Care Home: St Faith`s Nursing Home

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What the care home does well St Faiths is a very well managed home, that provides a safely maintained and clean environment for people to live in, and offers a very welcoming and homely atmosphere for visitors. People are admitted to the home on the basis of a comprehensive assessment of their individual needs. Upon admission each person has their own personal documented careplan to address their individual needs. People observed appeared comfortable and appropriately cared for, most were unable to tell us their experience of living at the home but two who were spoke positively about the way in which they were looked after, of caring staff and good care and attention. Relatives through surveys conveyed that `you couldn`t fault it here; it`s just the best`, "The carers are excellent" "we are happy here", "Staff in the main communicate well with us but occasionally staff forget to pass on a message", "staff are well trained and the management are very approachable". Relatives indicated that they felt well supported and reassured by the home. One relative seen at the inspection said, "I have no complaints, I`m happy with the care my wife receives, staff are very caring, gentle and compassionate" and "staffing is usually adequate" and the food is very good". The care planning system involves the individual and their families and ensures that all members of staff have a clear understanding of the person centred care each person requires. Care records underpinned the care practice seen within the home and peoples` privacy and levels of independence were respected and maintained as much as possible. Appropriate support equipment was in use in conjunction with individual risk assessments, there was evidence of appropriate medical reviews and input from appropriate healthcare professionals, and there were many examples seen of people receiving good care and support. People are reassured that the home takes any complaints and concerns seriously and does all it can to help them. There are policies and procedures in place for the protection of the vulnerable people, which staff are familiar with. There are some excellent quality monitoring approaches adopted here, with people, their families and stakeholders encouraged to have a say in how the home is run. Staff are recruited in accordance with good recruitment procedures, with the necessary pre-employment checks taking place. The competence and skills of the staff group is developed through a structured training programme, and through ongoing training in topics relevant to the needs of the people living at the home. There is also a focus on the National Vocational Training programme for care staff. Staff surveys were extremely positive with regard to support from the Management team at the home, the development they receive and their working conditions. We found a warm and welcoming atmosphere that felt homely and comfortable for the residents and visitors. The management team are committed to an ethos of `continuous improvement` for the service they provide for people. DS0000016584.V368779.R01.S.doc Version 5.2 Page 7This is reflected in their approach to the inspection process and their willingness to implement appropriate changes / improvements that are bought to their attention. In conclusion St Faiths provides care and support with excellent outcomes for people living at the home. What has improved since the last inspection? Each of the statutory requirements for improvement issued at the last key inspection had been met. Redecoration and refurbishment is ongoing within the home, in order to maintain the environment in good order for the people living here. The Quality Assurance systems within the home has been developed further to give audit systems that inform the Annual Quality Assurance Assessment and the Annual Development plan for the home so that all issues are addressed before a problem occurs. CARE HOMES FOR OLDER PEOPLE St Faith`s Nursing Home Malvern Road Cheltenham Glos GL50 2NR Lead Inspector Mrs Helen James Unannounced Inspection 18th August 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000016584.V368779.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. DS0000016584.V368779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Faith`s Nursing Home Address Malvern Road Cheltenham Glos GL50 2NR 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) 01242 240240 01242 224353 patricia.mccluskey@lilianfaithfull.co.uk The Lilian Faithfull Homes Ltd Mrs Patricia Anne McCluskey Care Home 69 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (69) of places DS0000016584.V368779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Service User under 65 Years. Date of last inspection 31st July 2006 Brief Description of the Service: St Faith’s Nursing Home is a large attractive property, which has been extended and refurbished to provide comfortable accommodation for 69 elderly people who require nursing care and may have a Dementia care need. It is located in a residential area, close to the centre of Cheltenham and to local amenities. The home is owned and managed by a charitable organisation and is one of the Lilian Faithfull Homes. The fees for nursing care range from £527 to £850 per week and this is based purely on size of room and en-suite irrespective of whether the needs for care are high, medium or low. The fees do not include the cost of items such as newspapers, toiletries, magazines, chiropody and sundry items and there may be charges for some outings and trips. People are accommodated in two wings of the Home accessed by stairs or a shaft lift. Twenty-seven people are cared for in the Fairhaven Wing on three Floors with two mezzanine levels and forty-two people are accommodated in Northcroft wing on three floors. All the bedrooms have en suite facilities. A variety of aids and adaptations have been provided throughout the property to assist people. Communal areas consist of a number of comfortable lounge/sitting and dining areas throughout the building. There is also a well-equipped ‘Multi- sensory’ room where aromatherapy and reflexology treatments may be given. The Home is maintained and decorated to a good standard. The Home has the benefit of enclosed landscaped and well-maintained garden that is easily accessible and may be enjoyed by the people in pleasant weather. The Home has a day care facility for people with Dementia and their families. DS0000016584.V368779.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 star. This means the people who use this service experience excellent quality outcomes. 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. This Key Unannounced inspection took place over one day in August 2008 and was completed by two inspectors. Twenty-six Care Standards for Older People including all the twenty-two Key standards were assessed on this occasion. The Annual Quality Assurance Assessment (AQAA) record was completed and returned to the Commission from the Provider prior to the inspection. Surveys were sent to the service for distribution prior to the inspection and seven people who live at the home and ten staff returned these prior to the inspection. Some of their comments feature in this report. Time during the inspection was spent speaking with the Registered Manager, the Day-care/Activity coordinator, nine care staff and people living at the home to gauge their views and experiences of the service and the care. The opportunities for people to exercise choice and to maintain social contacts were also considered. Checks were made against the statutory requirements issued at the last key inspection, in order to assess the home’s compliance. Time was spent time cross-referencing information about the care and welfare gained from talking to/observing people with individual care records. A range of other records were examined to include accidents, staff files and training logs, quality assurance documentation and health and safety systems. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. What the service does well: St Faiths is a very well managed home, that provides a safely maintained and clean environment for people to live in, and offers a very welcoming and homely atmosphere for visitors. People are admitted to the home on the basis of a comprehensive assessment of their individual needs. Upon admission each person has their own personal documented careplan to address their individual needs. DS0000016584.V368779.R01.S.doc Version 5.2 Page 6 People observed appeared comfortable and appropriately cared for, most were unable to tell us their experience of living at the home but two who were spoke positively about the way in which they were looked after, of caring staff and good care and attention. Relatives through surveys conveyed that ‘you couldn’t fault it here; it’s just the best’, “The carers are excellent“ “we are happy here”, “Staff in the main communicate well with us but occasionally staff forget to pass on a message”, “staff are well trained and the management are very approachable”. Relatives indicated that they felt well supported and reassured by the home. One relative seen at the inspection said, “I have no complaints, I’m happy with the care my wife receives, staff are very caring, gentle and compassionate” and “staffing is usually adequate” and the food is very good”. The care planning system involves the individual and their families and ensures that all members of staff have a clear understanding of the person centred care each person requires. Care records underpinned the care practice seen within the home and peoples’ privacy and levels of independence were respected and maintained as much as possible. Appropriate support equipment was in use in conjunction with individual risk assessments, there was evidence of appropriate medical reviews and input from appropriate healthcare professionals, and there were many examples seen of people receiving good care and support. People are reassured that the home takes any complaints and concerns seriously and does all it can to help them. There are policies and procedures in place for the protection of the vulnerable people, which staff are familiar with. There are some excellent quality monitoring approaches adopted here, with people, their families and stakeholders encouraged to have a say in how the home is run. Staff are recruited in accordance with good recruitment procedures, with the necessary pre-employment checks taking place. The competence and skills of the staff group is developed through a structured training programme, and through ongoing training in topics relevant to the needs of the people living at the home. There is also a focus on the National Vocational Training programme for care staff. Staff surveys were extremely positive with regard to support from the Management team at the home, the development they receive and their working conditions. We found a warm and welcoming atmosphere that felt homely and comfortable for the residents and visitors. The management team are committed to an ethos of ‘continuous improvement’ for the service they provide for people. DS0000016584.V368779.R01.S.doc Version 5.2 Page 7 This is reflected in their approach to the inspection process and their willingness to implement appropriate changes / improvements that are bought to their attention. In conclusion St Faiths provides care and support with excellent outcomes for people living at the home. 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. DS0000016584.V368779.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 DS0000016584.V368779.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): 1, 2, 4 & 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information is available for prospective people and their representatives to make an informed choice about moving into the home. The home ensures that people are admitted to the home on the basis of a full assessment of their needs, ensuring that they can receive the care they require. The statement of terms and conditions and contract provides people with information about the service they will receive from the home. EVIDENCE: Before admission residents/relatives are encouraged to visit the home and talk with the manager, staff and residents. They are provided with sufficient information to make an informed decision. The manager is always available to meet with prospective residents and their families to offer advice and support. The home provides a Statement of Purpose, Terms and Conditions of the home and a contract as well as a comprehensive Residents Guide. A thorough DS0000016584.V368779.R01.S.doc Version 5.2 Page 10 assessment of the prospective resident’s needs is carried out by the manager, including any mental health needs, this may be in conjunction with other members of the primary care team, the social services department as well as the prospective resident and family members, if appropriate. NHS funded Continuing Healthcare is determined by NHS staff using the recognised assessment tool. Residents contracts are provided and include all required details to comply with the Office of Fair Trading Standard. The fees for nursing care range from £525 to £850 and the type of accommodation provided determines the fee. A comprehensive plan of care is produced for each prospective resident from the assessment documentation and this is evaluated and updated as required or at a minimum monthly. The home has introduced a ‘Meet and Greet service’ for new people when they are admitted. This has two benefits it ensures that new people coming to live at the home or for respite are not left waiting in the reception area and also allows them to meet members of the activity staff. They show them to their room, provide refreshments and discuss the persons hobbies and interests, settling them and making them feel at ease. People spoken with confirmed that they were ‘happy at the home and they liked the carers and received the help and care they needed’. Resident surveys confirmed visits to the home, the information given and the admission process. Respite care is provided but not intermediate care. DS0000016584.V368779.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 excellent. This judgement has been made using available evidence including a visit to this service. A person centred care approach is adopted underpinned by comprehensive care records that are reviewed and evaluated at regular intervals. This ensures that peoples care respects their choice and values their rights, privacy, dignity and respect. People are treated with respect and dignity and are facilitated and supported by staff to live as fulfilling and independent lives as possible within their own limitations. EVIDENCE: Care files were examined in detail and for specific detail of care. All had a full and informative assessments completed, based on the activities of daily living, which is reviewed regularly. All had care plans for the problems identified and these were reviewed on a monthly basis. The resident and their family are involved in the care planning process where able and this was demonstrated through signatory evidence. Daily records were completed in all the records. DS0000016584.V368779.R01.S.doc Version 5.2 Page 12 Risk Assessments were completed for all risks identified for the individuals and these were reviewed and updated monthly. Where someone has been assessed as at risk of pressure damage the appropriate equipment was provided and preventative measures that had been implemented had been documented. All equipment needed for residents’ health care was supplied appropriately. Speaking and observing the people whose files were examined confirmed that the needs identified reflected their current care needs. Nine staff spoken with confirmed that they were fully informed about the needs of the people living at the home and how to meet their needs. Care observed given was appropriate; carers were undertaking tasks diligently, respectfully and compassionately. During tasks they were talking and engaging with the individuals during all interactions. They were all carrying out the day’s duties in a calm unhurried manner retaining the resident’s dignity and respect. Records of doctors and other multi -disciplinary health care visits are kept, these and conversations with people at the home confirmed visits from chiropodist, optician, dentist, psychiatric nurse etc as required. Accidents and incidents were recorded and indicated that they were followed up and appropriate action was taken. All accident reports were filed appropriately and audited monthly by the management. The medication system was examined on one floor and no issues were identified. All medication administration records were seen, a monitored dose system is in place and the responsibility for medication is delegated to the Registered Nurses on each floor. There are good records of medication in and out of the home and medication charts are completed fairly diligently with the correct information. The deputy manager has implemented a monthly audit of the medication system, which was examined during the visit. This analyses practice on each floor and gives a written report to each floor and to each individual responsible for dispensing medication with the corrective action they must take to improve practice for continuous improvement. This information is then analysed to inform and add to the performance reviews of staff, the continuous self-monitoring for the Annual Quality Assurance report and the development plan for the home. People observed appeared comfortable and appropriately cared for, most were unable to tell us their experience of living at the home but two who were, spoke positively about the way in which they were looked after here, of caring staff and good standards of care and attention. Relatives through surveys conveyed that ‘you couldn’t fault it here; it’s just the best’, “The carers are excellent“ “we are happy here”, “staff in the main communicate well with us but occasionally staff forget to pass on a message”, “staff are well trained and the management are very approachable”. DS0000016584.V368779.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 excellent. This judgement has been made using available evidence including a visit to this service. People experience a stimulating and varied life at the home with visitors and community links encouraged. There is a full activity programme available to suit all abilities within the home and people continue to have the option for a varied lifestyle and continue to be able to exercise choice and control over their lives within their individual ability to do so. EVIDENCE: Residents and staff confirmed that people are assisted to exercise choice in relation to daily routines or these are established through discussion with relatives and prior knowledge of what people enjoyed and when. There is access to advocacy services if required. The Activity Coordinator produces the programme of activities and this is displayed in the home. The Activity Coordinator meets every person on admission and completes a profile of past life, hobbies and interests. The resource staff record the activities that are undertaken with individuals and these records are kept within the care file. The activity resource care staff work within the day centre and the care home. Four staff are available to see DS0000016584.V368779.R01.S.doc Version 5.2 Page 14 people in the care home in groups or individually or people from the home may go to the Day centre and join in activities. The Activity Coordinator meets the resource staff daily, as she is their coordinator and with the home manager almost daily. Residents/representatives spoken to and comments from surveys were very happy with the level of activities provided. These included; trips out, readings, singing sessions, music and movement, craft, board games, outings, hand and foot massage and sensory stimulation etc. Religious needs are met by the home through a variety of options out of the home and at the home. Visitors are welcomed into the home at any reasonable time and this was observed during the visit. One visitor told the inspector, “that they were always welcomed by the staff and always provided with a warm drink”. Meals can also be provided if required by visitors. Individual likes, dislikes and special needs in relation to food are ascertained on admission, recorded on individual care records and shared with the catering staff. The inspector was told that the catering liaison has regular meetings with the manager and audits the catering provision monthly. Surveys confirmed satisfaction with the catering provision. Staff were aware of peoples specialist dietary requirements and ensured their needs were catered for at each meal. A choice of food is available at all meals and the menus provided evidenced this. Snacks and drinks were available as required and there were well-stocked kitchenettes on each floor with plenty of fresh fruit throughout the home. Food health and safety checks are maintained and recorded in the kitchenettes. There is a nutritional assessment in place and the home are about to implement the new ‘MUST’ tool for nutritional assessment. Staff were observed assisting people with eating and this was done well with them sitting talking to the person and feeding them slowly and appropriately. Pureed diets are excellently presented with the pureed food served in mould formation so that the person eating the food can see what it represents. DS0000016584.V368779.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 good. This judgement has been made using available evidence including a visit to this service. People, their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon and people will be protected from abuse. EVIDENCE: The home has a clear and accessible policy for complaints, illustrating how complaints are dealt with and time scales. All residents and relatives are kept informed regarding The Complaints Policy and guidelines are found on the Residents Guide and the contract. There is a complaint file for recording complaints and these are audited. Concerns are dealt with as they arise. All staff are trained in the Protection of Vulnerable Adults (POVA) and training records seen confirmed POVA is a mandatory training session. Policies are in place to deal with Abuse, Neglect and the Protection of Vulnerable Adults. Staff spoken with confirmed they had received training and they knew what they would do if they saw abusive practice or saw anything that bothered them. All staff are trained in how to deal with challenging behaviour. There is a Guidance Policy on the Mental Capacity Act detailing the facts surrounding the Act, its boundaries and its implementation and staff have received training. Residents and relatives can be provided with information regarding advocacy. Residents are facilitated to vote in elections. DS0000016584.V368779.R01.S.doc Version 5.2 Page 16 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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in a safe well-maintained environment where the excellent standard of cleanliness means people live in a clean and hygienic home. EVIDENCE: People are encouraged to bring in their own furniture, pictures, paintings and ornaments to encourage a sense of ownership and recognition. All rooms are redecorated prior to admission and new residents may choose the colour if they wish. The home assists with orientation by providing colour coded wall coatings and individually coloured doors for the residents rooms. The provision of door numbers and door knockers encourages people to perceive their rooms as home. From the Quality Assurance questionnaires it was noted that one resident had been pleased to be able to choose the colour of her room. DS0000016584.V368779.R01.S.doc Version 5.2 Page 17 There is a team of domestics who work over seven days to ensure that the home is clean and free from risk of cross infection. All staff are trained in Infection Control. There are numerous areas where people may sit and relax and a secure garden which has recently been re-landscaped and is enjoyed by residents and visitors. The summer-house provides a seating area outside whilch gives shelter from the weather. All out door space is accessible to wheel-chair users. Aids and adaptations are available throughout the home and each individual room has an electric three-way profiling bed and each area within the home has at least one hoist to assist with transfers. A new area containing the laundry, store room, staff shower, staff rooms and training room has been added to the building. This allows the work areas of the home to be inaccessible to people living at the home and therefore ensures a safe environment for them. Access to all work areas, including laundry and kitchen is protected by key code doors. New furniture has been provided throughout the home to enhance the environment. Rooms and communal areas continue to be decorated and lights have been replaced to offer improved lighting. Middle Northcroft bathroom area had some broken tiles under the radiator and around skirting boards (appeared to be due to the hoist banging into the wall), a broken bath side panel and the door lock was broken. This is scheduled to be decorated in the next few months. The bathroom in Fairhaven also needs to be improved as it is looking a bit ‘tatty and tired’ . DS0000016584.V368779.R01.S.doc Version 5.2 Page 18 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. People living in this home receive care from a currently stable and competent workforce, and can be assured by the home’s recruitment procedures, which are robust. EVIDENCE: The AQAA states that there had been a change to the care staff and promotion of carers to senior care roles to enable the Registered Nurses to delegate specific responsibilities to them. Agency staff is never used as the home has its own bank staff, which allows for continuity for people living at the home. The rotas demonstrate that there will generally be the manager or deputy or both with three to four care staff and a Registered Nurse on each floor each day, with two on each floor at night; this was consistent with staff on duty on the day of inspection and reflected the correct staffing for the needs of people. The home has begun working more as individual teams on floors, taking ownership for individual areas within the home - this has resulted in competition between different floors, resulting in improved care for people and increased satisfaction and autonomy for staff. The introduction of audits of procedures within the home, which staff are embracing, is improving care for people, staff sickness rates and the home environment. DS0000016584.V368779.R01.S.doc Version 5.2 Page 19 An ancillary team of cleaning, catering, maintenance, administration and laundry staff supports the care team, and the manager works in a supernumerary capacity; the deputy manager also has regular supernumerary days. The home is making progress with the National Vocational Qualification (NVQ) training programme for care staff. There are five care staff qualified to at least level 2 at this time, with another four still working towards it. Personnel files relating to three staff were inspected and found to contain evidence that all pre-employment checks had been appropriately undertaken, prior to employment to comply with regulation 19. There were interview records and induction and training records on all files seen. Two employment issues were identified during the inspection on two files: • One file had a reference taken from the shift leader and not the Home Manager. • One file had gaps in the employment history. The inspector sampled new staff Criminal Record Bureau (CRB) disclosures and now requires the home to destroy them to comply with their obligations under data protection. Where the disclosures report criminal offences a written risk assessment is recorded and kept on the individual personnel file. The home has a new training manager who maintains records of training and training completed for all staff. Training is targeted and focused on improving the outcomes for individuals within the home. Records are available to the Manager via the computer network. Records seen demonstrated the range of training undertaken, with different courses and learning modes available according to the person’s needs and role within the home. Training records demonstrated that new staff receive a structured induction training that is in line with the national common induction standards for care workers, and that they worked under supervision for this period; supervision records were seen in staff files. One new member of staff said that she had received relevant training to her role, a good induction, and was kept up to date with new ways of working. Two other members of staff spoken with confirmed that they received regular training updates and were able to alert the manager when they felt they required training in areas of procedure or practice. All mandatory training is up-to-date confirmed by records. The training plan for the year was given to the inspector. DS0000016584.V368779.R01.S.doc Version 5.2 Page 20 The home is also supported by the Gloucestershire Care Home Support Team and have provided training within the home particularly in Dementia Mapping and Nutrition Assessment tools and this is ongoing. The Home is registered with the University of Surrey and Manchester University to run the Overseas Nurses Programme and also with the University of Gloucestershire to accept social work students and students undertaking Health and Social Care courses. People confirmed on surveys that they considered staff to be appropriately skilled and experienced for their roles. DS0000016584.V368779.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, 36, 37 & 38 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The Management of the home is open and transparent and leadership, guidance and direction is provided to staff on a ‘day to day’ basis. The systems for service user consultation and quality assurance are well developed in the home and monitor quality and standards to ensure continuous improvement within the home. There are processes in place to safeguard and protect the health, safety and welfare of the people using the service. EVIDENCE: DS0000016584.V368779.R01.S.doc Version 5.2 Page 22 The manager at St Faiths has thirty years experience within the care and nursing field and brings a wide range of expertise to the home. She is a Registered Nurse in General Nursing and Mental Health and has an appropriate Management Qualification and actively seeks to keep herself updated. The home has a clear and accountable management structure and the manager ensures that the service meets its aims and objectives. The management team ensures that the service is person centred and run understanding people’s needs in respect of equality and diversity. The home’s first AQAA was completed to a good standard. From surveys staff reported that the manager and deputy are very approachable and have an ‘open door’ policy, so are accessible at all times. They feel they have good support from them and enjoy their yearly appraisals with the managers. Appraisals of staff are done yearly and staff complete a self-assessment questionnaire prior to their appraisal, this is then discussed during the session and both parties sign this record. Staff pay and reward systems have been introduced and these are linked to statutory training completion, performance and attendance at work. This is reported to work well in motivating staff and staff gave positive feedback on the system. The Senior Registered Nurse on each floor undertake team supervision of staff via team meetings evidenced by minutes seen at the inspection. Where necessary this is developed into an individual session when there are issues to address. In the longer term the Commission would see that good practice would be to develop this into individual sessions for all staff, performed by senior staff that have received training. All Policies and Procedures are updated, at least, annually. New policies are added as the need is identified. A comprehensive Quality Assurance system is in place and the home has accreditation for Investors in People and ISO 9001 and a 5* Score for Food Hygiene. The manager has a comprehensive array of documented auditing tools/spot checks in place too examine quality of systems and effectiveness of care procedures/practice in the home and these were seen during the inspection. The ethos of the home is open and transparent and views of people using the service and their representatives are sought regularly and analysis reports were seen demonstrating that the service is listening to the views of its users and changing and developing things as required. Accidents/incidents are appropriately recorded in the accident book and notified to the Commission for Social Care Inspection (CSCI) via Regulation 37 notices. All accidents are audited to ensure there is no pattern of accidents involving residents or others and a yearly report produced. DS0000016584.V368779.R01.S.doc Version 5.2 Page 23 All the required Health and Safety checks were in place in the home and documentary evidence was available pertaining to this. There is a maintenance team who deal with repairs and maintenance issues daily and records are kept of the actions taken and these are audited regularly. All records are kept securely within the home and comply with the data protection act and confidentiality. All residents have a power of attorney where necessary and the home is able to arrange for someone to manage a residents financial affairs if they are not able to do so themselves. There is a safe place for people to keep their valuables. All financial dealings are completed through the invoicing system. The home has good training in health and safety and promotes practice that ensures people live and staff work in a safe environment. DS0000016584.V368779.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 4 3 X 4 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 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 4 X 3 X 3 3 4 4 DS0000016584.V368779.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. 1. 2. Refer to Standard OP29 OP36 Good Practice Recommendations Destroy all Criminal Record Bureau (CRB) disclosures that the Company hold for staff. The home should continue to work towards developing the supervision system to individual sessions for all care staff. DS0000016584.V368779.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 DS0000016584.V368779.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. 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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