Care Home: Stronvar

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What the care home does well Stronvar provides a comfortable, homely environment with pleasant communal areas and bedrooms that reflect individual tastes. One person said they "love the view" from their room. People living in the home and their relatives are complimentary about the environment and the care provided. One person said Stronvar is "very nice" and another said it`s "lovely". Relatives and visitors are made welcome. The staff team know people well and are able to provide support for people in a way that meets their needs and wishes. They ensure the personal and healthcare needs of people living in the home are met and relevant healthcare professionals are consulted where appropriate. People are treated individually and the management team are able to demonstrate a good awareness of individual needs, wishes and preferences. The menu in Stronvar provides people with a well-balanced and varied diet. Staff provide good home cooked food that is enjoyed by people living in the home. What has improved since the last inspection? Some record keeping has improved since the last inspection and work has been done in improving and developing care plans. What the care home could do better: Risk assessments could be developed further so that they contain greater detail around identified risks and the measures in place to reduce the risks. As at the last inspection staff continue to receive training and demonstrate that they are well skilled, but the proportion of care staff who have obtained or who are working towards National Vocational Qualifications (NVQ) could be improved. Records relating to the recruitment of staff could be better organised and need to contain all the information required by Regulations. The Quality Assurance system should be further developed to demonstrate how the service listens to people and acts on their wishes. Information gathered from listening to people living in the home and other interested parties should be used to form a development plan, which demonstrates that people`s views are being acted upon. CARE HOMES FOR OLDER PEOPLE Stronvar Strangers Corner Church Road Brightlingsea Essex CO7 0QT Lead Inspector Ray Finney Unannounced Inspection 9th April 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000017945.V362191.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. DS0000017945.V362191.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stronvar Address Strangers Corner Church Road Brightlingsea Essex CO7 0QT 01206 304007 F/P 01206 304007 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) Mr Edward Nigel Edwards Mrs Jacqueline Dixon Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places DS0000017945.V362191.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 16 persons) To provide day care for one named service user Date of last inspection 25th April 2007 Brief Description of the Service: Stronvar is an established care home situated in a residential area of Brightlingsea. The home is on bus routes both to the local shops and leisure facilities in Brightlingsea and to the town of Colchester. The home provides accommodation for up to 16 people over the age of 65 in single rooms. Nine of the rooms have en-suite facilities and the remainder have washbasins. Many of the rooms overlook the well maintained gardens. Access to the first floor is by means of passenger lift, stair-lift or stairs. Communal areas include a large dining area and a comfortable lounge. There are parking facilities to the front of the property. The home charges £420.00 a week for the service they provide. Other services such as hairdressing and chiropody are available at an additional charge. This information was given to us in April 2008. Information about the home can be obtained by contacting the manager. Inspection reports are available from the home and from the CSCI website www.csci.org.uk DS0000017945.V362191.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. Surveys were sent to members of staff, people living in the home and their relatives, although at the time of compiling the report no completed surveys had been returned. The manager completed an Annual Quality Assurance Assessment with information about the home. This document will be referred to as the AQAA throughout the report. A visit to the home took place on 9th April 2008 and included a tour of the premises, discussions with people living in the home, the manager, members of staff and a visiting relative. Observations of how members of staff interact and communicate with people living there have also been taken into account. On the day of the inspector’s visit the atmosphere in the home was relaxed, friendly and welcoming and the inspector was given every assistance from the manager and the staff team. What the service does well: Stronvar provides a comfortable, homely environment with pleasant communal areas and bedrooms that reflect individual tastes. One person said they “love the view” from their room. People living in the home and their relatives are complimentary about the environment and the care provided. One person said Stronvar is “very nice” and another said it’s “lovely”. Relatives and visitors are made welcome. The staff team know people well and are able to provide support for people in a way that meets their needs and wishes. They ensure the personal and healthcare needs of people living in the home are met and relevant healthcare professionals are consulted where appropriate. People are treated individually and the management team are able to demonstrate a good awareness of individual needs, wishes and preferences. The menu in Stronvar provides people with a well-balanced and varied diet. Staff provide good home cooked food that is enjoyed by people living in the home. DS0000017945.V362191.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. 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. DS0000017945.V362191.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000017945.V362191.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at Stronvar receive sufficient information about the home and may be confident their needs will be assessed before admission. EVIDENCE: Information received in the AQAA states that Stronvar provides good printed information. In the past year they have also set up a website. At the time of the inspection visit, the manager had recently left and the new manager was in the process of familiarising herself with the home’s records and was prioritising what needed to be updated. At this inspection the Statement of Purpose and Service User Guide were not examined as the manager had not made changes since the last inspection. Many of the people living in the home spoken with said that they had lived locally and knew of the home’s good reputation, which helped with their choice. DS0000017945.V362191.R01.S.doc Version 5.2 Page 9 A sample of records examined contained statements of terms and conditions that had been signed by the proprietors and the resident or their representative. The AQAA states that a full assessment of needs is undertaken before anyone moves into Stronvar. On the day of the inspection a sample of the records of three people living in the home were examined. All contain a comprehensive assessment, which includes an assessment of needs relating to diet, activities of daily living, elimination, eating/drinking, hygiene/dressing, sexuality, recreation, sleep, social history, personal habits/routines, relatives’ viewpoint and a cognitive assessment. People spoken with said that the home meets their needs. The home does not offer intermediate care, therefore National Minimum Standard 6 is not applicable. DS0000017945.V362191.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their personal and healthcare needs will be met in Stronvar and they will be treated with respect. EVIDENCE: On the day of the inspection a senior carer was working on updating care plans and a sample of three care plans were examined. All contain a range of information with varying levels of detail. One care plan had a personal profile of the person giving a brief history of the person’s past life. This was written in a person centred way and gave details of things that the person likes, prefers and dislikes. Staff spoken with were able to demonstrate a good awareness of people’s care needs and people living in Stronvar made positive comments about how staff provide care. DS0000017945.V362191.R01.S.doc Version 5.2 Page 11 Overall there have been improvements in care planning since the last inspection but the manager and the senior care team recognise that they can continue to develop care plans until they are all up to a similar standard. Care plans examined contain evidence of monthly review, which ensures that people’s changing needs will be reassessed and appropriate changes made to their care. Risks were also identified in the care plans examined, so people living in the home may be confident that any potential risk to their wellbeing is considered and steps taken to minimise the risk. However, some of the recorded information relating to identified risks was brief and this is another area that the manager and her senior care team may consider prioritising as they update the care plans. As at the last inspection people continue to have their healthcare needs met at Stronvar. The AQAA states that there are regular visits from healthcare professionals and this is confirmed by the information in the sample of records examined. There is evidence of input from a range of healthcare professionals, including District Nursing and G.P. services. One person spoken with said they had received good support following a stroke. Records examined also contain information about optical prescriptions, weight records, continence charts, and details of hospital outpatients appointments. One person spoken with said that they receive the support they need to attend hospital appointments. The home operates a Monitored Dose System for medication and at the time of the inspection no-one in Stronvar was self-medicating. The administration of lunchtime medication was observed and appropriate practices were followed. The Medicine Administration Record (MAR) sheets were completed appropriately and medicines were stored securely. Overall there are sound procedures in place around the storage, recording and administration of medication, which should ensure people are protected. Information about good practices around the storage and administration of medicines was discussed with the manager and she plans to download guidelines on ‘The Handling of Medicines in Social Care’ from the Royal Pharmaceutical Society of Great Britain (RPSGB) website so that staff have an up to date guide for reference. Interactions between staff and people living in Stronvar were observed and confirm that staff are courteous and treat people with respect. Staff spoken with demonstrated a positive attitude and an affection for the people they are caring for. Members of staff passing through communal areas acknowledged people and passed the time of day with them. This added to the comfortable, relaxed atmosphere in the home. The AQAA states that they treat people with respect and ensure they have privacy. People’s personal care needs were seen to be met promptly and discretely and staff knocked on people’s doors and waited for a response DS0000017945.V362191.R01.S.doc Version 5.2 Page 12 before entering. One person spoken with said the staff are ‘lovely’ and another said they are ‘very helpful and nothing is too much trouble’. DS0000017945.V362191.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Stronvar have opportunities to maintain a lifestyle that meets their needs and wishes. EVIDENCE: The AQAA states that activities are tailored around individuals and they choose whenever possible what they would like. A discussion with the manager confirms that there is not a structured plan of weekly activities, but they do things like playing bingo or scrabble as and when people feel like it. The atmosphere in the communal lounge was peaceful and relaxed, but no-one appeared to be bored and were reading books or newspapers or doing puzzles. Some people were seen to be socialising and staff asked if people wanted to watch television, although they chose to leave the television off until after lunch. Some people choose to stay in their rooms but one person said they are encouraged to join in any activities that are going on. A member of staff was observed chatting to someone and suggesting they could have a game of Scrabble after lunch. DS0000017945.V362191.R01.S.doc Version 5.2 Page 14 Sometimes entertainers come in to the home and this is something that the manager said she wants to develop further. The manager is keen to look at other ways of providing more activities that people will enjoy and that will keep them interested and stimulated, so that they have a good quality lifestyle. One person said that they go out to play cards at a local club and go to church regularly. Records examined confirm that people are supported to meet their religious preferences. A local vicar comes in monthly so that people can have Holy Communion and some people go out to church weekly. As previously reported people living in Stronvar are supported to vote and people spoken with like to keep abreast of issues of local interest. Throughout the day of the inspection relatives and visitors were coming and going and those spoken with said they are made welcome. One person living in Stronvar said that they had visits from relatives every day while another spoke daily to their relative by telephone. Two people spoken with said they have their own telephones to keep in touch with friends and family and have kept their previous telephone numbers. People living in Stronvar are able to make choices and express opinions; this was observed throughout the day of the inspection. People spoken with are confident that staff listen to them and take their wishes into account. The manager said that they have meetings with relatives and people in the home approximately quarterly so that people can make their views known. The manager plans to introduce a suggestion box as another way for people to give their opinions. As at the last inspection, Stronvar continues to offer good food that people enjoy. The dining room is pleasantly furnished and tables are laid complete with napkins. There is a mixture of larger tables where some people choose to sit together and socialise over their meal and smaller individual tables for those who prefer to sit alone. There is a four-weekly rotational menu that offers a choice of hot meals at lunchtime; this menu was revised after consultation with people at a residents’ meeting. The AQAA states that they provide a good, varied menu from which people can choose and meals are served to individual requirements whether that requires meat to be cut up, food pureed or any other special diet. One of the kitchen staff goes round in the morning and asks people’s preference for lunch. The choice on the day of the inspection was cottage pie with fresh vegetables or sweet and sour chicken with rice. Both dishes were popular and people were seen to enjoy the meal. Individual meals were brought to the table with the plate covered to ensure the food stayed hot. There was a choice of desserts afterwards. People spoken with all said the food was good. DS0000017945.V362191.R01.S.doc Version 5.2 Page 15 A tour of the kitchen and food storage areas showed that a good variety of food is available including a selection of home made cakes for tea. The cook said she likes to bake fresh cakes about twice a week. A choice of sandwiches or hot snacks are available at teatime. The kitchen staff keep the kitchen, storage and food preparation areas clean and well maintained and they complete records of food temperatures and fridge/freezer temperatures to ensure people are kept safe by good practices around food preparation. DS0000017945.V362191.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are kept safe by the procedures followed around complaints and protection. EVIDENCE: As previously reported, there is a process in place for logging and recording complaints. Since the last inspection no complaints have been made to the home and none have been received by us at the Commission. The AQAA states that the manager and staff handle complaints immediately and information on how to make a complaint is prominently displayed by the visitors’ book. People living in the home confirmed that they are able to speak to staff or the manager about any concerns they may have. People spoken with said they were confident that they would be listened to if they raised any concern. The manager and staff spoken with were able to explain how they deal with minor concerns when they are raised and they are always available to discuss issues with people living in the home or their families. However, minor concerns and how they are dealt with could be documented as well so that the manager can demonstrate that they listen to people’s concerns and act on them. The manager and staff spoken with were able to demonstrate an awareness of their responsibilities around safeguarding vulnerable people. As previously reported, staff have received training around Protection of Vulnerable Adults. DS0000017945.V362191.R01.S.doc Version 5.2 Page 17 Staff spoken with were able to demonstrate an awareness of their responsibilities around safeguarding vulnerable people. There have been no complaints or issues that have resulted in adult protection referrals to the local authority. People living in Stronvar are kept safe by staff who follow good practices. DS0000017945.V362191.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): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home provides a homely and well maintained environment for the people living there. EVIDENCE: A tour of the premises showed that furnishings are domestic and comfortable and people living in Stronvar benefit from the homely surroundings. The proprietor takes a hands on role in ensuring both the home and the grounds and gardens are well maintained. People spoken with on the day of the inspection said the home is comfortable. One person said Stronvar is “very nice” and another said it’s “lovely”. Bedrooms are bright and airy, overloooking pleasant well-maintained gardens; they are individual and show ample evidence of personal possessions such as ornaments and photographs. One person said they “love the view” from their room. Many of the bedrooms have an en-suite toilet which is separated from DS0000017945.V362191.R01.S.doc Version 5.2 Page 19 the room by a curtain. Although this affords people with a degree of privacy, people may feel a lockable door offers greater privacy. Stronvar is kept clean and fresh and there are no unpleasant odours. The laundry is small but has appropriate washing and drying machines for the size of the home and is clean and well-maintained. The laundry is situated so that soiled laundry does not need to be carried through areas where food is prepared or served, which helps protect people by maintaining good infection control. A sample of staff records examined showed evidence of Infection Control training. The bathroom and toilet areas are all clean and maintained to a good standard and contain liquid soap for hand washing. However, it was noted during a tour of the premises that toilets contain terry towels for people to dry their hands. The manager said that these are changed frequently and they were seen to be fresh and clean. The use of paper towels for drying hands in the toilets is better practice if people living in the home are to be protected by good infection control. DS0000017945.V362191.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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall people living in Stronvar benefit from being cared for by a competent staff team, although improvements could be made in processes around recruitment and training to ensure people are safeguarded by staff who have been recruited and trained following robust procedures. EVIDENCE: The AQAA states that there are good staffing levels and they work as a team with an assortment of skills. On the day of the inspection staffing levels were seen to be appropriate and people’s needs were being attended to promptly; staff took time to talk to people and care was delivered in an unhurried way. The management team know the people living in Stronvar well and ensure staffing levels are tailored to meet people’s changing needs. People spoken with were complimentary about the staff team; one person said, “nothing is too much trouble for them” and another said, “they are very good, they have a lot of patience”. As at the last inspection, less than 50 of care staff have obtained an NVQ at level 2 or above, as recommended in the National Minimum Standards. Although staff spoken with were able to demonstrate an awareness of good practices and observations confirm that staff provide care in a professional manner, the management team should continue to support staff to obtain an DS0000017945.V362191.R01.S.doc Version 5.2 Page 21 NVQ award so that people living in Stronvar benefit from being supported by a well-qualified and skilled staff team. The manager had acknowledged this in the AQAA as an area that they need to improve. The manager and senior staff are able to demonstrate a good awareness of the importance of vetting prospective carers by carrying out appropriate Criminal Records Bureau (CRB) checks and ensuring that they employ staff who will work well within the home. This is particularly important because the home is not large and staff need to be supportive and work well together to ensure people living in the home receive consistent support. Many of the staff working at Stronvar have been there a long time and, although some new staff were being recruited at the time of the inspection they were not yet in post, therefore the sample of personnel records that were examined related to staff who had worked for some years in the home. Files contained a range of information, however, they were not well organised and all the documents required by regulation are not in place. As previously reported, Regulation 19 and Schedule 2 of the Care Homes Regulations 2001 require managers to obtain information about staff before they are employed in the home. Documentation listed in Schedule 2 includes proof of identity including a recent photograph, two written references, a full employment history with a satisfactory written explanation of any gaps and a statement by the person as to their mental and physical health. Not all of this information was in the sample of personnel records examined. Two files did not contain two written references and did not have recent photographs of the members of staff. None of the records examined contained a statement from the staff as to their mental and physical health. Personnel records examined contain evidence of a range of training including Best Practice in Medication Management, Manual Handling, Fire Safety, First Aid and Infection Control. There is also evidence of induction training for new staff. Staff spoken with were able to demonstrate an understanding of good care practices. However, there is not a planned training programme for the current year. When staff are well trained and their training is up to date, people living in the home and their relatives can have confidence in the ability of staff to meet their needs. In order to ensure training is kept up to date there needs to be a more structured programme for staff training. DS0000017945.V362191.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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Stronvar is competently managed and run in the best interests of the people who live there. EVIDENCE: At the time of the inspection, the registered manager had recently left and a new manager was in post. The new manager had only been doing the manager’s job for a few weeks and was still becoming familiar with the records and the management role, although she knows the home well. The manager was able to demonstrate an enthusiasm for the job and stressed her commitment to getting on top of the role as quickly as possible. The manager and senior staff are working together closely and the proprietor still maintains an active role in the home and it is evident that their skills complement oneanother. Senior staff are supporting the new manager well and people spoken DS0000017945.V362191.R01.S.doc Version 5.2 Page 23 with said they were happy that things continued to run well despite the management change. On the day of the inspection the Quality Assurance system was discussed with the manager. Although the process is not formal, there is evidence that the views of people living in the home are sought and acted upon. Residents meetings are held about every three months; although formal minutes are not always recorded, people said they are asked about the way they like things done. People spoken with, including staff and people living in Stronvar, confirm that they are consulted on matters relating to the way the home is run. Overall the management team at Stronvar are able to demonstrate that the service responds to people’s views and wishes. However, the Quality Assurance process could be further developed and improved if all the things they are already doing are brought together to form an action plan for the home. The manager acknowledges in the AQAA that they could improve by clearer recording of their Quality Assurance processes. As at the previous inspection, there continues to be a process in place to support people with managing their finances where necessary. Individual records and small amounts of money are stored separately and securely and the process is robust and ensures people living at Stronvar are protected. Records examined show that appropriate maintenance checks are carried out, including Portable Appliance Testing (PAT), fire safety checks and gas safety certificate. The mobile hoist, bath hoist, lift and stair lift all received a recent safety check. There was evidence of recent local authority Food Hygiene and Environmental Services Premises Inspections in which all was found to be in order. Information regarding the Control of Substances Hazardous to Health (COSHH) is in place. People living in Stronvar benefit from the maintenance checks that are in place and the procedures that staff follow to ensure people’s health, safety and welfare is safeguarded. DS0000017945.V362191.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 2 3 3 X X N/A 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 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 DS0000017945.V362191.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19, Schedule 2. Requirement Records relating to recruitment that are required under Regulation 19, Schedule 2 of the Care Homes Regulations 2001 must be maintained. Staff who are not recruited through a robust procedure could put people living in the home at risk of harm, poor practice or abuse. This is an outstanding requirement from the last inspection. Timescale for action 30/06/08 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. Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose and Service user Guide should be kept up to date so that sufficient information is available for people wishing to move in to the home to be able to make an informed choice. Care plans and risk assessments could be improved by recording greater detail and by regularly reviewing and DS0000017945.V362191.R01.S.doc Version 5.2 Page 26 2. OP7 3. OP28 4. OP30 5. OP33 updating them. The manager should continue to support staff to obtain an NVQ award so that a minimum of 50 of care staff have the qualification. This level of basic skills supports the staff team in meeting people’s needs. The manager should ensure that the home has a staff training programme that ensures all staff receive training that is relevant to meet the needs of people living in the home and the training is kept up to date. The manager should continue to develop the Quality Assurance system so that when they seek the views of people living in the home and other interested parties, the information is used to form a development plan, which demonstrates that people’s views are being acted upon. DS0000017945.V362191.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000017945.V362191.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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