Care Home: Munhaven

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What the care home does well What has improved since the last inspection? What the care home could do better: CARE HOMES FOR OLDER PEOPLE Munhaven Munhaven Munhaven Close Mundesley Norwich Norfolk NR11 8AR Lead Inspector Jenny Rose Unannounced Inspection 27th November 2007 09:30 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 Munhaven DS0000035176.V355567.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. Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Munhaven Address Munhaven Munhaven Close Mundesley Norwich Norfolk NR11 8AR 01263 720451 01263 722579 trish.aston@norfolk.gov.uk www.norfolk.gov.uk Norfolk County Council-Community Care 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) Mrs Patricia Elizabeth Aston Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One wheelchair user at point of admission can be accommodated in room number 5. 13th June 2006 Date of last inspection Brief Description of the Service: Munhaven is a care home providing personal care and accommodation for 20 older people. It is owned by Norfolk County Council and at the time of asking, on the 25th May 2006, the fee for the home was £368.72. The home is located in the seaside village of Mundesley and is close to all local amenities including shops, pubs, post office and public transport. The home offers ground floor accommodation for up to twenty older people in nineteen single bedrooms and one shared bedroom used for single occupancy. The home has ample communal space, including five lounges and one dining room. There are also assisted bathing, including a spa bath, and toilet facilities within the home. The gardens to the front and rear of the home are easily accessible to service users. There is ample car parking space within the grounds and also on the road. Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This was a key, unannounced inspection carried out over a period of 8 hours, during which time a partial tour of the premises was undertaken; care plans, staff files and records for regulation were examined. There were twelve residents living in the Home on the day of the Inspection. The Manager was attending a meeting, but returned for the second part of the day. A Senior Carer was in charge in her absence and together with the Unit Administrator provided helpful information. Discussions also took place with a Care Coordinator and several other members of staff, as well as privately with four residents, two members of staff on duty and six visitors. The Annual Quality Assurance Assessment (AQAA), one comment card from a resident, two from relatives/friends and two from staff had been returned to the Commission prior to the Inspection which provided useful information which is reflected in this Report. What the service does well: • The Home stands in gardens providing pleasant views from many residents’ bedrooms and communal rooms, which are all on the ground floor. Major landscaping will be taking place in 2008 to provide access to a secure garden area for those people with a dementia diagnosis. Residents and relatives speak of the staff team being kind, caring and helpful although there are some concerns about staff time constraints. There are good training opportunities for staff and career development appraisals. A comprehensive needs assessment is undertaken prior to people being admitted to the Home in order to assess whether the Home can meet those needs. The Home is in process of changing its role predominantly to the care of people with a dementia diagnosis. Relatives and friends are able to visit whenever they wish and are made welcome. There are rooms designated for residents to see their visitors DS0000035176.V355567.R01.S.doc Version 5.2 Page 6 • • • Munhaven in private, other than their bedrooms; relatives are able to take meals with residents if they so wish. • Care plans are organised, indexed and reviewed and give clear instructions from which staff are able to support residents according to individual needs. There are a variety of communal areas where residents can choose to sit and these are decorated and furnished in a homely and comfortable manner and were clean and tidy on the day of Inspection. There is to be a major refurbishment, including storage for hoists and other equipment in one particular area in the near future in preparation for the changing role of the Home. Training in Dementia Care is already taking place; the Manager, Care Coordinators and a Senior Carer have undertaken training and are about to undertake an intensive course. • • What has improved since the last inspection? • • • Staff training and assessments of residents are taking place in the use of the Malnutrition Universal Screening Tool (MUST). An Annual Quality Assurance has been completed together with an Annual Development Plan. The Service User’s Guide now contains not only a directional map, but also a plan of the building for new residents to orientate themselves; this was at the request of a resident who visited the Home for short term care. Care staff are further encouraged to undertake NVQ qualifications by agreeing to undertake such training as and when they join the staff team. A safe radiator has been installed in hairdressing room and risk assessments have been carried out on fan heaters used in residents’ rooms. Some areas of the Home have been redecorated and refurbished and the Home has the services of a maintenance person on a part time basis. • • • What they could do better: Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 7 • There should be continuous development of care plans in building upon the details of personal life histories, with the resident’s permission, in conjunction with the activities programme in order to further improve the more person centred, holistic care already offered. More frequent auditing of residents’ monies should be undertaken in view of a small error discovered on the day of Inspection and also because, of necessity, residents’ monies are recorded by several members of staff, (although on this occasion the an error was in a resident’s favour). Training in supervision and appraisals for senior staff, once appointed, would allow the Manager to delegate those tasks and would enhance the career development of senior staff. It would be advantageous for the Manager to continue to ensure that there are sufficient staff on duty in the Home when staff members are required by the GP surgery to accompany residents to appointments and who then take their place in the waiting area in the surgery, which is in an adjoining building. Consideration could be given to relieving the Manager of some of the tasks, which could be undertaken by the maintenance person. Consideration should be given to reducing the time that staff posts are vacant and, in particular senior, posts. • • • • • 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. Munhaven DS0000035176.V355567.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 Munhaven DS0000035176.V355567.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, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People looking to live in the Home have their individual needs assessed before admission to ensure that these can be met within the Home. The Home does not offer intermediate care, but does offer respite care. EVIDENCE: Two care plans examined showed that prospective residents’ have their needs assessed prior to admission to ensure the Home is able to meet those needs. The assessment forms the basis of the care plans. This was confirmed by the two most recently admitted residents and a relative. They confirmed the information contained in the AQAA that prospective residents/relatives are encouraged to visit the Home and that the Manager/senior member of staff always visits a prospective resident. The pre-admission assessments also contain information from placing Social Workers and other Health and Social Care Professionals where appropriate. The comment cards were positive in that sufficient information was available before making decisions about the Home. Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 10 The Service User’s Guide contains a directional map and a floor plan of the Home, following a request from a resident who had received short term care in the Home (See Management). The AQAA states that a folder of photographs showing facilities is under consideration. The two residents spoken to who had recently been admitted to the Home confirmed this process and that there had been a review after four weeks and they felt that their needs were being met. Munhaven DS0000035176.V355567.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home are satisfied with the way that staff deliver their care and respect for their dignity. EVIDENCE: The care plans seen were person centred and focussed on the individual’s personal preferences in various respects, including preferred time for daily routines, social contacts and interests. These were well organised, indexed and the most recent care plans contained a checklist for auditing, which is good practice. It is the intention to complete all care plans in this manner. Four care plans examined each contained a photograph of the resident and comprehensive details necessary to enable staff to deliver the particular care needed. In one care plan seen there were details of the support for the particular resident’s emotional needs. Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 12 Risk assessments are in place where necessary and these were discussed with the residents and relatives, as appropriate, particularly with regard to falls. These and the care plans seen were regularly reviewed with the resident and/or relatives. If a resident was unable to sign, a note was made of this inability. Information on weight and nutrition was included in care plans and the action to be taken regarding dietary supplements or particular dietary needs, such as those associated with Diabetes. Staff have completed MUST training. Examination of care plans showed involvement of Health and Social Care Professionals. There was evidence of eye tests, dental care, chiropody and visits from the Continence Advisor. The District Nurse visits on a regular basis when needed and this was confirmed by two residents spoken to. Observation of the medication round demonstrated that medication was appropriately stored in a locked cupboard in the medical room and there was appropriate storage for controlled drugs. The trolley is an unsuitable height, as recorded in the Regulation 26 visit on 7th June 2007, and accordingly there is a recommendation that consideration be given to a replacement when refurbishing the Home, as it is difficult to view the records accurately on top of the trolley. The administration of medication was observed to be safely carried out by staff who had been trained and who were observed communicating appropriately with residents about their medication. The MAR sheets appeared to be appropriately completed. There is a mini audit on each shift by a senior member of staff and a weekly and monthly audit. There are no residents administering their own medication, although there are procedures for this if necessary. It was observed, and residents spoken to confirmed, that they were treated with respect and that their privacy was protected. Two residents spoken to were satisfied with the way staff promoted their dignity during personal care tasks. There is a telephone room so that residents may receive calls in private or residents may have telephones in their rooms. Bedrooms are lockable and all bedrooms have single occupancy with lockable facilities within them. Relatives’ comments: “Our relative is happy here. Staff are very kind. It is as much like home as possible.” Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home have choice in their lifestyle, including well balanced meals. EVIDENCE: Many residents enjoy the garden, which provides the Home with pleasant views. Plant tubs and containers have been planted-up by residents and other areas are tended by relatives and friends as well as by the general maintenance agency. A capital grant has recently been awarded for garden improvements including making it secure as the Home develops towards caring for people with Dementia. There are five communal sitting areas for residents including an octagonal lounge overlooking the GP’s surgery opposite and views down the road towards the village. The local nature of the Home means that residents know each other, the staff and visitors. TVs, Video’s and DVD’s are available in a number of areas of the building and a quiet room with reading materials. Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 14 There is evidence from the large print Minutes that social activities, outings and meals are discussed at each monthly residents’ meeting as well as the forthcoming changes. There are in-house celebrations with special food prepared by the newly appointed cook, for example Halloween and festive food being planned for Christmas and Family Days. There are weekly religious services with one taking place on the day of the Inspection. Visitors are encouraged to take meals with residents. Manicures are available and entertainers visit the Home; some residents enjoyed playing cards on a regular basis. The Home has a resident cat, which adds to the homely, relaxed atmosphere. The Manager reported that staff input for social activities is limited, although staff endeavour to provide activities every afternoon and that there is an activities programme displayed. There is a recommendation that consideration should be given to designating an Activities Organiser to develop a programme in line with the needs, wishes and life histories of the people living in the Home, the latter being particularly important when the Home applies to register for Dementia care. There were several visitors in the Home on the day of the Inspection; five were spoken to. They confirmed that they were welcomed in the Home at any time. One resident spoken with goes out on a regular basis with her family, sometimes taking another resident friend with her. The residents and visitors spoken to commented favourably on the range of choices open to them. For example they said that they could get up when they liked and there were residents in the dining room taking breakfast on the morning of the Inspection at about 10.00 am. One resident spoken with occasionally likes to spend the day in bed. On the day of Inspection one resident was observed being asked whether she would like to have her food minced. Comment cards and residents confirmed that meals could be taken where the residents chose. Residents can choose to take their meals in the pleasant, light dining room overlooking the garden. Care is taken for those residents with poor sight to be seated with their backs to the window. The meal on the day was a choice of a meat dish and a vegetarian one, but one resident spoken with said that sometimes there were at least three choices and also a choice at teatime. This resident was also pleased that he was always asked if he would like a further helping. There was a choice of several hot and cold desserts and the food was appetising and hot. The cook visited each table to hear the views of the residents and she is also involved in the residents’ meetings in order to discuss menus and any changes needed. The Manager encourages staff to sit with those residents who need discreet assistance or further encouragement to eat. Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 15 Nutritional needs are being monitored by the MUST system, which is particularly important for one resident who has a very small appetite. Two visitors spoken with said that their relative had put on weight since being in the Home because they were enjoying their meals. Following a recommendation at the last Inspection, the Manager has made the time for the evening meal slightly later at 5.00pm. Staff comments: “Meals for residents and option of choices is fantastic.” “The ambience of the Home is generally relaxed and friendly.” Munhaven DS0000035176.V355567.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home feel that complaints and concerns are listened to and acted upon and that the Home’s policies and procedures help ensure that residents are safeguarded. EVIDENCE: All comment cards indicated that people would know how to make a complaint as well as being confirmed by the six visitors spoken with. The Home has a clear policy and procedure for dealing with complaints; a record is also kept of compliments. The Manager said that the Home is currently reviewing the recording of complaints, including those which might have previously been considered as “minor” individual concerns. This was on the agenda for the staff meeting to be held the following day. Since the last inspection three complaints had been received; all had been dealt with appropriately. From the examination of training records and from speaking to staff it was evident that staff have received training in recognising the signs and symptoms of abuse. All residents spoken with felt they were well treated by staff. Munhaven DS0000035176.V355567.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): 19,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The refurbishment of the Home has been delayed; but all areas of the Home were clean and well cared for on the day of Inspection, offering a comfortable environment for the people living there. EVIDENCE: The plans for refurbishment works had been due to commence at about the time of the Inspection, but the start date has been delayed until the first week in January 2008 due to certain health and safety issues. Refurbishment plans include renewal of the heating system, replacement of the metal windows, enlarging toilets and making a shower area, a storage area for the moving and handling equipment and re-landscaping the gardens. The monthly residents’ newsletter shows that residents and relatives are being kept informed of the developments. The Minutes also demonstrate that there will be one person designated as a co-ordinator of the Works to whom any difficulties may be Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 18 referred. The requirement regarding this refurbishment from the previous Inspection is repeated. The Home has the services of a part time maintenance person; on the day of Inspection the Home was clean, tidy and hygienic throughout. Munhaven DS0000035176.V355567.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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the Home are satisfied with the delivery of their care, but swifter recruitment to vacant posts, especially those on the senior team, would further improve the quality of the service. EVIDENCE: All the residents spoken with, together with the relatives’ comment cards received, were positive about the staff team, although there were comments from staff that staff time was limited. The members of staff spoken with also confirmed that they would like more time to be spent one-to-one with residents. The Manager felt at present that, although not ideal, the staff team, with some agency input, was providing sufficient cover, (there were four resident vacancies). The Home is located opposite the GP surgery. It has been the usual practice for all residents to visit the GP at the practice unless they are too unwell to do so. On average this takes place about 4 or 5 times a week with a member of staff accompanying the residents, which occurred on the day of the Inspection. The member of staff has to wait with the resident and this can take up to an hour on each occasion. The Manager is aware that she has to continue to ensure that when a member of staff is absent with a resident at the surgery that there are enough staff remaining in the building to continue to care for the residents. A repeated recommendation is made in this respect. Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 20 The Manager said that there had been delays in filling recent staff vacancies due to the time taken in receiving Criminal record Bureau checks; in part also due to the postal strike and prospective applicants finding other jobs in the meanwhile. However, there is a requirement that the dependency levels of residents are monitored in order to determine staffing levels, particularly when the Home prepares to offer Dementia Care. It is also recommended that the Manager continues to increase domestic and laundry staff hours to free up Care Assistants from undertaking some of these non-care related tasks. There are two senior carer posts vacant; the Manager is therefore unable to delegate responsibilities such as supervision. She is looking to delegate appraisals and supervision to senior staff, when they have completed training. The previous inspection report and the Regulation 26 Report records the difficulties in recruiting new staff due to reasons which prevail nationally regarding working in the care sector. It was evident on the day of the Inspection, including talking to staff in private that there is an enthusiastic staff team who enjoy working with residents in a caring and respectful way and promoting individual dignity and choice. Staff members undertaking kitchen and cleaning tasks were enthusiastic about their duties and took obvious pride in performing them well. From examination of files Induction Training is completed by all staff and all are offered various additional training opportunities, such as training in Diabetes and MUST training. All care staff will receive training in Dementia. The AQAA stated that fifty percent of the staff team staff had gained NVQ2 qualifications or above and that there is one person undertaking these qualifications. Newly recruited members now need to agree to undertake an NVQ2 qualification before starting employment. The documents and information needed prior to making staff appointments were seen to be in place. Members of staff spoken with were aware of the issues involved in Safeguarding Adults and had received training in this area. According to the residents and staff spoken with there is a key-worker system which works well. One member of staff spoken with said she really enjoyed this designated relationship and looking after individual resident’s needs. There are regular staff meetings which all members of staff said they found helpful. Staff also said that they felt there is sufficient time at the beginning and end of shifts together with support within the staff team, which enables them to carry out their work in a competent manner. Residents’ comments: All comments were positive. Relatives’ comments: “The staff are a friendly bunch.” Staff comments: “It can be difficult when there are lots of service users needing more attention. The more independent ones can feel neglected.” Munhaven DS0000035176.V355567.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): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager and the staff team work hard to ensure the people living in the Home receive a good standard of care. EVIDENCE: The Manager has been in post for some years and has the NVQ4 Registered Managers Award, as well as the Certificate in Social Services (CSS). Prior to the Inspection she had returned the AQAA, which was detailed and informative. Together with other members of staff she has recently undertaken a course in Dementia and was about to undertake a course in Dementia Care Mapping. On the morning of the Inspection the Manager was attending a Local Authority Managers’ Meeting and a Senior Carer stepped into her role in an efficient manner. It was evident from observation and talking to Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 22 staff, relatives and residents that they found the Manager and Senior Staff approachable. On her return the Manager proved herself to be competent and knowledgeable; she is assisted by a part time Administrator who has an NVQ3 in Business and Administration. The quality of the service provided is monitored by the Local Authority, which includes questionnaires to residents, their relatives and other interested parties. The Manager has also completed the AQAA and there is an Annual Development Plan. The Home undertook their own quality assurance survey and there are also staff questionnaires; action has been taken on comments. A newsletter for the Home has recently been introduced and this is appreciated as a means of improving communication, in addition to regular Staff, Senior Staff and Residents’ meetings. Regular Regulation 26 visits take place; copies of these have, in the past, been shared with the Commission on a monthly basis. In the future, copies will be kept at the Home and provided to the Commission when requested. A suggestion from a former short term care resident has been put into action in the Service Users’ Guide which now contains a directional map and a floor plan of the Home, which is good practice. All transactions of residents’ monies are recorded and signed by the member of staff dealing with the transaction at the time. These had been audited during an internal audit some months before the Inspection. Three residents’ money transactions for such items as chiropody and hairdressing were tracked. Two were found to be correct, but in one there was an error – in the resident’s favour. There is therefore a recommendation that residents’ money should be more frequently audited. All staff have received Staff Appraisals. However, there are still some gaps in regular, recorded supervision, due to pressures of time for the Manager, who is missing the support of a full senior team, although there was evidence of continuous ‘on the job’ supervision. There is, therefore, a recommendation for this. Staff files contained evidence that all staff receive training in respect of Moving & Handling, First Aid, Food Hygiene, Fire Safety and Infection Control; this was confirmed by members of staff spoken with. Accidents and Incidents are recorded and Regulation 37 forms are completed as appropriate. Door closers have been fitted on all doors in the Home and Fire Alarms are tested weekly. The Manager undertakes weekly flushing of the water system for Legionella and records the weekly and monthly checks. There is a recommendation in this area. The requirement from the previous Inspection Report concerning the radiator in the hairdressing room has been addressed and the radiator has been replaced with one that is safe to touch. The Manager also said that the Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 23 recommendation regarding risk assessments on fan heaters in residents’ rooms has been complied with. Relatives’ comments: “Nothing is hidden. Can ring when we like” Staff comments: Suggestions for improvement: “Have “Friends” of the Home like you have “Friends” of a hospital.” When we go to “Dementia Care” will there be provision for a tranquil room?” “PAT dogs visiting the Home are very therapeutic.” Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 1 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP25 Regulation 24.1(B) Requirement Timescale for action 30/04/08 2. OP28 18(1)(a) The improvement plan as set out in the Annual Development Plan. for the replacement of the heating system, the metal window frames and enlarging of toilets should be implemented This is a repeated requirement Staffing ratios should continue to 31/03/08 be determined according to the assessed needs of residents, to ensure that the needs of the people living in the Home come first. Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Consideration should be given to replacing the present medication trolley with a lower one, in order for staff to more accurately view records and to prevent errors, thereby further ensuring the safety of the people living in the Home. Consideration should be given to appointing a designated Activities Organiser to develop the present activities programme in line with the needs, wishes and life histories of the people living in the Home. It is recommended that the manager continues to ensure that when staff are accompanying residents to the local GP practice that there are sufficient numbers of staff remaining in the building to care for the people living in the Home. Repeated recommendation It is recommended that the Manager continues to increase domestic and laundry staff hours to free up Care Assistants from undertaking some of these non-care related tasks to ensure the quality of care delivered to the people living in the Home. Consideration should be given to the auditing of residents’ monies more frequently to further safeguard the finances of the people living in the Home. Consideration should be given to the training for the senior team in staff supervision and appraisals to further ensure the quality of the care delivered to the people living in the Home. Consideration should be given to the delegation of Legionella testing away from the Manager to release her for staff managerial tasks to further ensure the quality of the care delivered to the people living in the Home. 2. OP14 3. OP27 4. OP27 4. 5. OP35 OP36 6. OP38 Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Munhaven DS0000035176.V355567.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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