Care Home: Saville Manor Nursing Home

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What the care home does well The home is very well run by Mrs John who is very well supported by senior managers. Mrs John has a really good knowledge and overview of the home and of the needs of the residents and how to make sure their needs are well met.Staff treat residents in a kind and considerate way when supporting them to meet their needs. Staff also work very hard to makes sure residents needs are well met. Residents` meals are of a good variety and quality. Meals are nutritionally well balanced and well presented. Residents take part in a range of social and therapeutic activities. This helps residents to enjoy a good quality of life. The environment is highly suitable for residents and is decorated to a very good standard that further enhances the home. Staff do a really good range of training that is relevant to the needs of the residents. What has improved since the last inspection? The resuscitation policy has been reviewed and updated. This relates to the need to reflect the mental capacity of residents to make an informed choice about end of life decisions. What the care home could do better: For the protection of residents ensure there are two written references in place for all new staff who start work in the home. To ensure that all medicines are given appropriately staff should make sure that clear written guidance is available for staff on the use of medicines prescribed to be given "when required". The quality of handwritten additions to the medicines administration record sheets needs to be improved to reduce the risk of any mistakes being made with medicines. CARE HOMES FOR OLDER PEOPLE Saville Manor Nursing Home Saville Road Sneyd Park Bristol BS9 1JA Lead Inspector Melanie Edwards Unannounced Inspection 14th January 2009 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 Saville Manor Nursing Home DS0000072386.V373791.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. Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saville Manor Nursing Home Address Saville Road Sneyd Park Bristol BS9 1JA 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) 0117 9687412 SavilleManor@cedarcarehomes.com Cedar Care Homes Limited Mrs Reni Poonchal John Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 42. New Service Date of last inspection Brief Description of the Service: Saville Manor is located in a residential area in the centre of Bristol. It is close to local amenities and the Downs. The house is a converted older property that has lift access to each floor. The home is registered to provide nursing care for up to forty two residents There are a range of single and bedrooms that have en suite facilities. There is a dining room and two spacious lounges. Fees range from around £600 per week. Saville Manor Nursing Home DS0000072386.V373791.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 3 stars. This means the people who use this service experience excellent quality outcomes. We met eighteen of the thirty-three residents living at the home. We also met a number of visitors. We sampled lunch and observed the staff serving residents their meals. We met Mrs John the registered manager. We also met two registered nurses three care assistants and the activities co-ordinator. We discussed with them their roles and responsibilities, their training needs and how they assist and support residents. We observed residents being assisted with their needs by staff. We read a selection of records relating to the day-to-day running and management of the home. We read three residents assessment records and care plans. We saw the majority of the environment. The only areas that we did not see were a small number of bedrooms. The ‘AQAA’ (an annual quality assessment document that all services are required to complete) has been used to help form the judgments in the report. The pharmacist inspector looked at handling of medication in the home on 19th January 2009. We found the home was operating within the required conditions of registration set down by us. The conditions of registration set out the type of care and the needs of residents as well as the numbers of residents who may stay at the home. What the service does well: The home is very well run by Mrs John who is very well supported by senior managers. Mrs John has a really good knowledge and overview of the home and of the needs of the residents and how to make sure their needs are well met. Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 6 Staff treat residents in a kind and considerate way when supporting them to meet their needs. Staff also work very hard to makes sure residents needs are well met. Residents’ meals are of a good variety and quality. Meals are nutritionally well balanced and well presented. Residents take part in a range of social and therapeutic activities. This helps residents to enjoy a good quality of life. The environment is highly suitable for residents and is decorated to a very good standard that further enhances the home. Staff do a really good range of training that is relevant to the needs of the residents. 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. Saville Manor Nursing Home DS0000072386.V373791.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 Saville Manor Nursing Home DS0000072386.V373791.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): 1,3,6.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ assessed needs are well met. Residents and their representatives have the information they need to make an informed choice about the home. The home does not provide intermediate care for residents. EVIDENCE: Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 9 We read a copy of the service users guide (known as the residents manual) and the statement of purpose to see what sort of information there is for people to find out about the home. Each resident is given their own copy of the guide so they have access to helpful information about life in the home. There are colour photographs of the home and of staff and residents together, to show what daily life is like at the home. The guide includes information about the service provided, the qualifications of the staff employed and the accommodation. The philosophy of the home and how the service aim to meet residents needs is included. The complaints procedure is in the document so residents know how to complain if they need to. In the ‘AQAA’ document the home tell us that they:‘ send a detailed brochure to the prospective client explaining what service we can provide at Saville Manor. We then invite the prospective client to the home for a viewing and explain to them further the service and facilities that we can provide for them. We do this alongside a in-depth viewing checklist to ensure that we have given the client all the necessary details. They also get a chance to view our statement of purpose and previous inspection reports. We also invite the perspective residents themselves to view the home so they can inspect the home for themselves and help them make a decision ’. These are really good ways for prospective residents to find out about the home and if it is what they are looking for’. There were a significant number of comments of high satisfaction expressed by residents about the care they receive and how they feel their needs are being met. One resident said, `they look after me very well’, another comment made was, `the staff come when I need them ’ and ‘the staff are very good they are kind and come when you want them to ’. We read three residents assessment records (we chose three residents who had been recently admitted to the home), to find out how well residents’ needs are assessed. The assessment records were informative and showed the residents had been consulted with about their range of physical, mental and social needs. We saw detailed information that showed us that registered nurses are reviewing in good detail residents’ range of needs to show if the home can still meet them. The assessment records also linked clearly to each resident’s care plans, and showed a detailed assessment of the persons needs had been carried out. The care plans had been written based on the information in the initial assessments. Residents are not provided with intermediate care at the home. Saville Manor Nursing Home DS0000072386.V373791.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): 7,8,9,10.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are well met and care plans demonstrate how they are met. Procedures are in place for the safe administration of medicines. However residents’ health could be better protected if there were clear care plans available for some medicines prescribed to be given when required. Residents are treated with respect and their privacy is maintained. EVIDENCE: We read three resident’s care plans, to see how people are supported to meet their personal care and nursing needs. The care plans were informative and detailed how to meet the care needs of the person. The care plans stated what actions staff must follow to assist the resident to meet their needs. Included with each care plan was good evidence that residents have been consulted with, to find out what their needs are. There was also a range of Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 11 helpful information about the life history of each person and what matters to them, including important family and friends. We saw that care plans had been reviewed and updated in really good detail regularly. This demonstrates residents’ needs are being monitored and kept under review. The home tell us in the ‘AQAA’ document that they do the following to ensure that race, gender identity, disability, sexual orientation, age, religion and belief are promoted and incorporated into what we do: ‘Care plans are formulated through consultation with residents and relatives to ensure that they take into consideration residents race, gender identity, disability, sexual orientation, age, religion and belief. Residents’ cultural choices and preferences are recorded at the point of admission and incorporated into their daily care. Admissions, care plans and leisure and social activities are regularly monitored to address any shortfalls in provision’. There was supporting information in the care plans that demonstrated residents are well supported with their physical health care needs by the GP, the dentist, and the chiropodist. We saw all of the staff on duty assisted residents in a very polite and respectful manner. This was noticeable throughout the inspection. The staff assisted residents with their needs in a very courteous way. Residents are registered with a number of different doctors practices. Staff request repeat prescriptions and check them before sending them to a pharmacy in London to be dispensed. Prescriptions written at other times are dispensed by a local pharmacy. Suitable storage is available for medication and action has been taken to make sure that suitable supplies are kept and that storage temperatures are safe for medicines. Additional secure storage is available for medicines that need this. Records showed that these medicines had been looked after safely. Systems are in place to make sure that staff can check the medicines kept to make sure that they have been given correctly. At the time of the inspection only one person looks after any of his or her own medicines. This person told us that they were happy with the way that their medicines were looked after. Some improvement is needed to the care plan concerning self-medication because this had not been updated to reflect the current situation. It is important that care plans are accurate to ensure that all staff are clear how medicines should be given. We watched staff give out medicines at lunchtime using a safe procedure and signing the medicines administration record when the medicines were given. The medicines were given after lunch had been finished so that residents lunch was not interrupted. Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 12 The pharmacy provides printed medicines administration record (mar) sheets for the home, which staff complete when they give the medicines. There were a number of handwritten additions to these records because the pharmacy only includes the medicines that have been supplied that month on the printed sheet. This could mean that medicines used when required, that may not be ordered every month, could be missed off the record sheet. Resulting in people not being offered their prescribed medicines. We also saw that the standard of some handwritten entries, added by nursing staff, was poor. Some of the entries had not been signed or dated and had not been checked by a second member of staff. This can increase the risk of mistakes being made leading to medicines being given wrongly. It is recommended that staff discuss with their pharmacist how the need for handwritten entries on the record sheet can be minimised to reduce this risk. We looked at care records for two people prescribed medicines to be taken when required each with a variable dose. Neither had care plans in place for the use of the medicine explaining when the medicine should be given or how staff would know how much to give. For one of the medicines with a variable dose, staff had not recorded the dose they had given each morning. Nursing staff we spoke to told us why they would use the medicines. However, if there is no care plan in place there is a danger that different nurses may give the medicines in different circumstances, leading to inconsistent care. Action should be taken to address this. Saville Manor Nursing Home DS0000072386.V373791.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. Residents can do a variety of social and therapeutic activities that are suitable for their needs. Residents are supported to receive visits from family and friends. Residents are provided with a nutritious well-cooked diet. EVIDENCE: In the ‘AQAA’ the home have written about some really good examples of ways that residents can live a full and varied life, as well as how residents dietary needs are well met:‘ A Personal Preference form is completed at admission which includes preferences for waking time, bed time, social preferences, mealtimes, bathing/washing and beverages. An activities plan has been developed in response to Residents preferences. We also published a Newsletter for all the activities that have taken place. We also take loads of pictures of events and general activities so that residents can look back and remember the events. Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 14 Communion services are held monthly. We operate an open visiting hours policy, Relatives are welcomed to join the Resident for a meal, if they wish. The Residents Handbook details the arrangements for maintaining relatives and friends involvement. A few residents have control of their personal pocket money it is either kept with the administrator where residents can request it at any time or the resident themselves keep hold of it. Residents are actively encouraged to personalise their rooms. They are given access to their room 2 or 3 days prior to admission to facilitate this. Policy for access to personal records is implemented, Residents are given information about this in the Residents Handbook. We offer a cooked breakfast, two choices for lunch and hot supper. Hot and cold beverages are provided throughout the day along with a choice of Biscuits, cakes and fresh fruit ’. Residents are well supported to take part in a good range of social activities. There is an activities co-ordinator who works for five days a week and puts on a range of activities for residents. Each resident is given a copy of the timetable of social activities planned to take place. This helps to ensure residents are aware of current activities taking place. Activities that are planned for the near further include, drives, arts and crafts sessions, games, musical afternoons, and gentle exercise classes. We saw art works that residents had made on display in the home. We noticed that there is a library with a range of big print books for residents to read. We saw the activities co-ordinator engaging residents in a range of different social activities. We also saw the daily discussion group taking place and residents looked to be very involved in this daily discussion of topical events. We ate a portion of the lunchtime meal this was a choice of roast lamb with potatoes and cooked vegetables, or quiche lorraine with the same vegetables followed by home made deserts. The meal tasted satisfactory and was nourishing and well presented. We looked at the residents’ food menus to see if they are offered a varied and healthy diet. We saw that meal options are nutritionally well balanced and varied. There are choices available each day. We saw some staff show residents the choice of meal on a plate in front of them. We could also see from the menus and from information we read in care plans that residents’ special diets are well catered for. There are a variety of special meals provided for residents who need them. Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18.Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home deals with complaints extremely well and responds to them promptly and takes them very seriously. Residents are satisfactorily protected from abuse. EVIDENCE: We saw in residents care records detailed written evidence that showed us that Mrs John meets with residents relatives and significant others on a regular basis. She spends time listening to any concerns or complaints that people may have. We also saw detailed evidence of how she addresses the concerns thoroughly and robustly. Mrs John also told us that she takes this part of her role really seriously and always makes as much time as she can for residents and their representatives. Residents and visitors told us that they see Mrs John daily and she walks around the home to see them. Residents said they could speak to her or to any of the staff about any concerns they may have. We saw Mrs. John spending time with residents and visitors during the inspection. We checked the complaints records and we found that there had been three complaints .We saw written evidence that showed us that the home addressed the complaints and investigated them thoroughly. Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 16 All residents and people who may represent them are given their own copy of the homes complaints procedure. This helps to make sure residents have the information they need to make a complaint. The complaints procedure includes our up to date contact information if a person wants to contact us directly. In the ‘AQAA’ document the home have written about how complaints are dealt with ‘ The Complaints Procedure complies with the specifications of this standard. It is displayed in the entrance hall and is included in the Residents Handbook. It is also explained during the viewing and admission. We are required to inform Senior Management of any complaints received. The Company takes an active interest in the positive resolution of complaints’. We saw a copy of the homes policy relating to the issue of protection of vulnerable adults from abuse. The policy is to help to guide staff to take the correct course of action if they ever have to respond to an allegation of abuse The staff we met told us they have done training courses in understanding the principle of the protection of vulnerable adults from abuse. We also saw evidence in training records that demonstrated staff had done recent training on understanding how to ‘safeguard’ residents from harm. Saville Manor Nursing Home DS0000072386.V373791.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): 19,20,24,25,26.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is safe well maintained and suitable for their needs. EVIDENCE: Saville Manor is a spacious building, built over four floors, which can be accessed by stairs or lift. The building is over three hundred years old is situated in the city of Bristol .The home is situated on the Downs area of Bristol, this is a large suburban park area. We found the environment was clean at the time of our visit. Visitors told us that a good standard of cleanliness is always maintained. We saw soap and hand-towels available in the toilets and bathrooms this helps minimise the risks of cross infection in the home. Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 18 We checked most of the bedrooms and all the communal living areas .We found the rooms to be decorated in light neutral colours that looked homely in design. We saw that the environment was clean, tidy and satisfactorily maintained in all of the areas we looked at. We saw that bedrooms have been made to look more personal and homely with residents photographs, mementos and items of furniture. When we asked a number of residents they said they liked the environment and setting of the home. There is a spacious lounge leading to the dining room. There is also a quiet lounge and a seating area in the entrance to the home. We saw residents sitting in communal rooms and looking relaxed and comfortable in the surroundings. We saw up to date specialist equipment and adaptations in place throughout the home, to help people who may have reduced mobility. Saville Manor Nursing Home DS0000072386.V373791.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 good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by enough competent trained staff. Overall recruitment procedures are safe and protect residents EVIDENCE: We checked the number of staff on duty to find out if there is enough staff to meet residents’ needs. We saw that there are two registered nurses and a minimum of six care staff on duty in the morning. There are two registered nurses and six care staff in the afternoon. At night there is one registered nurse and three care staff on duty. There is also a lounge assistant who works in the home most days to spend one to one time with residents and to offer them drinks and snacks. There are domestic staff on duty every day, a cook and a kitchen assistant and a full time maintenance person. The home also have a full time administrator. Mrs John works full time and works a range of different hours, to fit in with the needs of the residents. We observed staff assisting residents with their care needs in a courteous and patient manner. Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 20 We checked the training records of the staff team to see if staff are keeping up to date in their knowledge of the needs of residents. There was good evidence that staff had attended training sessions and updating over the last twelve months. The company employ their own national vocational qualifications trainer who supports and helps train care staff to achieve this qualification. Many of the care staff has either completed National Vocational Qualification in care awards to Level 2 or Level 3. This is good evidence that demonstrates a commitment by the care staff to developing the skills that they have. We checked the staff recruitment records of three staff to see if the home carry out the required employment safety checks on staff before they start work. We saw two written references taken up for new staff before they start work as well as criminal records bureau disclosures checks and protection of vulnerable adult (POVA) first checks. This demonstrates residents are protected by the homes recruitment procedures. One very newly recruited lounge assistant was being supervised by the activities co-ordinator as this was their second day .We noticed in the file that references had not come through We advised that the person could not work directly in the home with residents until two satisfactory references had been obtained. After the visit to the home this information has been sent to our area office about the new member of staff. Saville Manor Nursing Home DS0000072386.V373791.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): 31,33,35,38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from the management and leadership in the home. The health and safety of residents and staff is protected. EVIDENCE: Mrs Reni John has been the registered manager of the home since August 2008. Before this she was the registered manager of another home that is owned by Cedar Care Limited from 2007 until she moved to Saville Manor. Mrs John has over twelve years experience as a first level registered nurse. A senior operations manager supports Mrs John in her role. Mrs John says she receives regular support from them. She is also supported by a national vocational qualification trainer who works for the company as we have already Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 22 mentioned. There is also now a health and safety manager who has been recruited to support the registered managers maintain health and safety standards in all the homes run by Cedar care. Mrs John completed a very detailed and informative ‘AQAA’, the annual quality assurance assessment tool that we send out to all homes. We saw written evidence that showed there are regular staff meetings held so that the team have additional opportunities to make their views known. We saw copies of recent audits that are done in the home. We looked at a copy of the recent audit tool. We could see that Mrs John and the team have recently reviewed and audited the care and the service. The home does take responsibility for looking after some residents finances We checked three residents finance records. We saw receipts for items bought and two signatures for money taken out .The records were up to date and correct.We also noticed that where posible residents themselves sign for their money .This is a good way for people to keep some control in their lives. We found that residents’ records were satisfactorily maintained, up to date, legible and in order. The records relating to the management of the home were also satisfactorily maintained up to date and in order. Individual records and the home’s records were kept secure in the home and are available to staff when needed. We have referred to other records elsewhere in the report. Mrs John wrote in the ‘AQAA’ document about how health and safety is maintained in the home : ‘The Company appointed a Health and Safety consultant who conducts work and equipment risk assessments to develop written Safe Working Practices. The Safe working practices are part of mandatory induction and refresher training. Annual Health and Safety audits are conducted in the following areas: Building, Residents and Management of Health and Safety. Equipment and Services are inspected as required and corrective action taken where necessary. All staff receive comprehensive health and safety training during induction and on a 6 monthly basis thereafter ’. We found the environment looked satisfactorily maintained throughout. The health and safety manager has been supporting the home to do regular health and safety audits of the whole environment, equipment and furniture. A sample of recent health and safety audits were looked at. These were detailed and aimed to address health and safety areas throughout the home. The kitchen was clean and tidy and in good order. All kitchen staff do regular food hygiene training to ensure they have a good understanding of safe Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 23 practises for preparing and cooking food. All staff do regular health and safety training in range of areas including food hygiene, fire safety, and infection control. This helps ensure staff maintain a good understanding of health and safety principals and practises. Saville Manor Nursing Home DS0000072386.V373791.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 3 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 4 17 X 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 4 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X 3 4 Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation Schedule2 .5 Requirement There must be two written references in place for all new staff who start work in the home. Timescale for action 15/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Saville Manor Nursing Home DS0000072386.V373791.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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