to bed. This would help to provide a picture of how people spend their day. Information about advocacy is displayed in the home; this enables people to access these services without having to ask someone for the information and promotes privacy and independence. The AQAA records that staff have undertaken training on the Mental Capacity Act and it is clear that there is an understanding of the implications of this legislation for residents living in care homes. Care plans record a person’s likes and dislikes regarding food. When asked in the survey, ‘Do you like the meals provided by the home?’, all three residents that completed a survey told us that the meals were good. On the day of the site visit we observed that the menu was displayed outside the dining room, and that there were two choices of meal on offer; residents were asked mid morning what they would like for lunch. Residents confirmed that there is always a choice of meal available. We saw that ‘soft’ diets and diets for people with diabetes were provided. People were offered a variety of fruit juices to have with their meal, and were encouraged to have more that one glass of juice. We observed that people were not rushed and that staff offer appropriate assistance where needed. There are two sittings at lunch time; those people Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 15 that need assistance with eating a meal have their lunch first, followed by those that need minimal assistance. We were told that this system works well at the home, and enables those residents that need assistance to have one to one attention from a member of staff. Londesborough Court Care Home DS0000019691.V360742.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 available evidence including a visit to this service. Residents and others know how to use the complaints procedure and residents said that staff listen to them. Residents are protected from the potential to be abused by the training and skills of the staff group. EVIDENCE: There are appropriate complaints policies and procedures in place, and the complaints procedure is displayed in the entrance hall. There have been no complaints made to the CSCI since the last key inspection. All of the residents that completed a survey said that they knew how to make a complaint, and the relative spoken with on the day of the site visit confirmed that they knew who to speak to if they were dissatisfied with any aspect of their relatives care. When asked, ‘Do staff listen and act on what you say?’ all residents that completed a survey responded ‘Yes’. The AQAA completed by the manager records that there have been no complaints to the home since the last key inspection. However, the complaints log recorded two complaints; records evidenced that the complaints had been dealt with satisfactorily. Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 17 There are appropriate policies and procedures in place regarding the protection of residents from all forms of abuse. The AQAA records that all staff undertake training on safeguarding adults as part of their induction training; training records seen on the day of the site visit confirmed this. Most staff have either undertaken or are undertaking NVQ Level 2 in Care and will undertake further training on this topic as part of their training programme. We spoke to a new member of staff who confirmed that they had undertaken training on safeguarding adults from abuse. Since the last key inspection, the home has reported two allegations of abuse to the CSCI and to the local authority representative dealing with safeguarding referrals. One allegation was about a new resident and, following the involvement of various health and social care professionals, the resident concerned was readmitted to hospital. Another allegation was made about a member of staff; an investigation undertaken by Social Services concluded that this was a staff training issue rather than one of abuse. Londesborough Court Care Home DS0000019691.V360742.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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained and well furnished and provides comfortable surroundings for residents. EVIDENCE: There is a service calendar in place that records when equipment is due to be serviced and maintained, and monthly maintenance reports record work undertaken to maintain standards. On the day of the site visit we observed that the home is well maintained and that equipment is replaced as necessary, as well as being well decorated and furnished to a high standard. Communal areas provide a light and bright atmosphere for residents. Bedrooms are furnished and decorated to reflect the needs of the resident concerned; we saw that one bedroom had been rearranged so that a settee could be placed in the room at the request of a relative. Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 19 The manager recorded in the AQAA form that some communal areas of the home have been redecorated and that en-suite facilities are also in the process of being redecorated. Bedrooms continue to be redecorated whilst they are vacant, in preparation for occupancy by a new resident. Laundry facilities at the home are satisfactory but could be improved by some redecoration of the laundry room to provide impermeable floor and wall finishes that are easily cleanable. A laundry assistant is employed so care staff do not have to undertake laundry work alongside care tasks; this enhances infection control and reduces the risk of cross infection. We observed that resident’s laundry is handled with care. We observed that hand disinfecting gel is available for staff and visitors at the entrance to the home, as well as in the laundry room and other key areas. The inspector observed good hygiene practices being used by staff on the day of the site visit. There were no strong odours identified on the day of the site visit and the home was seen to be clean and hygienic. Londesborough Court Care Home DS0000019691.V360742.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 available evidence including a visit to this service. Care staff are recruited in a safe way and receive induction and on-going training to ensure that they are qualified and skilled to care for the residents living at the home. EVIDENCE: There is a staff rota in place that records the role of each member of staff and we observed that, on the day of the site visit, the staff rota was a true reflection of the actual staff on duty. Domestic staff and laundry staff are employed in addition to care staff; this enhances infection control at the home. Lunch and tea continue to be provided by the sister home in a nearby town so no cook is employed. Three care staff have completed NVQ Level 2 in Care; one of these is continuing with training to work towards NVQ Level 3 in Care. A further 7 staff are currently working towards this award. Although the home has not yet achieved the target for 50 of care staff to hold this award, they have an action plan in place that should result in this target being met. The inspector examined the recruitment and selection records for a new member of staff. These evidenced that the person completed an application Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 21 form that included details of their employment history, their previous experience and their training achievements. One member of staff had worked at the home previously; new references had been obtained and a POVA first check had been received prior to them commencing work at the home. A new CRB check had been applied for. There is evidence that new employees have induction training when they are first in post and that this meets Skills for Care standards. When asked in a survey, ‘Did your induction cover everything you needed to know to do the job when you started?’ four staff said ‘very well’ and three said ‘mostly’. The manager told us that she has a meeting planned with the manager of their sister home; they intend to produce a new training and development plan for all staff working for the organisation. There is currently a copy of an ‘old’ training plan in use and individual staff records of training achievements and needs are comprehensive. These records evidence that twelve staff did First Aid training in August 2007, five staff did Mental Capacity Act training in November 2007, ten staff did fire training in November 2007 and eleven staff did bed rail training in August 2007. The manager was reminded that dates should be recorded on the training and development plan so that the need for ‘refresher’ training can be identified. Londesborough Court Care Home DS0000019691.V360742.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 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, welfare and safety of residents and others are protected by the systems in place at the home. EVIDENCE: The AQAA records that, ‘we have recently appointed a new manager who comes with over 20 years experience in health care. We expect that she will bring along fresh ideas for improvement’. The manager is in the process of applying to the CSCI for registration. She told us that she keeps her practice up to date by undertaking in-house training along with the rest of the staff group; she has done dementia care, fire safety and food hygiene training in the past few months. She also told us that she had undertaken training on moving and handling and medication; this training will allow her to be an inLondesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 23 house trainer for the organisation. We observed on the day of the site visit that there were good interactions between the manager and staff, and between staff and residents. A member of staff recorded in a survey, ‘We have regular meetings and supervisions as well as handovers from shift to shift. This covers the needs of the home and service users. Management is approachable and is often ‘on the floor’ and another said, ‘We work as a close knit team so help and support each other should the need arise’. The home has achieved the Investors in People award and the Quality Development Scheme (QDS) Parts 1 and 2, the quality scheme operated by the local authority. The quality assurance systems in place at the home enable residents and others to affect the way in which the home is operated. Surveys were distributed to residents and visitors in October 2007 and the results of these have been evaluated. A document has been produced by the organisation to record the outcome of the surveys and the manager told us that the results are discussed at both staff meetings and residents/relatives meetings; a copy of this document should also be forwarded to the CSCI. We recommend that this information be displayed on the notice board so that anyone who has an interest in the home can see the outcome of quality surveys. Surveys will be distributed again in a year’s time so that progress can be monitored and new targets can be set. Resident/relative meetings take place every 2 or 3 months and staff meetings take place every 2 months. There is a QA calendar in place and this records the audits, meetings and reviews that will take place each month as part of the quality assurance system. We examined the records for monies held on behalf of residents and crosschecked these with actual monies held - both were found to be accurate. Receipts are obtained for monies received from relatives and for any purchases made on behalf of residents. We noted that the hairdresser and the chiropodist provide a shared receipt – these transactions are cross-referenced to individual financial records so they are accurate. Ideally, these people should provide individual receipts to ensure that the Data Protection Act is not breached. We examined health and safety documentation held at the home. Monthly health and safety checks are undertaken by the manager, and environmental risk assessments have been undertaken that record details of any areas of risk and how the risk is controlled. There is a fire risk assessment in place and weekly fire tests take place as well as regular fire drills. All other health and safety documentation was seen to be in order, such as a gas safety certificate and maintenance certificates for mobility hoists, bath hoists and the passenger lift. On the day of the site visit we saw evidence that water temperatures at outlets accessible to residents are tested on a regular basis to reduce the risk of Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 24 scalding; a different sample area is tested each month. Temperatures were seen to be consistently between 42 – 44°C; 43°C is the recommended temperatures to ensure safety for residents. There has also been a test to detect the presence of Legionella in the water supply and the result of this was negative. Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 OP12 Good Practice Recommendations Recording in daily records should be more comprehensive to include information about areas identified in individual care plans and to provide a record of how a person has spent their day. An entry should be made on medication administration records when residents refuse ‘as required’ medication, and medication records should be signed by two members of staff when medication is prescribed part of the way through a month. The management team should consider finding alternative storage arrangements for medication to enhance safety and security. 2. OP9 3. OP9 Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 27 4. OP29 The registered persons are reminded that POVA first checks should only be used in exceptional circumstances, not routinely. The outcome of quality surveys should be published and a copy should be forwarded to the CSCI. Obtaining individual receipts from the hairdresser and chiropodist would ensure that Data Protection regulations are not breached when recording financial transactions on behalf of residents. 5. 6 OP33 OP35 Londesborough Court Care Home DS0000019691.V360742.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Londesborough Court Care Home DS0000019691.V360742.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. 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