Care Home: The Old Rectory

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What the care home does well What has improved since the last inspection? All bedrooms now have en suite facilities. Weekly menus for lunch and supper are now available offering choice of several options for each meal that residents may choose from. More structured activities. CARE HOMES FOR OLDER PEOPLE The Old Rectory School Lane Longhope Gloucester GL17 0LJ Lead Inspector Mrs Janet Griffiths Key Unannounced Inspection 09:30 1st May 2008 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 Old Rectory DS0000071008.V360957.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 Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address School Lane Longhope Gloucester GL17 0LJ 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) 01452 831135 01452 831135 E.C. Investments (Gloucestershire) Ltd Mrs Rosemarie Jane Halifax Care Home 20 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (20) of places The Old Rectory DS0000071008.V360957.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 either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) The Maximum number of service users who can be accommodated is 20. 3rd March 2007 2. Date of last inspection Brief Description of the Service: The Old Rectory is situated on the edge of Longhope village, a short distance from the church. It is a Georgian building pleasantly situated in its own grounds, offering privacy and residential care for twenty residents. A single storey extension offers five single rooms with en-suite facilities and a shower room. Communal space consists of a lounge with a large adjoining dining room, overlooking the gardens, and a smaller lounge with a television. A further extension is currently being built which on completion in September 2008 will offer a further four en-suite rooms, more communal space and a new kitchen and food preparation area. The home currently offers single room accommodation for twenty elderly residents and with recent upgrades completed all now offer en-suite facilities. The home was recently re-registered so that they are now able to admit residents with mild dementia care needs. Nineteen residents are accommodated in the main building and one is accommodated in the converted lodge/cottage at the rear of the home. This is available for a more independent resident who has a lounge, kitchenette, bedroom and bathroom for their use alone and a bedroom for a carer to sleep-in during the night. All the facilities of the home, care, catering and laundry/domestic services are provided for the resident accommodated here. The first floor rooms are accessed by a shaft lift to assist those less able residents. Assisted bathroom facilities are also available on each floor. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 5 A picturesque patio area with a water feature and well-maintained gardens are accessible to all the residents and there is a car park at the front and side of the building. Information about the service to include CSCI reports is made available by the provider to prospective service users through the homes’ Statement of Purpose and Service Users Guide. At the time of inspection the fees are from £470 to £498 per week. Additional charges are made for hairdressing, toiletries, chiropody, newspapers and some activities. People funded through the Local Authority have a financial assessment carried out in accordance with fair access to Care Services procedures. The Old Rectory DS0000071008.V360957.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 3 star. This means the people who use this service experience excellent quality outcomes. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection site visit took place over seven and a half hours on one day in May 2008. A further day was spent collating the surveys received. During this time the inspector spoke to a number of residents, staff working in the home and the manager and proprietor of the home. Communal areas and some resident’s rooms were visited on this occasion. Four residents’ files were examined in detail to include their medication records. Other records examined included staff recruitment and training records, accident, quality assurance records and maintenance/servicing records. Survey forms were issued to the residents, staff and relatives prior to the inspection, to complete and return to CSCI if they wished; sixteen responses were received from residents, fifteen from relatives and twelve from staff. An Annual Quality Assurance Assessment (AQAA) was completed and its contents used as part of the inspection process and report writing as was the collation of survey results. What the service does well: The home provides a flexible level of support, within a homely environment enabling residents to continue their lives as they were before, wherever possible. It maintains well-established links with the local community and ensures that residents with specific cultural needs are catered for. The admissions process is set up to maximise the opportunities for potential residents to make a positive decision to move here. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 7 The home has a well-motivated staff team, who all love the work they do and are all very committed to providing a good quality of care for the residents. The manager and provider are always accessible to both staff and residents and are very supportive. When asked in surveys what the home does well, the following statements were included: • ‘Treating residents as individuals. Making visitors welcome and listening to concerns. Keeping the home in an immaculate condition and the grounds well cared for so that it is a nice place to be. Being considerate and patient when patients are wearing as a result of their physical/mental condition’. ‘.Offers a well staffed and appointed house with good facilities’. ‘ The home is spotlessly clean and very well maintained. the environment of the home and its amenities are excellent’. • • 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. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3. Standard 6 not applicable. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families have all the information they need to make an informed choice regarding placement at the home, and pre-admission visits take place to carry out an assessment and ensure that needs can be met. Residents normally move in on a long-term basis therefore Std. 6 was not assessed. EVIDENCE: The Statement of Purpose and Service Users Guide have both been recently reviewed and amended to reflect the change of registration and all information provided for the residents is now printed in black ink on yellow paper for easier visibility. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 10 All of the resident and relative surveys received stated they felt they were provided with enough information about the home prior to admission. Two surveys made the following comments: • ‘Before agreeing to my mother’s entering the home I visited this and others considered to be of a similar standard. There were also recommendations and comments from local people who knew this home by reputation’. ‘We were welcomed in without prior notice to see a normal day. All our questions were answered in detail’. • The manager sees all prospective residents and an assessment is completed to ensure that the home would be able to meet their needs; examples of these were seen. They are also invited to spend some time at the Old Rectory prior to admission to give them a chance to see how they like it and for the staff to see how they fit in with the other residents and to assess them more fully. The AQAA states that they are now using a more in depth admission procedure with more than one assessment, but plan to have an even more holistic procedure in the future using reminiscence to gain more information about past lives. There have been a number of new admissions since the last inspection and most of these residents were seen and spoken with. All said they were very happy with the home, the facilities provided and the care given, with the following statements made: ‘All the staff are friendly and will do anything for you’. ‘This is an excellent home. It has a good atmosphere, staff who are content and friendly’. Four care files were examined and all had a full and comprehensive assessment, which is reviewed regularly. The admission details, which are also recorded in full, are designed specifically so that they can be sent with the resident should they have to go to hospital, and contains all the relevant information health services would require. Contracts were also seen and all the resident’s surveys again confirmed that they had all received contracts. Staff surveys confirmed that they received the training relevant to their roles and to meet the residents needs. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is excellent. These judgements have been made using available evidence including a visit to this service by the key inspector. People who live in this home have their personal care and health needs met through individually planned care. They are also protected by the medication administration procedures. Residents are treated with respect and their privacy and dignity are protected. EVIDENCE: Four care files, some with general needs and some with dementia care needs, were selected for this inspection and examined in full. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 12 All had a very full and comprehensive assessment and moving and handling risk assessment completed, from which care plans were devised which reflected the current needs of these residents. All are reviewed monthly with either the residents themselves or their relatives’. A daily system of review, called the ‘traffic light system’ has been in place for some time now and is very effective in determining levels of dependence for each activity of daily living, which in turn identifies when care plans are required. Full and informative daily records were kept, signed and dated and gave a good indication of action followed through when any untoward event was recorded. A life history is also now being completed for each resident, either with the information they give themselves or in some cases provided by relatives. This is particularly beneficial with those who have short-term memory or mild dementia in understanding past lives and current/past family life etc, enabling staff to understand them much better and have more meaningful conversation. Records examined confirmed that the home liaises with other agencies as the need arises. One doctors’ practice visits the home on a weekly basis and other doctors visit on request; district nurses also visit when required, and are currently visiting several residents on a regular basis for pressure area and catheter care. Others such as the continence advisor, community psychiatric nurses, physiotherapist and speech and language therapist visit on request. It was reported that one resident returned from a ‘spell’ in hospital with a pressure sore, which is now almost healed. Several residents have pressure relieving mattresses and cushions in place. The chiropodist, dentist and optician either visit the home or residents are taken out to visit them. Most of the surveys confirmed that the residents always receive the medical support they need with one saying: ‘The doctor will always be contacted if you request it or if they consider it necessary’. One relative felt that the attitude and commitment of the staff at the Old Rectory has been superior to that of both hospitals that his mother had recently been in. Professional visitors to the home to include district nurses, a doctor and chiropodist all completed surveys about the home in the homes’ own quality assurance programme and included the following comments: • ‘ Staff are very receptive to ideas and suggestions to enhance quality of life’. DS0000071008.V360957.R01.S.doc Version 5.2 Page 13 The Old Rectory • • • Staff are very welcoming and open to suggestions/ideas. I feel the clients I visit are very settled and enjoy their time at the Old Rectory’. Very happy to visit with caring staff and happy clients-nothing is too much trouble’. Always helpful- never a problem’. All the medication records were checked with particular reference made to those resident’s whose care records were examined. Medication is dispensed by a local pharmacy using a blister pack system. Records were seen of audits completed by the dispensing pharmacy and also annual medication reviews completed by the Primary Care Trust. Monthly pre-printed medication records are provided with the medication and were well maintained with no gaps noted. There were one or two hand written entries made and in most cases two signatures to indicate that these had been checked and were accurate. The home does have a specific cupboard for controlled medication and separate records are kept of these. There are currently no controlled medicines but Schedule 3 medications are stored and recorded as required and were audited and found correct during the inspection. Several residents self-medicate their medicines following an assessment and agreement by their doctor and monthly reviews are completed to ensure they remain competent to do so. Records were seen of assessments and reviews. Each resident’s room has lockable facilities to store their medication. All medication was stored correctly. All staff responsible for the administration of medicines have completed medication training and also receive updates when necessary. Residents spoken with, and observations made confirmed that their privacy and dignity is respected and staff were observed knocking on doors and addressing residents by their preferred name. All of the residents have a single room and all have en suite facilities. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in the home are supported to realise their own preferences and expectations, and are able to maintain contact with the larger community, friends and family. They receive a wholesome, appealing and balanced diet in pleasant and comfortable surroundings. EVIDENCE: A weekly programme of activities is in place, which includes scrabble, card games, bingo, and music and movement. A number of games such as Countdown, pairs, and word search have been produced on yellow paper with black writing, to again make it easier to see. A pianist entertains on a monthly basis and trips are regularly taken to local garden or craft centres, or on an individual basis shopping. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 15 Several theatre trips were also organised through the winter and more trips are now being organised for the Spring. Residents surveys indicated that most always or usually take part in the activities that are organised and individual record sheets are now being kept of daily activities, who takes part and how successful each one is, for audit purposes. It was discussed that for those who don’t take part in organised activities, but have daily input such as staff sitting and chatting or reading a paper to them etc, then all forms of social interaction should be recorded. One survey did state that they missed conversation and said that some residents tend to withdraw rather than mix and one relative survey stated: • ‘Excellent nursing care and welfare but underestimate mental capacity and need for stimulation’. However, observations (see example below) and activity records confirmed that all residents are invited to join in any of the activities organised and oneto-one input is also available. Residents are able to go out independently if they are well enough to do so, but many go out with relatives; one resident said that arrangements are made so that that local clubs previously attended can still be attended and another Made particular mention of weekly outings for a meal and to visit local supermarkets with her son. Links with the community are maintained and when asked if the home helps the resident keep in touch the following comments were made: • • • ‘If there is a problem they phone me’. ‘My mother is really not capable of using the telephone on her own, I have been kept informed of any problems etc’. ‘ I regularly visit but my mother needs occasional reassurance then the home will make sure she phones me’. Visitors are welcome at any time of the day or evening and residents have access to privacy to receive them, if they wish. Arrangements are also made to attend the local church and a monthly communion service is held at the home. One of the care staff has just completed a course on activities with Orchard Trust. She was spoken with and said how much she enjoyed this course and discussed some of the plans she had for the future. All the carers help with the daily activities but this one carer has a particular interest and enjoys organising something each day to provide a stimulating atmosphere. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 16 On the afternoon of the inspection the sound of laughter could be heard coming from the lounge and the residents were engaged in an exercise of throwing and catching balloons. One resident who suffers from dementia and had been seen during the morning but gave little response, was now sat holding and stroking a small ‘fringed’ ball and looked quite animated and alert amidst all the activities taking place. One innovation that the manager has suggested is that relatives each bring in personal-meaningful objects to place in individual reminiscence boxes, which in turn can be used as points of conversation. The hairdresser visits weekly and residents may also continue to use their own hairdressers if they wish. There are plans once the new extension is completed to turn one existing ground floor bathroom into a beauty therapy room, where residents can go for hairdressing and beauty treatment such as manicures. Since the last inspection weekly menus are now printed and are on display in the dining room and also given to those who remain in their rooms and choices are offered at every meal. Curries and chilli are two meals that are becoming more popular now with some of the residents. With the completion of the new kitchen a second cook or kitchen assistant is to be appointed specifically to cook breakfasts and suppers, which has been completed by care staff up to now. Some of the surveys received indicate that they are looking forward to this and more varied recipes. The majority said they always or usually enjoyed the meals provided but one stated they would prefer china cups to mugs to drink from. One stated • ‘There is always an alternative if you do not like the main dish’. Lunch on the day of inspection was a choice of ham and parsley sauce or an omelette and there was chilli (which smelt delicious) or sandwiches for supper. Home-made cakes are also produced regularly (sampled on this inspection) and were very good. Fresh fruit is also provided daily. The Old Rectory DS0000071008.V360957.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 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People in the home are protected by the systems in place. EVIDENCE: There is a complaints procedure in place which is reviewed and updated as required and is accessible for all the residents in their service users guide and is on display for visitors. Resident’s surveys confirmed that all knew who to speak to if they were unhappy and all but two knew how to make a complaint with one stating: • ‘The question has never arisen. Any issues are dealt with before a complaint has arisen’. When asked if they knew who to speak to if they were unhappy about anything, the following comments were given: • ‘The manager is always sympathetic and helpful but I would only call on her if I felt my problem really upset me. • ‘We all have a keyworker who will investigate anything we are not happy about’. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 18 All but three of the relative’s surveys stated they knew how to make a complaint, with one saying any issues raised have been dealt with immediately. All of the staff stated that they knew what to do if a resident or relative had any concerns about the service. It was reported that no complaints had been received. Training records confirmed that staff have attended the Alerters’ Guide training course on safeguarding adults from abuse and senior staff have also attended enhanced training. Policies and procedures are in place and are reviewed annually. The Old Rectory DS0000071008.V360957.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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained, clean and hygienic throughout. Equipment is provided to aid mobility and promote independence. Individual bedrooms are decorated and equipped to meet the needs of their occupants. EVIDENCE: During a walk around the building the inspector visited at least six of the residents in their own bedrooms. All of the rooms seen were clean, comfortably furnished and in excellent decorative order, with evidence that each person had the opportunity to personalise their rooms with photographs, items of their own furniture and other treasured possessions. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 20 The provider and manager, continue to ensure that the home is maintained to a very high standard. With the completion of the refurbishment of two rooms, all rooms now have en suite facilities and both have been refurbished to very high standards. All of the communal areas were visited to include the large lounge dining room and smaller/quiet lounge. All were again furnished and decorated to very high standards. Building work is continuing on a further extension and on completion will have a further four bedrooms with en suite facilities, an extension to existing communal facilities and a new kitchen and preparation room leading from the current dining room. It is hoped that this will be completed by September 2008. A further assisted bathroom will also be available and the current ground floor bathroom will become a hairdressing/beauty salon. There are also plans to build offices for the manager and proprietor in the basement. All of the residents spoken with and the surveys completed commented on their satisfaction both with their own rooms and with the overall cleanliness of the home, which again is maintained to a very high standard. The following comments were made in the surveys received: • ‘It is maintained to a very high standard’. • ‘Spotless’. • ‘ The home is spotlessly clean and very well maintained, the environment of the home and its amenities are excellent’. • Keeping the home in an immaculate condition and the grounds well cared for so that it is a nice place to be’. The Old Rectory DS0000071008.V360957.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, & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in the home have their needs met by sufficient skilled staff who are able to meet the needs of the current number of people living at the home. They are protected by the homes recruitment system and staff are supported to undertake regular and relevant training. EVIDENCE: There were three care staff, a cook and the housekeeper on duty during the morning and the manager who was off-duty, came in for the inspection. Care staff do currently carry out some catering duties in the absence of the cook, but there are plans with the expansion of the home to employ a second cook or a kitchen assistant. The same applies to night duty where there are currently one ‘waking’ and one ‘sleep-in’ member of staff. Once the further four beds are occupied, there will be two ‘waking’ staff each night. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 22 One member of staff who does normally do night duty and some ‘sleep-ins’ said how much she enjoys her work, particularly night duty and rarely has to call for assistance although this is readily available if there is an emergency or someone is ill. This member of staff has completed both NVQ 2 and 3. There appeared to be adequate staff on duty to meet the needs of the service users. There was a calm and unhurried atmosphere in the home and no residents or their relatives made any negative comments about having to wait for attention. One survey stated ‘the only time you have to wait for attention is if there is an emergency with one of the other residents for example- a fall or a stroke for which there is no warning’. From surveys received and speaking with staff they felt that they usually had enough time to meet the needs of the residents. The home does have a low turnover of staff, which provides continuity for the residents and indicates that staff are happy working at the home. One staff survey stated that the manager works hard to ensure that staffing levels are meeting the needs of the service users and is always ready to listen to any concerns and increases staffing levels to meet changing needs. Staff observed during the inspection appeared to be carrying out their work in a professional and organised manner and all of the residents spoken with were very happy with the care provided Most of the staff have been working at the home for a number of years and their personnel files have been checked at previous inspections. Two new members of staff have been appointed since the last inspection and their records were checked. Both had applications completed and all the relevant documentation and checks carried out. Interview records were seen and there was some record of explanation where there were gaps in a career history, but this needs to be completed more fully. Also, although there was a health declaration this did not refer to mental health fitness as required. This is to be amended. Staff surveys confirmed that they all felt their recruitment had been carried out thoroughly and that their induction covered everything they needed to know. Seven staff have now completed NVQ 2 with one currently undertaking this training and two have NVQ 3, and one is currently doing this. One, in addition to the manager also has NVQ 4. Induction, based on the ‘ Skills for Care’ induction standards is completed for all newly appointed staff and records were seen to confirm this. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 23 Appraisal, supervision and training records were seen and copies of certificates obtained confirmed the training undertaken. Recent training included MUST (Malnutrition Universal Screening Tool), National Certificate in Infection Control, certificate in Human Ageing and dementia- distance learning course, mental capacity act training and safe handling of medication and stoma care. Mandatory training updates are also organised on a regular basis and includes moving and handling last completed in November 2007 and first aid in March 2008. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 24 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): 31,32, 33,35, 36, & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in the home have their best interests met by the manager, proprietor and staff who are committed to their responsibilities. They and the staff are generally protected by the health and safety systems in place in the home. The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager has a number of years experience in management and care of the elderly and has been at the Old Rectory since 1987, becoming manager in 1999. She has completed NVQ 4 and registered managers award, obtaining HND in Social and Healthcare management, is an NVQ assessor, and has a City and Guilds certificate in mental health working towards a BA/BSc (Hons) in Health and Social Care. She is also in the first year of three of a Diploma in management with the Open University. Both she and the staff at the home endeavour to keep up to date by attending any courses/study days relevant to care of the elderly. She is due to complete a palliative care-end of Life study day and a dementia care training day. Staff spoken with and surveys received all confirmed that the manager was an excellent role model and that both she and the provider continue to be very supportive and always accessible to them. The home has a quality assurance programme in place and annual satisfaction surveys are distributed to residents and their families, health professional who visit the home (see standard 8 above) and staff. A copy of the results of the last resident survey completed in 2007 was provided for the inspection and was very positive on the whole and an action plan has been produced as a result of the surveys. Residents or /representatives generally are responsible for individual’s finances but a few of residents have requested that the home holds a small amount of ‘pocket money’ for them. This is held securely. Receipts are given for money received and records kept of money spent with receipts. Records were seen of individual financial transactions undertaken. The home has all the relevant policies and procedures, a copy of which is also given to each member of staff. All the policies are kept under review and amended as required. Records were provided to show that statutory maintenance/servicing of equipment is arranged in a timely fashion. Recent fire training was completed and fire alarms and emergency lighting are tested weekly. An excellent fire risk assessment with evacuation procedures is also in place and was also seen. This has also been seen and approved by the fire safety officer. The Environmental Health Officer has also visited recently and will be visiting again once the new kitchen has been completed. The Old Rectory DS0000071008.V360957.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 4 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 4 4 4 4 The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 27 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. 1. Standard OP29 Regulation 19 Requirement Application form must include a full employment history, together with a satisfactory written explanation of any gaps in employment and a statement by the person as to their mental and physical health. Timescale for action 02/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Old Rectory DS0000071008.V360957.R01.S.doc Version 5.2 Page 29 - 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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