Care Home: The Limes

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What the care home does well This is a pleasing inspection result with "good" outcomes for the people who live in the home.The Statement Of Purpose and Service User Guide are very informative and tell people clearly what services the home offers. Staff have a person centred approach and care is delivered with dignity and respect. People who live at the home have a "voice" and feel involved in the daily life of the home. The home is well managed and the manager is approachable and runs an open door policy. The home is managed in the best interests of the people who live there. What has improved since the last inspection? A Controlled Drugs cabinet has been installed in order to comply with new legislation and ensure that Controlled Drugs are stored securely and safely. The temperature of the rooms used to store medication are now monitored and recorded. This is to ensure that medication is stored at the correct temperature. What the care home could do better: The home is registered to care for up to 10 people with dementia needs. As such, it is recommended that all care staff are given training in dementia so that they will be better able to understand and meet the specific needs of these people. The fabric of the home both internally and externally is looking worn and tired and the home is due to close in September 2009. It is recommended that general maintenance of the home be continued in order to ensure that people live in a suitable and comfortable environment. Trips out do take place but not often. As such, it is recommended that more funds are made available for activities, particularly for trips out for the people living in the home to enjoy. CARE HOMES FOR OLDER PEOPLE The Limes Linley Road Rushall Walsall West Midlands WS4 1HL Lead Inspector Yvonne Allen Unannounced Inspection 24th September 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 The Limes DS0000071296.V372301.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. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Address Linley Road Rushall Walsall West Midlands WS4 1HL 01922 654 810 01922 724 716 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) www.housing21.co.uk Housing 21 Manager post vacant Care Home 34 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (34) of places The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 10 Old age not falling within any other category (OP) 34. The maximum number of service users to be accommodated is 34. 2. Date of last inspection Brief Description of the Service: The Limes is registered to provide accommodation and personal care for a maximum of thirty-four older people. The service is now provided by Housing 21 The Limes is a two-storey building with lift access between floors. Accommodation in the home is provided in 32 single rooms, plus 1 double room and is divided into 4 separate units. Each unit comprises of bedrooms with wash hand basin, bathrooms, separate toilets, a lounge area and a kitchen/dining area. The home can accommodate up to 34 older people for personal care (residential), including up to 10 who may have dementia care needs. The Limes is located near to the centre of Rushall, Walsall, next to a bus route and shops and a health centre are nearby within walking distance. There is a small car park at the front of the property. People can obtain information about this service from the Statement of Purpose and Service User Guide. These documents contain information on the fees charged by the service, currently recorded as £420.00 per week. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 5 The home is due to close in September 2009. The Service User Guide outlines the details of this closure. People who live in the home and their representatives are being kept fully updated of the planned closure. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. The inspection process commenced several weeks prior to the visit. The visit to the home took one inspector 4 hours to complete. All of the Key minimum standards were assessed and for each outcome a judgement has been made, based on the evidence gathered. These judgements tell us what it is like for the people who live in this home. The ways in which in we gathered evidence to make our judgements were as follows – We looked at any information we had received about the home since the last Key Inspection. Several weeks prior to this inspection visit we sent out surveys so that people could tell us what it is like at the home. We received 8 completed surveys from people who live at the home, 2 surveys from relatives and 5 from staff who work at the home. Their comments have been included in this report. We spoke with the people who live in the home. We spoke with the staff who work at the home. Discussions were held with the acting manager of the home. We examined relevant paperwork and documentation at the home. We walked around the home. At the end of the inspection visit we discussed our findings with the acting manager. There were no requirements and 3 recommendations made as a result of this inspection. This home was previously owned by Walsall Council and requires complete modernisation. The new owners (Housing 21) are planning to close this home in September 2009. What the service does well: This is a pleasing inspection result with “good” outcomes for the people who live in the home. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 7 The Statement Of Purpose and Service User Guide are very informative and tell people clearly what services the home offers. Staff have a person centred approach and care is delivered with dignity and respect. People who live at the home have a “voice” and feel involved in the daily life of the home. The home is well managed and the manager is approachable and runs an open door policy. The home is managed in the best interests of the people who live there. 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 The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Limes DS0000071296.V372301.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 The Limes DS0000071296.V372301.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): Standards 1,3,4 and 5 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their representatives have the information needed in order to assist them in making a decision. People can be assured that this home will be able to meet their assessed needs. EVIDENCE: The home provides a Statement Of Purpose (SOP) that is specific to themselves and the people they care for. It clearly sets out the objectives and philosophy of the home and is supported by a Service User’s Guide (SUG). The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 11 People told us that they are given a copy of the guide. When requested the home can provide a copy of these documents in a format, which will meet the capacity of each person. The guide states - “Should you require this pack in large print, Braille or on audio tape, we can provide this. Please let us know your individual requirements.” The SUG and SOP are very informative and helpful documents for people to refer to in order to be able to make a decision about moving in to the home. The Yearly Quality Assurance audit identifies that – “Service users, their relatives and friends are given an opportunity to visit the home, access its facilities and assess its suitability. Service users are asked to attend a day assessment prior to admission to ensure the home meet the service users level of need.” We were informed by the acting manager Helena, that people are mostly being admitted to this home for short stay, but the home are still accepting people for a four week assessment with a view to becoming permanent residents. This is if they are happy to accept the forthcoming changes and possible moves to a new building. Referrals and assessments are undertaken by Social Services – we saw this for a person recently assessed. A full and comprehensive assessment of individual needs is carried out by a member of staff from the home (who is qualified to do so). The manager told us that it is mainly herself who goes out to assess people following a referral but that any of the managers within the company can assess in her absence. She told us that sometimes she has to decline admissions, if she feels that the home cannot meet the needs of an individual and gave an example of this. The manager told us that people and/or their representatives are encouraged to come in for a look around the home and to stay for lunch, and come back again if necessary. When we spoke to some of the people who live in the home they confirmed that either they or their relatives had been to have a look around the home prior to admission. People are admitted to the home initially for a trail period of 4 weeks. The Limes DS0000071296.V372301.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): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered and delivered in a person centred way. Healthcare needs are monitored and met, with access to outside healthcare professionals. People are treated with dignity and respect. EVIDENCE: The SUG tells people – “All residents who reside at our homes should receive a 6 monthly review. This is to review the care plan, and ensure that everyone is happy with the current level of care being delivered. Next of kin will always be notified of the review, and we are happy to change times and dates to accommodate your attendance.” The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 13 About medication the SUG says – “Staff will, if requested to do so by residents, give out your medication to you at the prescribed times. Should you wish to administer your own medication, please discuss this with the duty officer who will make arrangements for you to store your own medication safely.” We looked at the mediation system and found it to be safe, efficient and supported by procedures, which staff understand and are familiar with. Staff who administer medication have had suitable training to allow them to do so. We looked at some individual care plans and spoke to people who live in the home as well as some visiting relatives and staff. We also observed staff interaction and care practices. We looked at records relating to the receipt, storage, administration, and disposal of medication and observed administration of medication on two of the units. People told us that they felt “safe” and “well cared for” at the home. People also explained how their preferences and choices are upheld throughout the routines of daily life in the home. This included choices relating to times of going to bed and getting up, bathing and personal care. One person said “I have help when I need it but at the same time I manage to keep my independence.” A visiting relative told us that “the home is very good – my mother is well cared for.” We observed staff interacting in a caring and sensitive manner with people – and speaking respectfully with them, whilst still maintaining a sense of humour. People looked well cared for and were dressed smartly in their own coordinating clothing. One lady told us “My son chooses my clothes for me to put on each day.” Health care needs are met well at the home. There is a good support system of GPs, District Nurses and other visiting professionals. There we are good records of these visits within care plans. People are able to stay at the home if they become terminally ill – with the support of these health care professionals. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 14 The Limes DS0000071296.V372301.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): All the standards for this outcome were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at this home are able to make choices about their life style, and supported to develop their life skills. EVIDENCE: The SUG tells people that – “Residents are encouraged to pursue a range of social activities, hobbies and leisure interests. The ring and ride is accessible to residents wishing to pursue activities away from the home. Within the home, staff arrange and encourage residents to participate in a range of activities and to utilise the facilities of the local community where appropriate. The home also has a residents’ computer linked to the Internet available for all residents to access.” Also – “within the home there are no restrictions on visiting times. Friends, relatives and representatives are free to visit and telephone at any time. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 16 Additionally, at an individual’s own cost additional telephone lines may be fitted into bedrooms.” Outings are arranged by the home throughout the year. Many service users also attend social evenings. There are no restrictions on service users leaving the building or going out. We would merely request to know an appropriate time of return for safety reasons. Assistance may be available in relation to trips, escorts, transport or holidays.” “Religious services are held periodically within the home.” In the SUG the programme of activities includes – “Bingo, Sing-a-Long, Quiz, Reminiscence, Board Games and Movies.” We also noted – exercise classes and nail beauty sessions. The staff at the home enable people to develop and/or maintain any existing interests or hobbies they might have. The key workers and co-workers help people to identify their goals, and work to achieve them. Trips out do take place. These have included visits to Walsall lights, Blackpool, meals out and shopping trips. It is recommended that more funds are made available for activities, particularly for trips out for the people living in the home to enjoy. Church services are held at the home every second Sunday of the month. One lady told us “Great home” “Meals are great.” She went on to explain how choices are upheld and “whatever you fancy” is usually catered for “I love the somosas!” This person also has a very personalised bedroom with an abundance of books around. She told us - “Oh I love my books – I get them form the visiting library mostly.” I like adventures and historical books.” She also told us that – “The hairdresser comes on a Monday” and “I go out to the shops now and again and I go my sister.” We were told that one lady has her own vicar coming to visit her from the Church and her son confirmed this to us. We were told that activities take place on each unit. When entertainers come in to the home then everybody comes together. On Churchill Unit people were in the lounge involved in activities. The menus are rotational and offer a nutritious variety of meals. We were informed that these would soon be changing to 3 choices for main meals as per company policy. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 17 People told us that they enjoyed the meals and always had a choice. Special diets are catered for at the home. The SUG contains information about the availability of advocacy services. People are given help to access these if they wish to. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The open culture of the home encourages people to raise any concerns they might have and these are dealt with effectively. The systems adopted by the home help to protect people and keep them safe from harm. EVIDENCE: The SOP tells people – “Housing 21 has a “comments, compliments and complaints” procedure, copies of which are available at the home. A copy of which is provided to each new resident within the Service User Guide. In addition to the above where informal comments, concerns and complaints are made to staff, these are recorded and investigated within Housing 21’s procedures.” They also say – “There may be times when the services we provide are unsuitable, or do not meet the required standards. When this happens we want to know about it as soon as possible, so that we can make the necessary changes to put things right. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 19 If you are unhappy with any aspect of our service, please raise your concerns in the first instance with the Care Home Manager.” The SUG then goes on to outline the complaints procedure and tells people how their concern or complaint will be dealt with. The Complaints procedure was displayed on wall in entrance to home. Helena (acting manager) told us that she was not currently dealing with any complaints nor had she done so since the last inspection. We saw the Complaints log containing no recorded complaints or concerns. Helena explained - “I deal with concerns as soon as I am aware of them so they don’t grow into complaints. Very often people come to me on a one to one basis – my door is always open to them.” We spoke to people in the home and they told us – “I go and see Helena if I have a concern and she sorts it out straight away!” “If I had any concerns I would see Helena but I don’t have any”. Another staff member also told us that any concerns are usually discussed openly during residents’ meetings. When I asked people if they felt “safe” in the home they said “yes”. When we spoke with Helena – she was familiar with the safeguarding procedures and told us what she would do if she had suspected abuse reported to her. Staff are generally aware of the local policies and procedures relating to Safeguarding people. Two other staff members whom we spoke to were able to tell us what they would do in the above circumstances. They told us that all staff received training in the Protection Of Vulnerable Adults (POVA) and we saw records of this training. Staff are very carefully recruited to work at the home and examination of staff files identified that Criminal Records Bureau (CRB) and POVA checks are carried out prior to offering employment at the home. Also 2 written references are obtained. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is in need of complete modernisation and closure of the home is planned for September of next year as the company plan to build a new home on a different site. However, the home is currently providing a safe, clean and homely environment for the people who live there. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 21 EVIDENCE: The SUG tells people – “Specific rooms will be allocated on admission, and confirmed within the Social Care Contract. In the event that a new bedroom is allocated this will be fully discussed within the care planning process.” Also –“Residents are free to come an go in their own rooms as they wish. Keys to your room are available, some residents choose to have their own keys, others do not wish to. There are also keys available to your wardrobe; we recommend that all residents should hold their own wardrobe key to lock away valuables.” We walked around the home visiting all the communal areas and a random sample of bedrooms. The environment has been adapted to meet individual and collective needs with various aids and equipment. This includes adapted baths and showers, grab rails, ramps and hoists. The home is split into separate units, each one with its own character. Each unit has a kitchenette, dining facilities and communal lounge. This works well and creates a homely feel to each unit. Each bedroom that we looked at was personalised with people’s own effects and adapted to suit their needs. The home was clean and well presented throughout but looking very tired and worn. The kitchen was clean and well presented and the home had received an inspection from the Environmental Health Department. We saw this report to be satisfactory with no outstanding recommendations. The home has replaced the refrigerator and freezer in the main kitchen since the last inspection. This home is due to be closed in September 2009 and the company will be building a brand new home on another site. With this closure in mind, we will not be requiring any major improvements to the environment but recommend that the home be maintained to a satisfactory and comfortable standard. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 22 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): All the standards for this outcome were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in this home are cared for by a dedicated staff team, who are equipped with the necessary skills required to be able to meet their needs. EVIDENCE: The SOP documents the staffing and management structure of the home. The SUG tells people “all care staff undergo Skills for Care Training which they complete within the first 6 weeks of starting. After completing a successful probation period, care staff are registered to undertake NVQ2. All care staff undertake training in Moving and Handling, Dementia awareness training and POVA. Nursing care is not provided directly by the staff at the home, but is available following a nursing assessment and provided by a registered nurse or other community nursing services directly employed by a Primary Care Trust. The home is sufficiently resourced to meet the needs of residents.” The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 23 We spoke with a number of staff members who all confirmed that they received training including mandatory health and safety training. We looked at their training records, which confirmed this training takes place. There is a staff training and development programme in place at the home and one of the team leaders told us that 70-80 of care staff who work at the home are trained to NVQ level 2 and above. Another staff member who had only worked at the home for a few months told us that her induction training was “very good.” She said that she had worked alongside a mentor for several weeks until she was signed off as “proficient” in all the areas of care. She told us that she had done moving and handling training, fire safety and a practice drill. She is very impressed with the home and said “its all about the residents here, which is how it should be.” At the time of the inspection visit there was a total of 20 people accommodated in the home all with some degree of personal care needs. We looked at staff rotas. From 8am to 3.30pm there are 7 care staff on duty and from 3.30 pm until 10pm there are 3 care staff. From 10pm until 8am there are 2 waking night staff plus 1 manager on call. There is also an administrator and the home has access to contractors who will complete maintenance tasks. These contractors were observed on site at the time of the inspection. Adequate kitchen and domestic staff were also observed. The manager – Helena works supernumery in her management role and is supported by three team leaders. As we walked around the home staff appeared caring and attentive towards the people living in the home. Staff interaction is good and there is an adequate number of staff on duty throughout each 24-hour period to meet the needs of the people. As this home is registered to accommodate up to 10 people with dementia care needs it is recommended that all care staff be given training in dementia so that they will be better able to understand and meet the specific needs of these people. We looked at a random sample of staff files with regards to staff recruitment. We found the recruitment procedure to be robust. Staff are carefully selected according to their qualifications and experience. The required CRB and POVA checks are carried out and satisfactory references are obtained prior to them being offered a job at the home. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 24 The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,34,35, and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is well run and managed in the best interests of the people who live there. EVIDENCE: The SOP states that – “Helena is the acting manager at The Limes, and has over 19 years experience in the management of residential homes for older people within the local authority framework. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 26 Helena has worked with both older people and disabled people during this time. She completed her in-service course in Social Care in 1989, and has also completed her NVQ Assessors award in 2006 and her ILM (management award) in 2008. Helena has maintained her professional development over the last 19 years having attended various training courses as follows – First Aid, Financial Management, Good Practice in Recruitment and Selection, Development Centre, Equal Opportunities, Adult protection, Infection Control and Management” Helena is supported by 3 team leaders and an administrator as well as all the other staff who work in the home. Staff in the home speak highly of Helena and find her both “approachable” and “supportive.” People who live in the home tell us that Helena is “always there for you” and relatives said that they can go to her at any time. Another person said “nothing is too much trouble for her.” One person told us -“I know who the boss is if I have any complaints I will go to her.” Through discussions with people and observations made during the visit it was identified that Helena runs an open door policy and manages the home in the best interests of the people who live there. There is an effective Quality Assurance system in place at the home. We were given a copy of a recent audit, which the manager had carried out entitled “QA Yearly Audit.” This audit looks at all the minimum standards for older people and assesses the home’s competencies in meeting these standards. Where there are areas of weakness the manager had taken action to address this. People who live at the home feel that they have a say and that any suggestions they might have are listened to and taken seriously. There are regular “residents’ meetings” held and one of the people who lives at the home is the “link resident” and he goes to meetings at other homes to discuss various topical issues relating to the company. He then feeds back these issues at the residents’ meeting at The Limes. He told us about these meetings and how he enjoys his role. He was leaving the home to attend one of these meetings on the day of the inspection visit. Prior to this inspection visit, we received information to confirm that Housing 21 submitted their Annual Review and Financial Statements 2005 – 2006 in November 2006. Based on the information provided there were no concerns about the financial viability of the organisation. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 27 We looked at the maintenance of personal allowances. The SOP says – “The home ensures that service users control their own money unless where they state they do not wish to, or where they are unable to do so. In this event safeguards are in place to protect the interests of the service user. The SUG tells people – “within their rooms service users are provided with lockable facilities for the safe keeping of any small personal items. However, if there is a need for more secure safekeeping then the home’s manager can arrange this.” The home works to a clear health and safety policy. All staff are fully aware of this policy and are given the required mandatory training. Regular random checks take place to ensure they are working to it. We looked at records relating to Health and Safety and maintenance of the home. Equipment used in the home has been regularly inspected and services as required. Tests are carried out to ensure that the safety of people is maintained. These tests include – testing of hot water, fire alarm tests and other environmental checks. At the time of the visit, the maintenance person was carrying out work on the home. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 x x 3 The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 29 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 3 Refer to Standard OP30 OP19 OP12 Good Practice Recommendations It is recommended that all care staff are given training in dementia so that they will be better able to understand and meet the specific needs of these people. It is recommended that general maintenance of the home be continued in order to ensure that people live in a suitable and comfortable environment. It is recommended that more funds are made available for activities, particularly for trips out for the people living in the home to enjoy. The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 The Limes DS0000071296.V372301.R01.S.doc Version 5.2 Page 31 - 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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