Care Home: Spencer Court

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What the care home does well Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 6All prospective service users and their representatives are encouraged to visit the home, stay for a while to meet the staff team and other service users, before making a decision to move in on a trial period. All service users are admitted for a trial period of four to six weeks, before a decision is made to make Spencer Court their permanent home. Service users were observed to be well groomed and appropriately dressed, attention had been given to ensuring service users had their spectacles, dentures, hearing aids and walking frames/sticks. The healthcare needs of the service users are met by a local GP practice and a range of healthcare professionals are available as necessary. From evidence seen and from discussion with service users and staff on duty, the health and medical needs of service users are well met. Staff were observed addressing service users by their preferred term of address and interacting with service users in a professional and respectful manner. There is a good rapport in the home between service users and all members of staff, this was confirmed in discussion with service users and staff on duty. Service users confirmed that the routines in the home are flexible, such as being able to choose how to spend their day, when to go to bed and when to get up in the morning. The home is purpose built and is maintained to a high standard. The location and layout of the building is suitable for its stated purpose. Service users expressed their satisfaction of the premises, facilities and grounds. Communal areas of the home are comfortable and well furnished. All areas of the home were seen to be clean, well maintained and free from unpleasant odours. From discussion with members of the housekeeping staff on duty, it is evident that they take pride in maintaining high standards of cleanliness throughout the home. From discussion with the manager, staff and examination of the duty rosters, staffing levels appear to be adequate to meet the needs of the service users. The home is currently fully staffed. Staff spoken to during the inspection expressed their satisfaction of working in the home, felt that working conditions were good, felt well supported and that they were able to make a difference to the daily lives of service users. In discussion with service users, visitors to the home and staff on duty, all expressed the view that the home was well managed and run in the best interests of the service users. What has improved since the last inspection? The requirement and three good practice recommendations made at the last inspection have been addressed. Care planning documentation has been reviewed and developed. CARE HOMES FOR OLDER PEOPLE Spencer Court Union Street Woodstock Oxford OX20 1JG Lead Inspector Marie Carvell Unannounced Inspection 21st August 2008 10:20 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 Spencer Court DS0000067335.V369311.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. Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spencer Court Address Union Street Woodstock Oxford OX20 1JG 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) 01993 812725 manager.spencercourt@osjctoxon.co.uk www.oxfordshire.gov.uk The Orders Of St John Care Trust Post vacant Care Home 46 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (46), of places Physical disability over 65 years of age (4) Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of residents to be accommodated at any one time must not exceed 46 28th September 2006 Date of last inspection Brief Description of the Service: Spencer Court is a care home providing personal care and accommodation for 46 older people. It is situated in Woodstock which is a small picturesque market town approximately six miles north of Oxford and close to many amenities The home provides 24-hour support for all the service users accommodated at the home, and meets the assessed needs of the service users. The home does not provide nursing care. The care home is owned and managed by the Orders of St John Care Trust, which is a charitable organisation that also owns homes in Wiltshire and Lincolnshire. The fees for this service range from £505.00 to £780.00 per week. Items not covered within the fees include hairdressing, podiatry, newspapers and magazines, toiletries and contributions to some outings and activities. Spencer Court DS0000067335.V369311.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. This inspection of the service was an unannounced ‘Key Inspection’. We arrived at the service at 10:20 and was in the service until 16:30. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager in December 2007, and any information that CSCI has received about the service since the last inspection. We asked the views of the people who use the service and other people seen during the inspection or who responded to surveys that the Commission had sent out. Eleven service users, eight members of staff and two healthcare professionals responded to surveys sent out. We looked at how well the service was meeting the standards set by the government and have in this report made judgements about the standards of the service. We toured the building, examined records including case tracking five service user files, met with service users individually and in groups. We also spent time with the manager, care staff, ancillary staff, relatives and briefly with the service manager. In addition we spent time observing how care was being delivered to service users and joined service users, in one unit for lunch. At the last inspection carried out September 2006, one statutory requirement and three good practice recommendations were made. The requirement was that appropriate monitoring and recording of refrigerator temperatures are undertaken. The good practice recommendations were that liquid soap was made available for hand washing in communal bathrooms and toilets, that systems are put into place to ensure that details of medical or nursing treatment are passed on to the care staff or manager and that staff files contain a recent photograph. These are referred to in the body of the report. Feedback was given to the manager throughout the inspection. What the service does well: Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 6 All prospective service users and their representatives are encouraged to visit the home, stay for a while to meet the staff team and other service users, before making a decision to move in on a trial period. All service users are admitted for a trial period of four to six weeks, before a decision is made to make Spencer Court their permanent home. Service users were observed to be well groomed and appropriately dressed, attention had been given to ensuring service users had their spectacles, dentures, hearing aids and walking frames/sticks. The healthcare needs of the service users are met by a local GP practice and a range of healthcare professionals are available as necessary. From evidence seen and from discussion with service users and staff on duty, the health and medical needs of service users are well met. Staff were observed addressing service users by their preferred term of address and interacting with service users in a professional and respectful manner. There is a good rapport in the home between service users and all members of staff, this was confirmed in discussion with service users and staff on duty. Service users confirmed that the routines in the home are flexible, such as being able to choose how to spend their day, when to go to bed and when to get up in the morning. The home is purpose built and is maintained to a high standard. The location and layout of the building is suitable for its stated purpose. Service users expressed their satisfaction of the premises, facilities and grounds. Communal areas of the home are comfortable and well furnished. All areas of the home were seen to be clean, well maintained and free from unpleasant odours. From discussion with members of the housekeeping staff on duty, it is evident that they take pride in maintaining high standards of cleanliness throughout the home. From discussion with the manager, staff and examination of the duty rosters, staffing levels appear to be adequate to meet the needs of the service users. The home is currently fully staffed. Staff spoken to during the inspection expressed their satisfaction of working in the home, felt that working conditions were good, felt well supported and that they were able to make a difference to the daily lives of service users. In discussion with service users, visitors to the home and staff on duty, all expressed the view that the home was well managed and run in the best interests of the service users. Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 7 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. Spencer Court DS0000067335.V369311.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 Spencer Court DS0000067335.V369311.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): Standards 1 and 3. Standard 6 is not applicable, as the home does not provide intermediate care. Quality in this outcome area is good. Service users and their representatives are provided with information about the home, including a copy of the home’s Residents Guide. Service users are assessed prior to admission to ensure that their care needs can be effectively met by the home. All service users are able to move into the home for a trial period, before making a decision to stay permanently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All prospective service users and their representatives are provided with a copy of the home’s Statement of Purpose, Service Users Guide, home’s brochure Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 10 and a copy of the last inspection report. Oxfordshire Social Services have a block contract with the home for twenty of the forty six beds. Copies of the Care Management needs assessment is provided to the home with supporting information from health and social care professionals as appropriate. The manager then undertakes a pre- admission assessment to ensure that the home is able to meet the prospective service user’s needs. All prospective service users and their representatives are encouraged to visit the home, stay for a while to meet the staff team and other service users, before making a decision to move in on a trial period. All service users are admitted for a trial period of four to six weeks, before a decision is made to make Spencer Court their permanent home. Surveys completed by eleven service users confirmed that they had received enough information about the home before they moved in to be able to decide if it was the right place for them and had received a contract/ terms and conditions. Spencer Court DS0000067335.V369311.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): Standards 7,8,9 and 10. Standard 9 was subject to a good practice recommendation at the last inspection. Quality in this outcome area is good. Care plans need to be further developed to include emotional and social care needs. Medication storage, administration and recording were seen to be well maintained. Service users feel that they are treated with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection all care planning documentation has been reviewed and developed. Care plans are now draw up from the pre- admission Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 12 assessment, agreed and signed by the service user and/or representative as appropriate. The care leader and service user review the care plan on a regular basis and record any changes. Although the information regarding health and personal care is well recorded, no information is recorded about the emotional and social care needs of the service user or how these are to be met. The activity organiser records information about social activities and hobbies, however this needs to be incorporated into the care plan. The manager has agreed to address this using the OSJCT care planning documentation. Surveys completed by nine service users confirmed that they ‘always’ received the care and support needed, one service user ‘usually’ received the care and support needed and one service user ‘sometimes’ received the care and support needed. Comments made by one service user included ‘Care and support given are very good’ All service files include falls, moving and handling, pressure sore and fire risk assessments. These were well documented and up to date. Healthcare professionals, such as the falls specialist, are involved with risk assessments as necessary. Service users were observed to be well groomed and appropriately dressed, attention had been given to ensuring service users had their spectacles, dentures, hearing aids and walking frames/sticks. The healthcare needs of the service users are met by a local GP practice and a range of healthcare professionals are available as necessary. From evidence seen and from discussion with service users and staff on duty, the health and medical needs of service users are well met. The manager expressed her satisfaction of the service provided and said that she had a good working relationship with the visiting GPs and healthcare professionals. All eleven service user surveys confirmed that they receive the medical support they need. Comments made on surveys completed by two healthcare professionals included ‘ staff are very quick to mention their concerns about the residents and phone messages for the district nurses are left appropriately. Instructions for example in applying creams to skin conditions are discussed and carried out correctly. Very good care with privacy, respect and dignity given, but just occasionally some care staff may discuss a resident within the hearing of another resident. Terminal care dignity a great strength in the home. Care staff are very keen to learn, very good uptake when district nurses have given training sessions. All staff respond positively towards any concerns raised. I would recommend this residential home to anyone’. ‘ The care leaders liaise closely with the community nursing team. Communication between the teams of carers is usually good but occasionally recommendations are not cascaded to all team members’. This was subject to a good practice recommendation at the last inspection. ‘The carers try very hard to meet all the residents health Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 13 care needs whenever possible. Some residents have very complex social and healthcare needs and the care staff do not have the capacity/ time to meet these needs all of the time. Residents are treated as individuals and members of ‘the family’. The carers at Spencer Court genuinely care for the residents. They do their utmost to provide excellent care in what can be a difficult situation- when staffing levels are low or residents dependency high’. All medication was seen to be appropriately stored. Medication administration records are well maintained and no obvious gaps in recordings were observed. All staff who administer medication have received appropriate training, this is updated on a regular basis. Risk assessments would be undertaken for any service user wishing to take responsibility for their own medication. The manager undertakes monthly medication audits in the home. Time was spent with service users in private or in groups. Service users were complimentary about the care provided. Comments made included ‘wonderful staff’, ‘ nothing is too much trouble’, ‘ excellent care’, ‘ only need to ask if I want something’. Staff were observed addressing service users by their preferred term of address and interacting with service users in a professional and respectful manner. There is a good rapport in the home between service users and all members of staff, this was confirmed in discussion with service users and staff on duty. The home has a ‘key worker’ system in place, described in the service user guide as ‘ the carer who will take a special interest in your care at this home’. Several of the service users asked were able to name their key worker and in discussion with care staff all were clear about the role of key worker. As in many other care homes, there is a wide range of racial, ethnic and faith backgrounds represented within the staff team compared with the current service users. From discussion with the manager and staff on duty, we consider that the home is able to provide a service to meet the needs of individual service users of various religious, racial or cultural needs. Spencer Court DS0000067335.V369311.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): Standards 12,13,14 and 15. Quality in this outcome area is good. Service users are encouraged to make choices and to remain independent for as long as possible. There is a wide range of activities in place to meet the social needs of service users. Service users are provided with a varied, wholesome and nutritious diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about weekly activities in displayed on notice boards throughout the home and there is a monthly activities schedule also displayed. All activities undertaken are recorded on a daily basis. An activity organiser is employed for six hours a day, Monday to Friday. Surveys completed by four service users confirmed that they felt that there were ‘always’ activities arranged by the home that they could take part in, four Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 15 service users felt that only ‘sometimes’ were activities arranged that they could take part in and three service users felt ‘ sometimes’ activities were arranged that they could take part in. Comments made included ‘activities are arranged, but often there are no staff available to assist with those that need help’ Many of the service users have friends and family who are able to visit on a regular basis. Service users are encouraged to maintain contact, as far as possible, with the local community. Service users said that their friends and relatives were always made welcome. Resident meetings are held every three months and are well attended. Religious ministers visit the home on a regular basis and arrangements can be made for service users to attend a local place of worship, if requested. Service users confirmed that the routines in the home are flexible, such as being able to choose how to spend their day, when to go to bed and when to get up in the morning. The inspector joined service users in one unit for the mid day meal. Tables were laid with napkins and condiments. The day’s menu was displayed and service users confirmed that they are offered a choice of meals and this is recorded. Menus seen evidenced that service users are offered a varied, wholesome and nutritious diet. The meal served was hot, tasty and served attractively. Staff were observed to be assisting service users in a discreet and dignified manner. Surveys completed by four service users confirmed that they ‘always’ enjoyed the meals at the home, six service users ‘ usually’ enjoyed the meals at the home and one service ‘ sometimes’ enjoyed the meals at the home. Comments made included ‘the meals are not very good, the meat is often tough and the vegetables served cold’ Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. The home has a comprehensive complaints procedure in place. Policies and procedures are in place to protect service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure in place and is displayed in the entrance hall and each unit. Since the last inspection the home has not received any complaints. The manager confirmed that currently verbal complaints are not recorded and agreed that in future all complaints whether received verbally or in writing will be recorded with action taken and outcomes recorded. Service users said that if they had a concern or complaint then they would speak to a member of staff or the manager, all felt confident that concerns would be taken seriously and addressed. Surveys completed by eleven service users confirmed that they knew how to make a complaint. Since the last inspection, the Commission has not received any information regarding complaints about this service. Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 17 All staff receive training in the home’s policies and procedures for protecting service users from abuse and the home’s whistle blowing policy, this was confirmed by staff on duty and training records. Training is provided during staff induction and then updated on a regular basis. The home has a copy of the Oxfordshire safeguarding Adults procedures. No safeguarding adult referrals or safeguarding adult investigations have taken place since the last inspection. No referrals have been made for inclusion on the POVA (Protection of Vulnerable Adults) list. Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20, 21,22,24,25 and 26. Standard 21 was subject to a good practice recommendation at the last inspection. Quality in this outcome area is excellent. The home provides safe, well maintained and spacious accommodation for service users. The home was found to be clean, hygienic and free from unpleasant odours. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is purpose built and is maintained to a high standard. The location and layout of the building is suitable for its stated purpose. Service users expressed their satisfaction of the premises, facilities and grounds. Communal Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 19 areas of the home are comfortable and well furnished. Throughout the home there are quiet areas for service users and visitors to use. Service users have access to a well maintained, safe and secure garden. Hot water outlets in bedrooms and bathrooms are maintained at the recommended temperature. All windows are fitted with window restrictors and radiators are covered. A nurse call alarm system is installed in all communal areas, bedrooms and bathrooms. All bedrooms are for single occupancy and have an en-suite shower, washbasin and toilet. Bedrooms are of a reasonable size and are able to accommodate wheelchairs and aids to assist with daily living with ease. Service users are encouraged to personalise their bedrooms. Most service users have a television set and some have a private telephone. Communal bathrooms and toilets are fitted with appropriate aids and adaptations to help maintain independence. At the last inspection a good practice recommendation was made that liquid soap be provided for hand washing, this has been addressed. All areas of the home were seen to be clean, well maintained and free from unpleasant odours. From discussion with members of the housekeeping staff on duty, it is evident that they take pride in maintaining high standards of cleanliness throughout the home. The laundry is well equipped. All housekeeping and laundry staff have received training in COSHH, infection control and health and safety. Policies and procedures are in place. Staff are provided with protective clothing, such as disposable aprons and gloves for use when carrying out personal care to service users. Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28 29 and 30. Standard 29 was subject to a good practice recommendation at the last inspection. Quality in this outcome area is good. Staff recruitment procedures are robust and protect service users from harm. Staffing levels appear to be adequate to meet the needs of the service users. Staff are well trained and supervised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with the manager, staff and examination of the duty rosters, staffing levels appear to be adequate to meet the needs of the service users. The home is currently fully staffed, having recently recruited staff to two vacant posts. Members of staff are encouraged to undertake NVQ (national vocational qualification) training. It is anticipated that the home will shortly have 100 of care staff with this qualification. From examination of a sample of five staff files, discussion with staff on duty and comments made on the eight surveys completed by staff, the home has Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 21 robust recruitment procedures in place. Staff files contained all documentation required by regulation and evidence was seen of formal interviews, undertaken by two senior members of staff, having taken place. At the last inspection a good practice recommendation was made that all staff files should contain a recent photograph. This has been addressed. All new members of staff undertake induction training, appropriate to their role once in post, complete mandatory training and specialist training. OSJCT has its own training centre that provides a high standard of training both in and external to the home. The home has a staff training and development plan in place. Regular updating of skills is provided to all staff. All surveys completed by members of staff stated that they received relevant training to their role. Staff spoken to were positive about training opportunities available and felt that this gave them confidence in carrying out their duties and assisted with career advancement within the organisation. Staff spoken to during the inspection expressed their satisfaction of working in the home, felt that working conditions were good, felt well supported and that they were able to make a difference to the daily lives of service users. Comments made on surveys completed by members of staff included ‘ the induction package I received gave me the confidence that I needed’, ‘we have very good handovers, which give us the information we need to deal with the resident. We have regular staff meetings. It is very rare we are short staffed as most staff will cover a shift if necessary’, ‘Induction training was very good, so far faith and sexual orientation haven’t been covered much, race only covered in dementia training’, ‘ the manager has regular meetings with staff and gives them comments on areas that carers are doing well and areas that need to be improved’, ‘we provide a safe, caring home with very caring staff. We also have a good relationship with most of our residents and relatives’, ‘ I feel that more staff are needed’, ‘ we could give more stimulation and encourage relatives to participate in some activities in the home’. Communication systems in the home appear to be well organised, with staff handovers taking place at the beginning of each shift. Staff meetings take place and staff feel that morale is good in the home. All grades of staff were observed to be professional in their approach to service users, throughout the inspection. Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36 and 38. Standard 38 was subject to requirement at the last inspection. Quality in this outcome area is good. Service users benefit from a well managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post since the resignation of the last registered manager in August 2007, and has submitted an application for registration earlier this year with the Commission. The manager is experienced and well trained, having completed the RMA (registered managers award) and has Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 23 healthcare qualifications. The manager is supernumery to the home’s staffing levels and is supported by an experienced administrator. In discussion with service users, visitors to the home and staff on duty, all expressed the view that the home was well managed and run in the best interests of the service users. Procedures are in place for dealing with service users monies and valuables held in safekeeping. From discussion with the manager and examination of a sample of financial records, it was evident that records are well maintained. Regular auditing of accounts take place. All staff receive formal 1-1 supervision every two months from either a senior member of staff or the manager. Records of supervision undertaken were seen to be well maintained, actions agreed, recorded and signed by both the supervisor and supervisee. The manager obtains feedback from service users, relatives and visitors to the home when talking to them in the home. Because the home has an open door policy, people are encouraged to see the manager without having to make an appointment. Policies and procedures are in place and are reviewed on a regular basis. Quality assurance systems are in place and the manager/ head of care undertake regular audits. Evidence was available to demonstrate how the views of service users are obtained to measure the home’s success in meeting the aims, objectives and home’s statement of purpose. Reports written by a Cluster Manager, who is also a registered manager of a OSJCT home, completes a written report on behalf of the provider, following a monthly unannounced visit to the home, these were available for examination. Communication systems in the home are well organised, with regular meetings held. A sample of records relating to health, safety and welfare were examined and found to be up to date and well maintained. At the last inspection a requirement was made that refrigerator temperatures are monitored and recorded. This has been complied with. Spencer Court DS0000067335.V369311.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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 17 x 18 3 4 4 4 4 x 4 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 Spencer Court DS0000067335.V369311.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. 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. Refer to Standard Good Practice Recommendations Spencer Court DS0000067335.V369311.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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