Care Home: Norwood Grange EMI Residential Home

What the care home does well People living in the home were asked about the care they were receiving. They made comments such as: ``I have no complaints, I am enjoying my stay``. ``I am very happy and glad to be here``. ``The place is nice and clean and I like my room``. ``I like the meals a lot. I like my food``. ``Nothing at all to complain about``. ``The care is very good``. ``Norwood Grange is one of the best I`ve been in to``. ``Brilliant meals``. ``I would like to say that all the staff are good, and they are friendly``. ``Staff are helpful and cheerful, and make me feel looked after``. Comments received from questionnaires and from talking to relatives included: ``The staff are always welcoming whenever we visit``. ``The residents are always clean and appropriately dressed``. ``The care home staff are very friendly people, and they tend to my relative very well``. ``I think the care and attention to detail is very good``. ``My concerns have always been noted and sorted``. ``Over worked, underpaid staff, but give there all``. ``The staff are kind and helpful from the manager to the domestics. This is a specialised job and carers have to be a dedicated lot, and they are!`` People do not move in to the home until a full needs assessment has been undertaken and the home can confirm they can meet the needs of that individual. People at the home have dementia and the staff members were trained in caring for people with dementia. People`s health care was monitored and access to health specialists was available. Staff members were observed being respectful towards people, and provided a range of activities. People said that they had a choice of food and that the quality of food served was "well cooked", and "enjoyable". The staff members were well trained and competent and led by a respected manager. Systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? Since the previous visit a large extension to the home has been built providing additional single bedrooms with en-suite facilities, additional communal areas, a new office and treatment room. The home has a new emergency call system, and changes to the garden and parking areas. At the previous inspection a number of areas for improvement were required and these have all been met. Medication records were up to date and medication had been signed for when given. Light pull-cords, some furniture and some carpets have been replaced around the home meeting previous requirements. The kitchen had adequate storage facilities, and an Environmental Health visit recently awarded them 4 stars for their service. At least 50% of the staff now have NVQ level 2 or above, and a thorough recruitment process is in place. Staff members have had training in Dementia care in order to improve the care they give to the people in the home. The manager has almost completed her registered Managers Award, but the training provider is no longer operational so she is looking for another one. The Operational Manager for the company visits the home at least monthly and provides a report on the homes progress. CARE HOMES FOR OLDER PEOPLE Norwood Grange EMI Residential Home Longley Lane Sheffield South Yorkshire S5 7JD Lead Inspector Ms Stephanie Kenning Key Unannounced Inspection 1st July 2008 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 DS0000032191.V366379.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. DS0000032191.V366379.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norwood Grange EMI Residential Home Address Longley Lane Sheffield South Yorkshire S5 7JD 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) 0114 2431039 0114 2431039 shides@redrosecare.co.uk Mr Baljit Kalar Mr Resham Singh, Mrs Rajinder Kalar Sheila Ann Hides Care Home 39 Category(ies) of Dementia - over 65 years of age (39) registration, with number of places DS0000032191.V366379.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: Norwood Grange is a residential care home for older people. It is registered to provide personal care and accommodation for thirty-nine people over the age of 65 years with dementia. The home is situated in a residential area of Sheffield, near to local shops, a main bus route and the Northern General Hospital. The home is privately owned and is an older stone built property, plus a large extension, with accommodation for service users on two floors. Access to the second floor is via a lift or staircase. The previous inspection report was made available to service users and their families on request. The weekly fees are £368 plus a £17 top up, this information was provided on 1st July 2008. The home charges extra for chiropody, toiletries, clothing, telephone and hairdressing. DS0000032191.V366379.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 that the people who use this service experience good quality outcomes. This was an unannounced key inspection carried out by Stephanie Kenning, regulation inspector. This site visit took place between the hours of 9:30 am and 4:30 pm. The registered manager is Sheila Hides who was present during the site visit. None of the registered providers were present during the site visit. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. Ten people living at the home, nine relatives, and six staff returned the surveys. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home and check the homes policies and procedures. Time was spent observing and interacting with staff and people. Seven staff, six relatives and eight people living in the home were spoken to. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last key inspection in July 2006. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. DS0000032191.V366379.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the previous visit a large extension to the home has been built providing additional single bedrooms with en-suite facilities, additional communal areas, a new office and treatment room. The home has a new emergency call system, and changes to the garden and parking areas. At the previous inspection a number of areas for improvement were required and these have all been met. Medication records were up to date and medication had been signed for when given. Light pull-cords, some furniture DS0000032191.V366379.R01.S.doc Version 5.2 Page 7 and some carpets have been replaced around the home meeting previous requirements. The kitchen had adequate storage facilities, and an Environmental Health visit recently awarded them 4 stars for their service. At least 50 of the staff now have NVQ level 2 or above, and a thorough recruitment process is in place. Staff members have had training in Dementia care in order to improve the care they give to the people in the home. The manager has almost completed her registered Managers Award, but the training provider is no longer operational so she is looking for another one. The Operational Manager for the company visits the home at least monthly and provides a report on the homes progress. 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. DS0000032191.V366379.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 DS0000032191.V366379.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): We looked at outcomes for standards 1, 3, 4 and 5. Intermediate care is not provided at this home. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not move in to the home until a full needs assessment has been undertaken and the home can confirm they can meet the needs of that individual. EVIDENCE: One person living in the home said, ‘‘I am very happy and glad to be here’’. One relative said in survey, ‘‘My mother has a nice, newly decorated and furnished room, finds her bed comfortable, enjoys the meals, likes the staff and looks forward to the meals and snacks which are excellent. I am reassured she is safe and well cared for when I cannot be here’’. DS0000032191.V366379.R01.S.doc Version 5.2 Page 10 The Statement of Purpose had been updated to show people the changes that had taken place to the home such as the extension and the new manager. Relatives said they were given enough information prior to choosing the home. Most said it was the welcoming atmosphere that attracted them to choose this home. They commented that it was always the same on visits and all staff members were pleasant and friendly. They felt that they were kept up to date with changes to their relatives. Most relatives visited before arranging admission, but only some potential residents depending on their circumstances. All had assessments on file from health or social services, and a copy of the homes assessment covering the required areas. The manager stated that she encouraged people to consider several homes before choosing, and that she, and sometimes another member of staff, would assess people at home or in hospital before confirming that they could meet their needs. Sometimes people would spend a few hours at the home so that the staff could check that they could care for people properly and so that the person could see if they liked the home. All people spoken to felt their needs were being met, and that it was a positive move. The home was full, thirty- nine people, all white British, with a small waiting list. People at the home have dementia and the staff members were trained in caring for people with dementia. They were observed to handle people well, returning several times to try to help someone that was refusing to be helped, and using a gentle approach. DS0000032191.V366379.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): We looked at outcomes for standards 7, 8, 9, and 10. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s individual personal and health care needs are met well, staff support them in this, and respect their privacy. Medication systems follow clear guidelines that promote the safety of residents. EVIDENCE: People living in the home said: ‘‘The care is very good’’. ‘‘Norwood Grange is one of the best I’ve been in to’’. Relatives made the following comments: ‘‘ My mothers care is excellent’’. DS0000032191.V366379.R01.S.doc Version 5.2 Page 12 ‘‘This is beginning to feel like home’’. ‘‘The residents are always clean and appropriately dressed’’. ‘‘The care home staff are very friendly people, and they tend to my relative very well’’. ‘‘I think the care and attention to detail is very good’’. ‘‘Is there a better way of sorting out laundry, spectacles and hearing aids? I seem to spend my visits sorting mums things’’. During the visit we noted that people were well presented, and were wearing sunhats when outside, showing that the staff were paying attention to detail. Care was carried out discreetly, removing people from the communal areas, and returning them quietly, showing respect and dignity for the people in their care. The care staff knew about the people in their care, and how to handle different situations. They were observed to reassure people in a kind and friendly manner. A staff member accompanied someone on a visit to the hospital and this was said to be usual practice, unless it was unexpected and would leave the home short staffed, in which case they would try to get their relative to go with them. Another member of staff was attentive to people sat in the communal areas, and stayed in those areas all the time, so that people could get assistance when they needed it. A Chiropodist visited during the morning and saw several people. Afterwards there were comments put in individual files about what he had done or problems noted. It was noted that people tended to use the two downstairs toilets before and after meals causing a queue. This was discussed with the manager who explained that there were more toilets upstairs but people preferred the ones near the communal areas. She suggested that she could assign one person to toilet duties to supervise that area after lunch. The sluice area was an unused bathroom with poor facilities and also used for storage. Staff members need adequate facilities close to their working area in order to promote good hygiene practices and this should be improved. The manager stated that it was due for refurbishment and may be relocated. The care records of three people were examined in detail, all had assessments, care plans and risk assessments on file. The format of the care plans was easy to follow. Care plans asked regarding their preferences for male or female carers, which had been a requirement previously. Some of the information was very good, with specific information about what to do, and some was less clear DS0000032191.V366379.R01.S.doc Version 5.2 Page 13 and could cause confusion for people carrying out the care. For example one person had a care plan on communication that also had standard typed areas that were not applicable. On the risk assessments were good identified risks, but in the precautions section the actions were unclear, for example, requires assistance - did not specify what assistance was needed. Someone who liked a bath twice a week just had ‘hygiene needs met’ recorded each day. Discussed with some staff the importance of details so that they could evidence it had happened. Similar other clarifications needed were found in all three of the care plans checked. It was evident that staff knew what to do, and knew the people living in the home well, by their knowledge when these issues were discussed. The lunchtime medication round was observed, both trolleys side by side in the dining room operated separately. Both senior carers were competent in administering, and signed after each person, ensuring that other people would know what had already been given. This was evidence that they had met another requirement from the previous inspection. The local dispensing pharmacist had visited the previous week to assess their medication storage and had helped them with an order for a controlled drugs cabinet. They were advised to check out CSCI information about medication on the website to ensure they had details of fixings for the cabinet etc. The manager and staff felt that they had good relationships with other professionals. Community nurses visit the home frequently to carry out care and offer support for people who are at risk. GPs visit each week and have been doing 6 monthly reviews on people trying to prevent poor health. One person has antibiotics prescribed for when chesty to reduce severity and prevent hospital admissions. One person was unable to be weighed as they cannot weight bear, and there are no sit on scales. Therefore they do not know how much weight she is losing. The manager explained that they were hoping to buy some scales in the near future. DS0000032191.V366379.R01.S.doc Version 5.2 Page 14 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): We looked at outcomes for standards 12, 13, 14, and 15. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to make choices about their lifestyle and activities, and a good range of activities is provided. People enjoy the meals and the home is developing the range of choices. EVIDENCE: People living in the home said: ‘‘I like the meals a lot. I like my food’’. ‘‘Brilliant meals’’. Relatives made the following comments: ‘‘Welcoming, encourage visits and participation in social activities. Telephone contact is easy and staff responsive’’. DS0000032191.V366379.R01.S.doc Version 5.2 Page 15 ‘‘I don’t think anyone with dementia is living the life that they choose. I think the staff do the best they can to retain some quality of life for their clients’’. ‘‘The meals always look and smell very good’’. ‘‘I think that they should get more from the community. They don’t see enough of what’s going on outside in the world’’. Communal sitting and dining areas are all interlinked and provide separate areas for different activities, but are still open and busy. There were televisions on in 2 areas, with some people watching, but nowhere was very quiet. Mid morning some people sat outside through French doors on to patio, and staff put music on in one sitting area encouraging singing and dancing, that was enjoyed by several people. No dedicated activities person was employed at the home, and although there was a schedule of activities on the board, if people had care needs staff have to give these a priority and therefore the activities may not happen, or not as well as they could. The manager stated that she was hoping to employ someone specifically for activities in the near future. People talked about playing dominoes and crib, hairdressing and nail care, outings to pubs, a trip to Cleethorpes, bingo, entertainers coming to the home. Families felt welcomed and involved on regular visits and at special events. Several people living at the home smoked cigarettes when sat outside, and staff confirmed that there was no designated smoking area inside for cold or wet days. The home needs to be clear about the issue of smoking and either provide adequate separate facilities inside or declare the home is nonsmoking. The home produces a monthly newsletter that gave information such as future events and family group meetings held. A training session on dementia was hosted for families by POPS and proved to be a great success. Visitors said that they are always given a tray of drinks on arrival, and that it made the visit turn into a more sociable event. All 6 relatives spoken to were highly satisfied with care, meals, contact, cleanliness, and staff. There was one issue with laundry not coming back accurately. Discussed with manager and systems are in place to address this, such as asking clothes to have name tapes on and by providing individual baskets for clean clothes to be collected in the laundry. Sometimes they do make mistakes and labels come off if not sewn on. No one person takes responsibility in the laundry as it is in the basement and not a pleasant environment, therefore domestic staff take it in turns to work in there, and care staff help by taking laundry out, and putting more in washers/dryers when domestics have gone home. Meals comments were very positive, and no one seemed to dislike the meals. Special diets of diabetic and soft/pureed were provided for a number of people. Menus were on 4- week rota, chef and manager altering this to the seasons. There were no obvious choices available on the menu, but manager DS0000032191.V366379.R01.S.doc Version 5.2 Page 16 and cook said that they were, for example ham salads, baked potatoes, or omelette. Chef normally uses a whiteboard for the days’ meals, but it had been taken down because it was loose. Staff members ensured that people had a choice by asking them at the point of serving. Assistance was given to some people, sensitively, and not rushed. One person had mashed potato and gravy, but was also on 4 nutritious drinks daily as she eats very poorly, showing that they consider her wishes as well as her health. DS0000032191.V366379.R01.S.doc Version 5.2 Page 17 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): We looked at outcomes for standards 16 and 18. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service, and their relatives, are able to express their concerns, feel that they will be listened to, and action taken. EVIDENCE: People living at the home said: ‘‘I have no complaints, I am enjoying my stay’’. ‘‘Nothing at all to complain about’’. One relative said in a survey, ‘My concerns have always been noted and sorted’’. Three complaints were recorded with none upheld. CSCI had been informed of all of them and full details of the investigations had been sent to us. The complaints procedure is displayed on the wall in the entrance and in the statement of purpose in individual rooms. People stated that manager and staff were approachable and one person discussed the laundry issue with staff during the visit. DS0000032191.V366379.R01.S.doc Version 5.2 Page 18 People living in the home have dementia, and staff were having training in the mental incapacity act and its implications for the people in their care. Training was also happening that week on safeguarding adults, for those who haven’t already had it, so that all staff would know what to do if they suspected abuse or a similar problem. Policies have been reviewed and have tried to streamline them so they are clearer for staff to follow. Referrals to adult safeguarding had been made due to people not paying invoices over a considerable length of time. Home is now an appointee for these people. DS0000032191.V366379.R01.S.doc Version 5.2 Page 19 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): We looked at outcomes for standards 19, 20, 21, and 26. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, well maintained, clean and comfortable home. It is suitable for the specific needs of the people that live there. EVIDENCE: People living in the home said: ‘‘The place is nice and clean and I like my room’’. Relatives made the following comments: ‘‘As the number of residents increases additional communal toilets/ bathrooms are needed for use during the day’’. DS0000032191.V366379.R01.S.doc Version 5.2 Page 20 ‘‘Provides a homely, pleasant atmosphere’’. ‘‘The home is always clean and despite lots of clients being incontinent it always smells fresh’’. The home has had a large extension since the last inspection additional bedrooms increasing the number from 25 to 39 people living at the home. These new rooms were well presented and still well maintained. Older areas have some damage to décor, different to previous requirements that have been addressed, and in particular to both the upstairs and downstairs corridors. Bedrooms were mainly well presented, with some personalisation. Very few people spent time in their bedrooms during the day, most choosing to be in the communal areas. The bathrooms were adequate, but would benefit from some homely touches to put people at their ease. Light pull-cords, some furniture and some carpets have been replaced around the home meeting other previous requirements. The kitchen had adequate storage facilities, and an Environmental Health visit recently awarded them 4 stars for their service. The sluice area was an unused bathroom with poor facilities and also used for storage. Staff members need adequate facilities close to their working area in order to promote good hygiene practices and this should be improved. The manager stated that it was due for refurbishment and may be relocated. There was a patio and garden area to the rear with some planting, and access from the communal sitting rooms. This was enclosed to allow people to walk freely, inside and outside. DS0000032191.V366379.R01.S.doc Version 5.2 Page 21 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): We looked at outcomes for standards 27, 28, 29 and 30. People who use the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are satisfied with the care they receive, and staff members are well trained and competent. EVIDENCE: People living at the home said: ‘‘I would like to say that all the staff are good, and they are friendly’’. ‘‘Staff are helpful and cheerful, and make me feel looked after’’. Relatives made the following comments: ‘‘I have confidence and trust in the staff and management of Norwood Grange’’. ‘‘Senior staff show positive attention, encouraging professional development of new, less experienced staff. Good role models. Sometimes staff shortages put more pressure on remaining staff’’. DS0000032191.V366379.R01.S.doc Version 5.2 Page 22 ‘‘Excellent, caring staff’’. ‘‘When necessary needs and requirements are attended to with diligence and care’’. ‘‘The staff are kind and helpful from the manager to the domestics. This is a specialised job and carers have to be a dedicated lot, and they are!’’ Staff made the following comments: ‘‘We are always striving for new updates and Sheila, the manager, is always ongoing regarding these matters’’. ‘‘They let us know about the needs of the residents and pass on any concerns we may have’’. The manager has improved the recruitment procedures stating that she ensures that at least 2 references are obtained, CRB and POVA checks done, gaps in employment history are explored. The staff files were examined and contained the relevant information including proof of identification. The files also contained Induction and other training records. A training matrix identifies gaps needed by individuals, so the manager is monitoring what each person is attending and can encourage and support. An in-house trainer is doing regular sessions so people can catch up when they’ve missed something. Access to POPS training was said to be good, and covers a wide range of relevant topics in care. They were doing training on the mental capacity act and safeguarding adults during the week of the visit. Other recent training included dementia, falls prevention and risk assessments. They now meet the standard for training with 50 of care staff trained to NVQ level 2 or above, and more people in training. Staff members were observed to be kind, handled people well, even in difficult and repetitive situations, were discreet and knowledgeable. People were very fond of them and praised them a lot, including relatives. One relative said the staff are still overworked and underpaid for the excellent job they do. The staff team said they were more settled and happy in their work. They like the manager and feel she is supportive and encouraging. DS0000032191.V366379.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): We looked at outcomes for standards 31, 33, 35, 36, 37 and 38. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home have implemented changes and systems to improve the lives of people living in the home. EVIDENCE: Staff members said: ‘‘She is always there if we need time to chat regarding work or personal’’. ‘‘ We have a good home here and a really good manager who is conscientious regarding training and standards’’. DS0000032191.V366379.R01.S.doc Version 5.2 Page 24 The manager Sheila Hides has many years experience working with older people and has almost completed the Registered Managers Award. Everyone at the home held her in high regard, and people said that she was approachable and supportive. She was observed giving clear direction to staff in a friendly and supportive way and demonstrated her knowledge of health and safety issues. At the time of the visit the manager was spending some of her time at another home in the absence of their manager, and this was said to be a temporary measure as it is not possible for one person to manage two homes. The Operational Manager does a monthly visit, meeting CSCI requirements, and audits a selection of care plans, medication, and other records when she visits. She also talks to people and looks around the home, so that she can check that things are as they should be. The Home Manager also does audits on care plans and addresses issues as she finds them. A different member of staff every 3 months does an audit looking at all aspects of the home. This helps staff to be familiar with the standards they should be meeting. Family meetings are held to discuss any issues that might be concerning people, and surveys are sent every 6 months with invoices. Responses are collated and action taken to address any issues raised. A good system was in place for looking after the monies of people in the home, with records, two signatures, receipts and monies in separate wallets in a safe. For five people the home is appointed to look after all their financial arrangements, and do this by having individual bank accounts for them. Despite some problems with income for fees, the manager stated that this had not caused the home to be unable to pay its bills, but had meant that some new equipment purchases had been postponed. This situation was in the hands of the Local Authority Safeguarding Team in line with their procedures. Staff supervisions are planned and recorded, they aim for 6 each year, and this was sometimes achieved in addition to appraisals/ staff development meetings with individuals. The home has a comprehensive range of policies and procedures to promote and protect peoples’ safety. Checks and maintenance on equipment were recorded, and accidents were recorded. DS0000032191.V366379.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 3 X 3 3 3 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 3 3 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 DS0000032191.V366379.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. 2. 3. Refer to Standard OP7 OP8 OP12 Good Practice Recommendations Record actions required and care given more accurately in care plans. Provide weight scales for frail people at risk that are unable to stand on scales. Activities to be provided by a dedicated person to ensure that they are given a priority, and by someone with specialist knowledge and skills specific to dementia for the people living in the home. An indoor smoking area must be provided for people living in the home that choose to smoke, if smoking is allowed. Redecoration of the corridors both up and down stairs to address the damage to paintwork, etc. Adequate, and hygienic facilities for sluicing must be provided. 4. 5. 6. OP14 OP19 OP21 DS0000032191.V366379.R01.S.doc Version 5.2 Page 27 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 DS0000032191.V366379.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!