Care Home: Sedbury Park Care Centre

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What the care home does well A stimulating and variable programme of activities is provided for all residents. Visitors are welcomed to the home and encouraged to exchange information about residents` needs and attend meetings in the home. Good individual attention is given by staff to residents in the Marlings unit when needed. The home has obtained information and staff have received training in the Mental Capacity Act 2005. The home has the facilities to offer residents a variety of communal areas both inside and outside of the home. The home has a well organised laundry where a hygienic environment can be maintained. What has improved since the last inspection? A more robust audit of care plans has been taking place as well as training with care plans and record keeping improving as a result. There have been improvements to the environment of the home with repairs to the roof and the refurbishment of rooms in Wye House and the Main House. Treatments given to residents such as chiropody are now carried out in private not in communal areas. More information is now available in the home about how to contact representatives of various Christian denominations or other religions should this information be needed by residents. Information from the local authority about protecting vulnerable adults is now more easily available to staff. Recruitment practices and the records kept regarding these have been improved. More staff working in the Marlings have completed dementia training. Residents records are now stored securely in all units of the home. The way residents` money is looked after by the home has changed with some residents now able to earn interest on the money. What the care home could do better: The home should insist on receiving written information from funding authorities relating to a resident`s needs prior to admission to the home. Care staff in the Wye House must make an accurate record of all medication given or not given for any reason and need to pay attention with this to creams and ointments. Handwritten directions or entries made on medication administration charts should be checked and signed. Where records are kept of meals provided for residents these should be accurately dated. CARE HOMES FOR OLDER PEOPLE Sedbury Park Care Centre Sedbury Park Sedbury Chepstow Monmouthshire NP16 7EY Lead Inspector Mr Adam Parker Key Unannounced Inspection 07:55 1st & 3rd July 2008 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 DS0000016574.V362123.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. DS0000016574.V362123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sedbury Park Care Centre Address Sedbury Park Sedbury Chepstow Monmouthshire NP16 7EY 01291 627127 01291 622327 sedbury.park@ashbourne-homes.co.uk 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) Ashbourne Homes Ltd ****Post Vacant**** Care Home 105 Category(ies) of Dementia - over 65 years of age (23), Learning registration, with number disability over 65 years of age (5), Old age, not of places falling within any other category (82) DS0000016574.V362123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate 3 Named Service Users with Learning difficulties under 65 years of age 4th July 2007 Date of last inspection Brief Description of the Service: Sedbury Park Care Centre is a large Georgian house that stands in its own grounds overlooking the Severn estuary. The care centre consists of three units: the Main House providing nursing care for older people, Wye House providing personal care for older people and The Marlings unit for older people with dementia. Although the home is registered for 105 beds in total, only 83 beds are operational, as the Company aims to offer single room accommodation only, unless a couple express the wish to share. All rooms offer en suite facilities and there are assisted bathrooms and toilets on all levels. The main catering and laundry facilities are located in Main House. Both Wye and Main House have shaft lifts and there are spacious lounges, a library, a ballroom and activities area (for the use of all the homes residents) and a dining room in Main and a lounge/diner and smaller lounge in Wye. The Marlings has two stair lifts, a lounge and dining area. There are extensive grounds around the home, which the more ambulant service users can access and some paths for wheelchair users. There is a sheltered courtyard and sitting area in the Main House and enclosed gardens for the residents in the Marlings and Wye House. Information relating to the home is on display in the main entrance, this includes copies of the homes Statement of Purpose and Service Users Guide and results of a recent quality assurance questionnaire. The fees for the home range from £447.35 at the lowest local authority level to the highest privately funded nursing fee at to £650 per week. Extras that are not included in the fees are hairdressing, chiropody, magazines and newspapers and toiletries. DS0000016574.V362123.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection visit was carried out by one inspector over two days in July 2008. The manager of the home was present for the two days of the inspection visit that consisted of a tour of the premises and examination of residents’ care files. In addition staff recruitment and training was looked at as well as documents relating to the management and safe running of the home. A sample of residents were selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. Observation was made of the care and supervision of the residents in some communal areas. Survey forms were received from residents’ relatives, staff working in the home and General Practitioners (GP). Five residents were spoken to during the inspection visit as well as two visitors. We requested an Annual Quality Assurance Assessment (AQAA) from the home, which was provided. Although this was brief in content, it gave us the information we asked for. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: A stimulating and variable programme of activities is provided for all residents. Visitors are welcomed to the home and encouraged to exchange information about residents’ needs and attend meetings in the home. Good individual attention is given by staff to residents in the Marlings unit when needed. The home has obtained information and staff have received training in the Mental Capacity Act 2005. The home has the facilities to offer residents a variety of communal areas both inside and outside of the home. The home has a well organised laundry where a hygienic environment can be maintained. DS0000016574.V362123.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. DS0000016574.V362123.R01.S.doc Version 5.2 Page 7 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. DS0000016574.V362123.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 DS0000016574.V362123.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s admission procedure generally ensures that all residents are admitted to the home on the basis of a full assessment of their needs so that they can receive the care that they require. However written information from funding authorities has still not always been obtained prior to admission. EVIDENCE: All Units. Assessment documentation for a number of residents was looked at and a discussion was held with the manager. A comprehensive pre admission assessment had been completed by the home as well as a pre admission draft care plan. Where residents had been admitted from hospital either with physical or mental health needs then information had been obtained from this source. At the previous inspection a recommendation was made that the home should insist on receiving written care plans from funding authorities. The DS0000016574.V362123.R01.S.doc Version 5.2 Page 10 manager confirmed that this was the position although with some residents it was still evident that this was not the case. Particular problems were identified with the local authority from South Wales not providing information but examination of documents relating to one resident funded by Gloucestershire County Council showed that the care plan had not been provided to the home. The supply of pre admission information from funding authorities still appeared to vary depending on the social worker allocated to the resident. The manager stated that she would follow these issues up and was planning to meet with the Welsh local authority social work manager. The home does not provide intermediate care and so Standard 6 does not apply. DS0000016574.V362123.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. Although there has been an improvement in care planning, some further work still needs to be done around medication administration recording particularly in one unit. However residents’ health needs are being met and their privacy and dignity is promoted. EVIDENCE: All Units Following initial assessment care plans were drawn up for resident’s needs. The majority of these were detailed and specific to the individual although a small number of those looked at in the Main House and Wye House were brief in their content. Care plans had generally been reviewed on a monthly basis and in two units care plan audits had been taking place. In Wye House and in the Main House residents had been invited to read and sign their care plans which some had done. DS0000016574.V362123.R01.S.doc Version 5.2 Page 12 Records had been kept of personal care given although one example in Wye House was undated. There were also records of contact with health and social care professionals and hospital appointments. Resident’s weights and wounds or bruises had been recorded in detail both in writing and on body map charts. Risk assessments had relating to pressure area care, nutrition, falls and for specific issues such as wandering. Staff were observed treating residents with respect and up-holding their privacy. Since the previous inspection treatments for residents such as chiropody are now carried out in private not in communal areas. Main House Medication in this unit was stored securely with storage temperatures monitored and recorded and liquid medication dated on opening as an indication of the expiry date. The medication administration record (MAR) charts were in good order and hand written entries had on the whole been made with a second member of staff signing to indicate that they had checked the entry. It was noted that despite a recommendation at the previous inspection about reviewing individual protocols for medication, this had not been done with some protocols in place that referred to medication no longer prescribed. However following discussion with the manager this was completed before the end of the inspection visit and up to date protocols were drawn up. Wye House Storage in this unit was again secure with temperature monitoring in place. Examination of the MAR charts showed that the administration of topical creams and ointments for some residents had not been recorded consistently either on the MAR chart or on separate recording charts. It was doubtful if residents had received their prescribed medication as directed. In addition there was a lack of directions on the MAR charts for some topical creams and ointments some directions stated, “As directed” and others had no directions at all. Directions for the administration of these medications should be confirmed with the supplying pharmacist and if necessary the GP. Some handwritten directions and handwritten entries on MAR charts where medication had been stopped had only one staff signature. These should also be dated and checked and signed by another member of staff. The Marlings Storage in this unit was secure and bottles of liquid medication were dated on opening as an indication of the expiry date. Following a recommendation at the previous inspection a review had taken place of the homely remedy list in use in the unit. However this had not resulted in an actual list of remedies approved by the GP. This was discussed with the registered manger who was planning to look into this. DS0000016574.V362123.R01.S.doc Version 5.2 Page 13 Where changes to medication directions or doses had been altered on the MAR charts these could be traced back to a documented discussion with a GP or other health care professional. Hand written entries on the MAR charts had on the whole been made with a second member of staff signing to indicate that they had checked the entry. Staff with responsibility for administering medication had received appropriate training. DS0000016574.V362123.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): 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. The home takes an active role in encouraging resident’s contact with family, friends and parts of the local community. This in conjunction with a varied activities programme provides a good degree of social contact. In addition residents receive a choice of varied and nutritious meals. EVIDENCE: All Units. The home employs 2 activities coordinators and there are plans to recruit a third. Activities are now planned and provided for residents on a unit basis. Examples of activities provided in the home are bingo, musical movement, quizzes, crafts and baking. A mobile shop gives residents the chance to buy a number of items and profits are used towards bingo prizes. Residents who do not take part in group activities receive visits in their rooms and individual work has been carried out on compiling life histories. Activities outside of the home are also organised with links being made and maintained with the local community. Trips out often make use of ‘Dial a Ride’ transport and visits have DS0000016574.V362123.R01.S.doc Version 5.2 Page 15 been made to a local church for coffee mornings and to various garden centres. Residents in Wye House and the Main House gave examples of trips out of the home that he had recently been on. Activities schedules were displayed in the units giving information about the week’s activities. At weekends when activities coordinators are not working boxes containing various activities are distributed to the units. The activities coordinator had completed a training course in ‘Provision of Activities in a Care Setting.’ Another activities coordinator is planning to attend a course in providing activities for people with dementia. The Church of England holds a service in the home once a month and the home now has information on local contacts with other Christian denominations or other religions should this be needed by residents. At Christmas local schools have visited the home to perform Carols. On a survey form a relative of a resident commented positively on the social activities provided in the home and the trips out. There is a policy of open visiting in the home. Meetings are held with residents and relatives, and a weekly surgery is held where relatives can consult the manager about the care of residents. A notice about the weekly surgeries was displayed in the entrance of the home. One relative commented positively on a survey form on how meals were provided for another visitor who had to travel a long distance to the home. A relatives communication record was in use in the home to provide two-way communication regarding any issues about the care of individual residents. On a survey form a relative of a resident commented “ they also care about the relatives.” Evidence was seen of service users bringing their own personal possessions into the home including items of furniture. The home has information on advocacy services for residents. The home had recently introduced a new menu planning system called the ‘Nutmeg’. This is designed to provide a balanced diet for residents as well as a choice. Records of meals provided had been kept where residents had been given alternative meals or there were concerns about nutrition. Some of these records were undated though and this should be improved to ensure there is an accurate record of meals provided. The service of lunch was observed in Wye House. Staff served the meal wearing blue tabards over their uniforms and it was noted that meals served to individual rooms were covered to keep them warm. Tables were attractively laid with drinks available. In Marlings staff were serving food wearing blue protective aprons. Due to the memory difficulties of residents in this unit choices are checked immediately before meals are served and it was reported that on occasions showing a resident two dishes is a useful aid to assisting with choice. One resident in Main House described the meals provided as “very good” and another stated that the food was “first class”. In Wye House the menu for the DS0000016574.V362123.R01.S.doc Version 5.2 Page 16 day was displayed on a notice board, one resident spoken to pointed this out and was impressed with the meals provided and the fact that choices were available. The arrangements for food preparation in the home had recently been inspected by the environmental health department of the local authority with four stars awarded out of a possible five for the standards of food preparation and cleanliness. On a survey form a relative of a resident commented positively on the preparation and variety of food. DS0000016574.V362123.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): 16,17 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available if any resident or their representative should wish to make a complaint and despite an incident in 2007 the home’s approach to training staff should ensure that residents are protected from abuse and their legal rights are upheld. EVIDENCE: All Units. The home has a register for recording complaints; four had been documented since the last full inspection although none had been received since April 2008. The procedure for complaints is that on receipt, a letter is sent and following investigation a response is given within 28 days. The complaints procedure was displayed in the each unit, although as at the previous inspection the information in Wye unit was out of date. This was remedied by the manager during the inspection visit. In relation to resident’s legal rights, the home has information on the Mental Capacity Act 2005 available on all units and training has been provided for staff on the Marlings unit where residents have dementia. The manager confirmed that the home has information on how to contact Independent Mental Capacity Advocates should the need arise. DS0000016574.V362123.R01.S.doc Version 5.2 Page 18 The home has a policy for protecting residents from abuse as well as a ‘whistle blowing’ policy. Training in protecting residents from abuse has been given to the majority of staff. In addition training is also provided in dealing with challenging behaviour. New staff are given a pack to read about protecting residents from abuse or are given training when they start working in the home. The registered manager was aware of local authority adult protection and information from the Gloucestershire County Council in the form of their ‘Alerter’s Guide’ was displayed in each unit. In November 2007 an incident took place in the home that was reported to the Commission and to other agencies regarding the handling of a resident’s challenging behaviour by a member of care staff. Unfortunately the incident was not reported immediately to the registered provider by staff. Following an investigation by the registered provider actions were taken in respect of the staff involved. The importance of reporting incidents was also communicated to staff. We are satisfied that a thorough investigation was carried out with appropriate follow up action taken. A group of staff spoken to during the inspection visit were able to recount what they had learned in training about protecting residents from abuse and about the ‘whistleblowing’ policy. DS0000016574.V362123.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): 19,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Maintenance work and refurbishment have been carried out to provide residents with a safe and generally clean environment suitable for their needs. EVIDENCE: Main House. The home is set in extensive grounds with outside areas available to residents and their visitors when weather permits. These include covered balconies around the side and front of the main house and a large lawn leading down to a pond where furniture could be provided for residents to take tea. A paved area between the main house and the Marlings unit was not in use until work had been carried out on uneven paving slabs. Inside the grand surroundings of the Main House there are a number of large communal rooms including a DS0000016574.V362123.R01.S.doc Version 5.2 Page 20 television lounge, a library, a function room and a dining room. At the time of the inspection communal areas were clean and tidy. The Main House was generally well maintained and it was reported by the manager that repairs had been made to the roof. At the previous inspection it was noted that a number of areas had been water damaged and remedial work either had been carried out or was in the process of being done. A small number of minor maintenance issues were pointed out to the manager during the inspection and some of these attended to before the inspection ended. The laundry was spacious, well ordered and clean with hand washing facilities available and easily accessible for staff. Wall and floor surfaces were washable providing a hygienic environment. The laundry is also used by the house keeper who undertakes various checks on such things as first aid boxes and cleaning materials. The Marlings. The unit was generally clean and well maintained although there were some odours in corridors on both floors. These were discussed with the manager and plans had already been made for the replacement of flooring in the effected areas. Residents’ individual rooms contained personal items. Extractor fans in ensuite facilities were being serviced during the inspection visit. Since the previous inspection work had been completed on painting bedroom doors in bright colours and these had their own door numbers. Since the previous inspection improvements noted were, a new ‘cinema’ facility that had been installed in one of the lounges and the old office was in the process of being refurbished to provide a sensory room. Wye. Both communal and individual rooms in this unit had been refurbished and redecorated. A small number of rooms had yet to be finished and it was noted that there was water damage to the ceiling in the ensuite of room 26. The unit was awaiting a site visit in line with its application to change registration to dementia care. An enclosed garden had been developed at the side of the unit with raised flower beds and water features. One resident stated that the unit provided “good accommodation.” DS0000016574.V362123.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): 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. Staff are provided with training relevant to residents needs and robust recruitment practices are in place to protect residents. However staffing levels may not be sufficient in the Main House at night. EVIDENCE: Main House. The staffing for the main house is two registered nurses and four carers in the morning with a breakfast assistant and one registered nurse and four carers in the afternoon. At night there is one registered nurse and two carers for the main house. Discussions with staff and the manager during the inspection visit indicate that the level of care staff at night may not be sufficient. A number of residents in the Main House need two staff to attend to them due to moving and handling and the environment is quite large situated on several floors. Staff have been given mobile communication equipment to keep in touch with each other. The Marlings. Normal staffing for the unit is four care staff in the morning and in the afternoon and two at night. A shift is also worked in the evening to support the night staff and as a response to a number of falls identified at this time. A DS0000016574.V362123.R01.S.doc Version 5.2 Page 22 senior carer always leads shifts. There is one cleaner working in the unit during the day. Wye. At the time of the inspection visit staffing in this unit was three carers in the morning and afternoon and two at night. A senior carer leads all shifts. As part of an application to re register this unit new staffing levels were being proposed. Out of three staff surveys received two contained comments about shortages of staff. All units. Based on information supplied during the inspection visit the home had 17 out of 37 care staff with an NVQ level two. Others are working towards this qualification and some staff are currently undertaking an NVQ level three. Records for recently recruited members of staff were examined. All the required information and documentation had been obtained including an employment history against which any gaps in employment could be explored. Checks against the Protection of Vulnerable Adults list were being made as well as with the Criminal Records Bureau. New staff receive induction training in line with national specifications. A number of staff from overseas had been attending English lessons. Staff also receive training in Nutrition, writing care plans, pressure area care and safe use of bed rails. A group of staff spoken to confirmed the training that they had received. DS0000016574.V362123.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): 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed with a variety of quality assurance audits in operation and safety checks to ensure that the home is run in the best interests of residents. EVIDENCE: All Units At the time of the inspection visit the manager had made an application to be registered although this was still being processed. The manager is a registered mental health nurse and has previous experience of managing care homes. She has achieved the registered managers award and has undertaken recent training in preventing elder abuse. DS0000016574.V362123.R01.S.doc Version 5.2 Page 24 A quality audit is carried out in the home every month; this is either a home manager’s audit or a validation audit. The home manager’s audit is sent to the head office of the registered provider. Other audits take place concentrating on accidents, health and safety, care plans, pressure area care, and residents’ weights. Since the previous inspection a new care plan audit had been introduced and evidence was seen of its use in the Wye House. Unannounced visits by a representative of the registered provider also take place and a short report is produced and copied to the registered manager. In addition satisfaction surveys are sent out to residents and relatives and comments books are available on each unit in the home. The home has a bank account for holding residents money. Following a recommendation at the previous inspection some residents with large balances have had these transferred into an interest earning account and documentation relating to this was examined. Staff have received training in fire safety as well as moving and handling, health and safety, control of hazardous substances, food hygiene, infection control and first aid. During the inspection visit staff in Wye House were observed moving a resident with a hoist and sling. Staff explained their actions to the resident throughout the procedure. The home had completed a fire risk assessment in January 2008 although had not received a recent inspection from the fire safety officer. Regular maintenance checks are carried out and recorded on equipment in the home such as hoists, lifts, bed rails and wheelchairs and window restrictors. In addition temperatures from hot water outlets are checked and recorded and these showed that appropriate temperatures were being maintained to prevent any accidental scalding to residents. The cleaning and disinfection of shower heads is carried out in line with reducing the risk of Legionella at the home. An audit regarding Legionella had been completed by a specialist consultant. Central heating boilers had been serviced and the electrical wiring in the home. There had been a recent check on the safety of portable electrical appliances. Cleaning materials are stored securely in all units however in appropriately labelled containers. Following a recommendation at a previous inspection a risk assessment had been carried out relating to the main entrance. Improvements had been made and further work was planned to improve control over the entrance in the interests of security. DS0000016574.V362123.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X 3 X 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 2 X 3 X 3 X X 3 DS0000016574.V362123.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 Requirements DS0000016574.V362123.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP3 OP7 Good Practice Recommendations Further work should be carried out with local authorities so that written information relating to a resident’s needs is always received by the home prior to admission. Where residents are receiving input from mental health services, the home should check if Care Programme Approach arrangements are in place and request any relevant information. The home should establish a homely remedy list through consultation with the local GPs. All medication administration or omission should be recorded accurately with particular attention given to topical creams and ointments in Wye House. Where directions are lacking or are described as “as directed” for topical creams and ointments then these should be confirmed with the supplying pharmacist and if necessary the GP. The practice of signing, dating and checking handwritten directions on the medication administration charts should also be used when any medication is stopped and the chart is marked accordingly. Where records of the food provided for residents are made then these should be dated. Considering the needs of the residents and the layout of the unit there should be a review of the number of care staff deployed in the main house on night shifts. 3. 4. 5. OP9 OP9 OP9 6. OP9 7. 8. OP15 OP29 DS0000016574.V362123.R01.S.doc Version 5.2 Page 28 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 DS0000016574.V362123.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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