Care Home: Summerhayes Residential Home

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What the care home does well Summerhayes provides a homely, relaxed and comfortable environment with a welcoming and friendly atmosphere. The home is kept clean and smells pleasant. A good admissions procedure is in place that ensures that only people whose needs can be met are offered places at the home. Prospective residents and their representatives have the opportunity to visit the home to see if they like it before they move in. The home has a good care planning system in place to ensure that staff have the information they need to meet the health and personal care needs of residents. A range of community health professionals support the care staff in looking after residents. Residents confirmed that they felt well treated. Residents are encouraged to exercise choice in their daily lives. Activities are on offer at the home that residents can join in with if they choose to. Visitors are always welcome at the home and residents are encouraged to maintain and develop relationships with people in the home, with their families and friends and maintain links with the local community. Meals are varied and a choice is always available. The dining area is pleasant and comfortable. The complaints and adult protection procedures reassure residents and their representatives that the well-being and comfort of residents is important to the home and that any concerns raised will be properly investigated and resolved. Sufficient numbers of well-trained staff are on duty throughout the day and night to be able to meet the needs of the residents. The home is well managed and organised with the care, contentment and safety of residents being central to the way the home is run. What has improved since the last inspection? Concerns were raised about medication administration following the inspection in March 2007 and a Commission pharmacy inspector visited the home in May to look at their system in depth and to provide guidance as to improvement. The home has taken on board this advice and significant improvements were noted in medication administration. In June ten members of staff attended training in adult protection. Some improvements to recruitment practice were required. Evidence of Protection of the Vulnerable Adult`s register checks are now in place prior to new members of staff starting work at the home. Staff members are now receiving training in line with Skills for Care Induction Standards. General records of training taking place in the home are kept, enabling training needs to be monitored and identified, ensuring that staff members have the skills and competencies to meet the needs of residents. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Summerhayes 1700 Wimborne Road Bear Cross Bournemouth Dorset BH11 9AN Lead Inspector Debra Jones Key Unannounced Inspection 22nd October 2007 10:15 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 Summerhayes DS0000003989.V353501.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. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summerhayes Address 1700 Wimborne Road Bear Cross Bournemouth Dorset BH11 9AN 01202 574330 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) summerhayesresthome@hotmail.co.uk Dr John Hutchings Mrs Jane Hutchings Mrs Tracy Anne Fitzpatrick Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 2007 Brief Description of the Service: Summerhayes is owned by Dr & Mrs Hutchings, the registered manager is Tracey Fitzpatrick. The home is registered to accommodate a maximum of twenty-one older persons requiring personal care. Located in Bear Cross, a suburb of Bournemouth, Summerhayes is close to local shops, pubs and post office and has main road access to both Poole and Bournemouth town centres. Resident accommodation is provided over two floors with a central stairway with a chair lift providing access between floors, there are nineteen single bedrooms and one shared room, three rooms have en-suite facilities, the remainder have use of conveniently sited bathrooms and toilets around the home. Communal space is provided on the ground floor, a lounge and dining area and a smaller sun lounge area are available. Pleasant gardens are accessible to residents and off road parking is provided for a limited number of cars. Summerhayes provides twenty-four hour care and domestic services including laundry and catering. Current fees are £442 to £487. See the following website for further guidance on fees and contracts: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choos.aspx Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days namely the 22nd and 24th October 2007. Debra Jones was the inspector who carried out the visit. The second day was spent with residents. The main purpose of the inspection was to check that the residents living in the home were safe and properly cared for and to review progress in meeting the requirements and recommendations made previously. The inspector was made to feel welcome in the home throughout the visit. A tour of the premises took place and a variety of records and related documentation were examined, including care records. Time was spent talking with residents in their bedrooms and in the lounge. Mrs Hutchings, one of the owners, assisted the inspector on arrival. The manager was not able to attend but her deputy and staff provided the support needed to enable the inspection to be fully carried out. Throughout the inspection the home welcomed ideas and suggestions and appeared keen to work with regulators for the benefit of their residents. Three requirements were made as a result of this visit and one recommendation. Some good practice suggestions were discussed at the inspection and these are referred to in the summary and in the main body of the report, intended to encourage further improvement. Prior to the inspection the home submitted to the Commission their completed annual quality assurance assessment (AQAA). This gave information about the service and it’s performance. This document was helpful in the planning of the inspection visit. The home also sent out comment cards on behalf of the Commission. Five were returned by relatives and these are some of the comments they made. ‘My relative has been content at Summerhayes for some years now.’ ‘I’m impressed with the friendly care my relative gets.’ When asked ‘what the home does well’ relatives said: ‘Looking after the elderly, welfare, excellent food.’ ‘Summerhayes responds well to my mother’s needs. As she has dementia she can be demanding at times, but is always treated with kindness and respect.’ ‘Everything.’ ‘Friendly care. All the carers seem to develop a friendly relationship with my relative quickly. Cleanliness.’ Comments from residents at the visit included: ‘You can’t fault it!’ ‘Anything we want, we get.’ Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 6 ‘Staff are helpful in every walk of life.’ ‘It is a home from home.’ ‘Staff are very willing you’ve only got to ring the bell.’ ‘I am appreciative of all they do.’ ‘I am happy but it is nothing like home.’ ‘I came for 6 weeks and decided to stay.’ What the service does well: What has improved since the last inspection? Concerns were raised about medication administration following the inspection in March 2007 and a Commission pharmacy inspector visited the home in May to look at their system in depth and to provide guidance as to improvement. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 7 The home has taken on board this advice and significant improvements were noted in medication administration. In June ten members of staff attended training in adult protection. Some improvements to recruitment practice were required. Evidence of Protection of the Vulnerable Adult’s register checks are now in place prior to new members of staff starting work at the home. Staff members are now receiving training in line with Skills for Care Induction Standards. General records of training taking place in the home are kept, enabling training needs to be monitored and identified, ensuring that staff members have the skills and competencies to meet the needs of residents. What they could do better: The home needs to confirm in writing to prospective residents that, based on their pre admission assessment, they are able to meet their needs. Further improvements need to be made to the medication administration system to make sure that residents get their medication as prescribed i.e. signing and countersigning handwritten entries on the medication administration records. Also the home should obtain a thermometer for the fridge they store medicines in to record the minimum and maximum temperature it achieves to make sure that the medicines are not getting too hot or too cold. As part of the recruitment process the home needs to ensure that they have all the documentation required by law, which is there to safeguard residents from unsuitable people working at the home. Such documentation includes photographic proof of the person’s identity and a full employment history. A quality assurance system needs to be in place so that the home can measure their performance, taking in account the views of the residents, in meeting the aims and objectives of the home. In addition to the 3 requirements and recommendation made in this report the following good practice suggestions are made that the home are urged to adopt and act upon. The home is encouraged to: • Date all information coming to the home that relates to residents e.g. assessments and reviews from local authorities. • Obtain the clinical triggers available on the CSCI website in respect of continence, dementia care, prevention of falls, pressure area care (tissue viability) and nutritional care (incorporating the malnutrition universal screening tool). • Clearly state in the care plans what staff are to do to ensure the safety of the resident where risks assessments identify risks. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 8 • • • • • • • Ask for an occupational therapy assessment for the resident they are hoisting to confirm their own moving and handling plan. Mark containers of tablets, that are dispensed outside of the monitored dosage system, with the date they are brought into use in order to easily work out how many tablets should be on the premises. Improve staff rosters by including what jobs staff are doing e.g. cook / cleaner etc. Obtain up to date information about completing fire risk assessments and expand the home’s fire risk assessment in line with this advice. Consider the frequency of fire training for staff as part of the fire risk assessment. (The local norm is every 6 months for day staff and every 3 months for night staff.) Improve accident records by consistently noting if accidents were actually seen by the person completing the report form or if residents told them what had happened. Carry out regular analyses of the accident records in order to see if there are any patterns or trends e.g. significant numbers of accidents involving certain residents, particular times or places where accidents take place. 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. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 9 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 Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough pre admission procedure is in place and assessments are routinely undertaken to ensure that only residents whose needs can be met by the home are offered places there. EVIDENCE: Two pre-admission assessments were seen for residents who had moved into the home since the last inspection. Prior to anyone moving to the home their needs are fully assessed by the senior staff from the home. The needs of the resident are assessed using a prescribed format that has been developed to encompass health and welfare needs. The records indicated that the needs and circumstances of the people had been properly taken into account. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 11 Prospective residents are given the opportunity to visit and spend time at the home as are their representatives. One of the newly admitted residents had visited the home and had their needs assessed at the same time. The home do not confirm in writing to residents that the home can meet their needs following the pre admission assessment. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 12 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. Systems are in place to provide staff with the information they need to meet the health and personal care needs of residents. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The information contained in pre-admission assessments, and also any assessments supplied by funding authorities, is used to help draw up a detailed plan of care. The home are advised to date any information that relates to residents with the date of it’s receipt at the home e.g. local authority assessments. All residents have a care plan and three of these were reviewed at this visit. Files were well laid out and plans easy to read; informative about the needs of Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 13 the resident in relation to their personal care, physical and mental health, social care and of how the home was to meet these needs. A series of assessments carried out on arrival at the home e.g. risk assessment, falls risk assessment, pressure area care and nutrition, also feed into the care plan. Where risks assessments show that risks have been identified staff were able to say very clearly what they had to do to ensure the safety of the resident but the specific details were not always transferred onto the care plans. Detailed daily records are maintained, written in the mornings, afternoons, evenings and at night. These evidence the delivery of care to residents and feed into the regular reviews of care plans. All five relatives who responded by comment card said that they were ‘always’ informed of important matters in respect of their relative. Four felt the home ‘always’ met the needs of their relative and three that the home ‘always’ gave the support or care to their relative that they’d expected or agreed. The others who replied said the home ‘usually’ managed to do these things. Comments included ‘Help is always given.’ ‘We find the staff and management helpful and easy to talk to.’ Evidence was available on file and through discussion with management that GPs, district nurses, opticians and chiropodists are available to residents. Notes demonstrated that residents received prompt attention from health professionals. One resident talked of seeing the dentist the day before and of regularly seeing a chiropodist. Staff are using a hoist to assist one resident. A moving and handling assessment was in place. It was suggested that the home ask for an occupational therapy assessment to confirm their own. Another resident has diabetes that needs to be controlled by drugs. The care plan was clear about what the home had to do to support the resident to manage this condition and the resident was well aware of when they needed assistance and the form that this would take. Medication procedures were reviewed. Risk assessments are carried out for those residents who self-administer some or all of their medications. The home keeps a record of sample signatures, as used on the medication records. Medication administration records were reviewed and no gaps were seen. Some handwritten entries were made on the printed medication records it was not always the case that these were signed by the person making the entry and countersigned by another competent person. Allergies were noted, or it was stated that none were known. The quantities of medicines arriving in the home were noted on the Medication Administration records and signed to confirm this once they had been checked. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 14 Photographs of residents were kept with these records to ensure that the right people got the right medicines. Most medicines arrive in the home in a monitored dosage system. A sample spot check was done of medicines that are not in this system e.g. tablets in boxes / bottles. Records confirmed what should have been in boxes in two out of three cases. Where tablets are dispensed outside of the monitored dosage system it is suggested that they are marked with the date they are brought into use so it is easy to work out how many tablets should be on the premises. I was told that all the people who have medication prescribed ‘when required’ are able to say if they need it or not. Medication was appropriately and safety stored. Some medicines are stored in a fridge. Whilst the temperature of the fridge is noted, the thermometer in use does not record the highest and lowest temperature that the fridge achieves so it is currently not possible to tell if the medication is always kept at the right temperature. Medication that is returned to the pharmacist is noted in the returns book, which was seen. No residents are currently being prescribed controlled drugs. Residents talked about their medication. Some talked of how the home looked after it for them and brought the medicines to them when they were supposed to. One resident spoke of how she looked after her own medicines, keeping them safe in her own room. She said that the home were going to get her a lockable wall cabinet for their room for her to keep them in. Care records seen referred to protecting residents’ privacy and dignity. Staff members knocked on residents’ doors before entering. Written care routines are now kept inside wardrobe doors so that they are discreetly available to staff members carrying out care and promote the protection of residents’ dignity. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 15 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. A range of activities is available for residents to participate in should they choose to. People are generally encouraged to make choices about their life style and to maintain contact with their family and friends. The meals in this home are wholesome and varied and are served in a pleasant environment. EVIDENCE: From discussion with people who live at Summerhayes it was clear that they enjoy a varied lifestyle, which meets with their individual preferences. The deputy manager talked of how some residents had expressed an interest in doing more crafts and of how the home had responded to this. During the day resident spend time in their own rooms or with other residents in the lounge. Residents also talked of going out with families and friends and attending the church and generally of how they liked to spend their days. ‘We enjoy eating and talking – in the lounge.’ ‘I have meals in my room. I am able to amuse myself. I have my own TV.’ Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 16 ‘The library service is really good.’ ‘I enjoy knitting.’ ‘I enjoy crochet / jigsaws – I prefer my own company – I am too busy. I go to the group scrabble once a month.’ ‘There is a church service monthly – I go out to church meetings / events – I am going this afternoon to a puppet workshop.’ ‘There are some entertainments. I watch TV – what I like – I read and write letters. We have a chat on our lunch table.’ ‘Hairdresser comes, she does our hair in the small lounge.’ The local library service visits the home regularly as does a hairdresser. An exercise session takes place fortnightly. Visitors are encouraged to visit the home at any time. Residents records and the visitors book demonstrate contact with family and friends as well as visits from professionals. ‘I have visitors they are made very welcome – they’ve got to know them. There’s always a cup of tea- they are very good like that.’ People are encouraged to pursue their own lifestyles within the home and make individual choices wherever possible. These include choosing when to get up and go to bed, what to wear, what to eat and drink and to generally do as they wish during the day. Many bring their own possessions into the home and personalise their bedrooms as was seen when the premises were toured. Residents are given a weekly menu, which shows the choice of meals available. Lunch on the 1st day of the inspection was cold gammon with parsley sauce, served with vegetables, followed by fruit and custard. Some residents have their meals in the home’s main lounge; others in their own rooms, according to personal choice. In general people said that the food was to their liking. Comments from residents at the visit included: ‘Meals are good and nourishing.’ ‘The food’s not bad – I am diabetic they find alternatives for me – I love the cook we have a great rapport her father is diabetic so she understands.’ ‘The food is good – I have a soft diet – it is very good – they know what I can eat.’ ‘Sometimes there is too much food– it is off-putting.’ Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a complaints procedure. Policies and staff training in abuse protect residents from harm. EVIDENCE: The complaints procedure is made available to residents and their representatives. This includes who to contact and how long it takes for the home to respond to a complaint. The procedure is displayed in the reception area of the home. No complaints have been received by the home or by the Commission for Social Care Inspection since the last inspection. Residents spoken with at the visit said that they knew who to speak to if they were not happy, either directly to staff or to their relatives to take things up for them with the home. All said that they had nothing to complain about. Relatives were also asked if they knew how to make a complaint if they needed to. Four of the five people who responded said yes. The other could not remember. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 18 The home has an adult protection policy. There is also staff training in this subject at the home from induction onwards. Ten staff had training about protecting people from abuse in June of this year. Prior to any members of staff commencing employment at Summerhayes the Protection of Vulnerable Adults list is checked to ensure their suitability. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in comfortable, safe and well-maintained surroundings, which are clean with no unpleasant odours. EVIDENCE: A tour of the premises confirmed that Summerhayes is generally well maintained. The home has a warm and homely atmosphere. It is well decorated throughout. The home has a lounge, which is also used as the dining room and there is a separate sun lounge. The lounges and dining area are comfortably furnished and provide sociable meeting places for residents. All individual rooms visited were personalised, with furnishings, photos and pictures. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 20 The home benefits from a call bell system, which is portable, so that residents can call for assistance when required. At the last visit it was noted that a shared bedroom was being converted to a room with en suite facilities to be offered to either a couple or for single room occupancy. This work has almost been completed. An area on the landing has been altered to make provision for storing the laundry that used to be kept in this room. Before new residents move in their rooms are redecorated / refurbished as needed. Aids and adaptations are available throughout the home e.g. raised toilet seats - and some residents with particular needs have their own personal equipment to assist with their independence. Some bedrooms have en suite facilities and there are communal bathrooms and toilets conveniently positioned around the home. There is a passenger lift in the home, enabling easy access between the floors. There are emergency alarm bells throughout the home. The home has suitable machines to launder clothes and bedding at appropriate temperatures. All areas of the home seen were clean and smelled pleasant. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient, well-trained care staff are employed and deployed to meet the care needs of residents. However residents are not currently fully protected by the home’s recruitment procedures. EVIDENCE: Rosters show that the home maintains adequate staffing levels to meet the number and needs of residents currently living at Summerhayes. More staff are available at peak times of day. Staffing rosters show who is on duty at any time and could be improved by including what jobs staff are doing e.g. cook / cleaner etc. The manager confirmed that nineteen members of care staff currently work at the home. Five members of staff currently possess a National Vocational Qualification in Care (NVQ) at level 2, seven have completed and are awaiting their certificates and 3 are studying for the qualification. Recruitment records were viewed for three members of staff who had started working in the home since the last inspection. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 22 Most documents that should be on file were. Prospective staff complete an application form and are interviewed. The files included proof that the person was not on the Protection of Vulnerable Adults list, held by the Department of Health and Criminal Record Bureau disclosure certificates. References had been also been received, although one file showed that only one reference had been obtained rather than the two required by law. Two of the three files contained proof of identity, although one of these was not photographic, and the reasons for the lack of a photographic proof of identity had not been recorded. One of the files did not contain a full employment history or written reasons for the gaps. At times the home has to rely on agency workers to keep the home fully staffed. It was good to see that records showed that the home had the required information about agency workers e.g. in respect of pre employment checks, proof of identity and training. New staff undertake induction and foundation training based on those provided by ‘Skills for Care’ – the industry standard. Individual summary records of training undertaken are kept on each staff member’s file as well as an overview of all staff members’ training. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well organised and the daily management and running of the home centres round the care and contentment of residents. Solid management practice, systems in place, and records kept, confirm the health and safety of people in the home. EVIDENCE: The manager of the home has the appropriate skills and experience to carry out her role and is undertaking the Registered Manager’s Award and the National Vocational Qualification at level 4 in care; hoping to complete these Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 24 by the end of the year. She is ably supported on a day to day basis by a deputy manager and the owners of the home. Prior to this inspection the home completed an annual quality assurance assessment (AQAA), which they submitted to the Commission for Social Care Inspection. This identifies what the home feels they do well and sets out their plans for improvement over the next twelve months. The home sent out and made available comment cards for the Commission as requested before this visit. Comments came back from 5 relatives. All were generally positive about the home. The home does not have a quality assurance system and development plan at present. The home have devised questionnaires to give to residents, relatives etc to find out more about what people think about the home. They are intending to issues these soon. Residents’ monies held by the home are securely and individually stored. At the last visit it was advised that all entries in records of amounts held should be signed and verified by two staff members. This has been addressed. Monies held for three residents were checked and corresponded with their balance sheets. Receipts for money spent are also kept with residents’ money. All records were available as requested at the inspection. An up to date insurance certificate was on display along with the home’s registration certificate. Practices at the home are underpinned by a range of policies and procedures which the home confirmed were recently updated. The home’s fire risk assessment was seen. This was last reviewed in April 2007. At this time no new fire risks were identified that needed to be addressed. The fire risk assessment was quite brief and the home were advised to obtain up to date information about completing fire risk assessments. Staff fire training and fire drills are frequently carried out to ensure all are fully aware of what to do should a fire break out. It was suggested that when the fire risk assessment is updated consideration be given to the frequency of fire training for staff. (The local norm is every 6 months for day staff and every 3 months for night staff.) Appropriate records are kept of the regular internal and external checks of fire safety equipment maintenance. Accident records were looked at. These were generally well completed. They could be improved by consistently noting if accidents were actually seen by the person completing the form or if residents told them what had happened. It is suggested that the home starts to carry out regular analysis of the accident records in order to see if there are any patterns or trends e.g. significant numbers of accidents involving certain residents, particular times or places Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 25 where accidents take place. Once analysed measures can be put in place to try and reduce accidents in future. Appropriate notifications about incidents and accidents are made to the Commission as required by law. In addition equipment is regularly maintained. Information sent to the Commission prior to the inspection confirmed that the home is undertaking appropriate checks of equipment and facilities at appropriate intervals. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 27 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 OP4 Regulation 14 Requirement Prior to admission the registered person must confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’ s needs in respect of his health and welfare. All items listed in the regulations in relation to recruitment / staffing must be obtained and kept on file e.g. full employment histories and proof of the person’s identity including a recent photograph. (Previous timescale 10/04/07 partly met.) 3. OP33 24 31/12/07 The registered persons must establish and maintain a system for reviewing and improving the quality of care in the home, a report of any such review must be provided to the Commission and be available to service users. (Previous timescale 31/03/06 not met.) Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 28 Timescale for action 31/12/07 2. OP29 17 30/11/07 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 OP9 Good Practice Recommendations The home should follow guidance from the Royal Pharmaceutical Society including: To ensure that prescribed medicines that are handwritten on the MAR chart have been copied correctly the person making the entry should sing it and a second trained carer should countersign. The home should obtain a thermometer for the fridge they store medicines in to record the minimum and maximum temperature it achieves. Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Summerhayes DS0000003989.V353501.R01.S.doc Version 5.2 Page 30 - 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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