Care Home: Tickford Abbey

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What the care home does well Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. Care plans have been produced for all people who use the service that are informative, which supports staff to implement appropriate care in a manner preferred by the individual. Meals are of a good standard and presented in an appealing way. Medication is well managed in the home with relevant procedures in place for the administration of medicines. There is a motivated and established staff team that consists of care/support staff who respond to service users in a respectful and appropriate manner. The home provides a very pleasant and comfortable environment in which people can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. Communication between service users and visitors was observed to be positive and open Training for care staff is good and service users benefit from a staff team who are appropriately trained to do the job. The care staff are undertaking relevant training and working towards their National Vocational Qualifications. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. There is a good range of policies and procedures, providing care staff with relevant information about all aspects of care and the home/organisation. There are effective Quality Assurance systems in place, including an annual service satisfaction survey and a monthly news letter which is to be commended. Health and safety policies and procedures are clear and informative. What has improved since the last inspection? Health and Safety practices within the kitchen are taking place with the labelling of food products stored in the fridge and regular cleaning of insectocutors. A process is now in place of named supervision for new staff appointed under POVA first arrangements until an enhanced Criminal Records Bureau certificate is obtained. The home have managed to maintain a good standard of care ensuring the personal, emotional and health care needs for service users continue to be met. Service users spoken to were very positive about the care they receive at the home. Improvements to the premises continue to be made to ensure a safe and homely living environment is maintained. What the care home could do better: No requirements have been issued following this inspection, however there are some areas of good practice that are recommended. Care plans would benefit from further detail ensure the care needs of people who use the service can be met. The daily notes require staff to include more information about the care the person has received, for example the care received on that day, activities undertaken, mood, health and visits. Where Criminal Records Bureau checks are dated 2003 and 2004 these are renewed. CARE HOMES FOR OLDER PEOPLE Tickford Abbey Priory Street Newport Pagnell Bucks MK16 9AJ Lead Inspector Barbara Mulligan Unannounced Inspection 10:00 30 January 2008 th 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 Tickford Abbey DS0000015073.V357893.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. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tickford Abbey Address Priory Street Newport Pagnell Bucks MK16 9AJ 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) 01908 611121 tickford@greensleeves.org.uk www.greensleeves.org.uk Greensleeves Homes Trust Ms Heather Joy Lee Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 32 older people. Date of last inspection 19th September 2006 Brief Description of the Service: Tickford Abbey is a care home providing residential and personal care for 32 older people. It is owned and managed by The Greensleeves Trust and is situated in a rural area close to the town centre of Newport Pagnell. The home is a large detached property with a modern extension. Part of the house is listed and was once an abbey set on the riverside of the River Ouse. There are extensive grounds which are well maintained. Accommodation is individual and comfortably appointed. There are 25 single rooms. Seventeen have en suite facilities. There are two double bedrooms with en suite facilities, which are currently being used singly. There are three spacious lounge areas and a separate dining room. Fees are between £409 and £490 per week. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was conducted over the course of a day and covered all the key National Minimum Standards for older people. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion. Information received by the Commission since the last inspection was also taken into account. No comment cards were received from people who use the service by the time the report was written. The inspection officer was Barbara Mulligan. The registered manager is Karen Campbell. The inspection consisted of discussion with the registered manager and other staff, opportunities to meet with some people who use the service, examination of some of the home’s required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Twenty-six of the National Minimum Standards for Older people were assessed during this visit. Standard six was assed as not applicable and the remaining standards were fully met. As a result of the inspection the home has not received any requirements. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff and service users are thanked for their co-operation and hospitality during this unannounced visit. What the service does well: Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. Care plans have been produced for all people who use the service that are informative, which supports staff to implement appropriate care in a manner preferred by the individual. Meals are of a good standard and presented in an appealing way. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 6 Medication is well managed in the home with relevant procedures in place for the administration of medicines. There is a motivated and established staff team that consists of care/support staff who respond to service users in a respectful and appropriate manner. The home provides a very pleasant and comfortable environment in which people can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. Communication between service users and visitors was observed to be positive and open Training for care staff is good and service users benefit from a staff team who are appropriately trained to do the job. The care staff are undertaking relevant training and working towards their National Vocational Qualifications. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. There is a good range of policies and procedures, providing care staff with relevant information about all aspects of care and the home/organisation. There are effective Quality Assurance systems in place, including an annual service satisfaction survey and a monthly news letter which is to be commended. Health and safety policies and procedures are clear and informative. What has improved since the last inspection? Health and Safety practices within the kitchen are taking place with the labelling of food products stored in the fridge and regular cleaning of insectocutors. A process is now in place of named supervision for new staff appointed under POVA first arrangements until an enhanced Criminal Records Bureau certificate is obtained. The home have managed to maintain a good standard of care ensuring the personal, emotional and health care needs for service users continue to be met. Service users spoken to were very positive about the care they receive at the home. Improvements to the premises continue to be made to ensure a safe and homely living environment is maintained. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 7 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. Tickford Abbey DS0000015073.V357893.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 Tickford Abbey DS0000015073.V357893.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): 3 and 6 Quality in this outcome area is good. Service users needs are thoroughly assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is the responsibility of the registered manager or a senior staff member to carry out the initial assessment of need. Staff will visit a potential service user either in the hospital or in their own home to undertake the initial assessment of needs. The inspector observed the assessment documentation for four people using the service, including those most recently admitted to the home. The assessment tool consists of a tick list and an example of the areas this tool covers is personal care, oral health, foot care, diet and weight, Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 10 communication, mobility and mental state and cognition. All assessments seen were fully completed, signed and dated by the author. When a person using the service is admitted to hospital another needs assessment is completed before they return back to the home. This is recognised as good practise. The home does not admit people for intermediate care. Tickford Abbey DS0000015073.V357893.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 and 10. Quality in this outcome area is good. The health and personal care needs of people using the service are well met, with personal care delivered in a way that promotes respect and dignity, ensuring that peoples health and wellbeing is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care of four residents was case tracked and their care plans were examined. The care plans show evidence of regular review and much thought has gone into its presentation and contents. Care plans seen are on the whole detailed and contain action plans that provide guidance for staff to follow. There is information about individuals health and medication, a personal profile, a record of visits by healthcare professionals, daily routines, daily reports and a core care plan. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 12 Some care plans would benefit from further information in the action plan. For example in one care plan it records “needs assistance to wash lower part of body” and under the action needed section it states “ensure all resources are available ie towels and toiletries”. This is a vague statement and would benefit from further detail. It will be a recommendation of the report that care pans contain further detail to ensure care staff can accurately meet the care needs of people who use the service. Daily notes were often very brief and contain no specific information. Examples seen include, “contented morning”, “had a contented day”, “content in room”. These statements are vague and do not inform the reader how the individual was or what they did on that day. It is recommended that these are more detailed and contain more relevant information about the person using the service. One person using the service said “I appreciative the care I get at Tickford Abbey. The manager and staff are always willing to help me”. Another person who uses the service said “I am fully satisfied, thank you”. Records show that people who use the service receive prompt attention to their health care needs and health screening in files is well recorded. There are records in individual files of appointments made to health care professionals. These include opticians, dentist, General Practitioner, District nurse, hospital appointments and chiropody. It is pleasing to know that there are no people using the service who require pressure area care. All people who use the service are registered with a general practitioner. Specialist services such as continence or tissue viability are accessed through the district nurses and health centres. Personal care is given in the privacy of the individual’s rooms and this was confirmed in discussions with people using the service. Two people living at the home said on the day of the visit “I get looked after by everyone very well”. Another person said, “If I have any problems with my health it is dealt with immediately.” Records of all medication received and returned are completed and recorded by the registered manager or senior staff. Medication storage and medication records were checked. Arrangements for the storage of medicines are satisfactory with medication being kept in a separate locked cupboard. The home receives a three monthly audit from the supplying pharmacist and a record of these are maintained at the home which Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 13 were observed by the inspector. These cover storage, medication practices and training. The home uses controlled drugs, and the controlled drugs register was looked at. This is fully completed with two signatures for each entry. All controlled drugs are stored in a separate lockable cupboard, which complies with the Misuse of Drugs Regulations 1973. There were no out of date medications held in the service users home and there is a returns procedure in place. The inspector examined medication records and it is pleasing to note there were no omissions observed. Photographs of service users, on medication charts, are used for identification. There is evidence in the staff training records that demonstrate staff have undertaken accredited training in the safe handling of medicines. Overall, the systems for the administration of medicines are robust and to be commended. People using the service receive care from staff and health care professionals in complete privacy. Individuals spoken to on the day of the inspection said that staff knocked on doors before entering and were courteous and respectful when speaking to them, or their visitors. One visiting relative said “I am always made to feel welcome when I visit my mother”. Post is passed to service users and they may make and receive telephone calls in private; many had their own telephone lines installed. Preferred terms of address are identified at the initial assessment and the inspector saw evidence of this in care plans. The homes induction programme includes training regarding privacy and dignity. The Statement of Purpose and Service Users Guide include information about maintaining the privacy of service user’s. Service users can have a key to their rooms if they wish to use this facility. Tickford Abbey DS0000015073.V357893.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 and 15. Quality in this outcome area is good. Systems in the home ensure that where appropriate people who use the service are supported to exercise choice and control over their lives and are able to receive visitors at the home, with no restrictions imposed on visiting unless requested by the individual. The presentation and standard of food is good and meets the nutritional needs of people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the care plans there is a very good section on “daily routine” which shows the individuals routines of daily living and the their preferences with regard to activity in the morning, afternoon, evening and night. Religious observance is recorded in care plans and individual’s interests are recorded. The home has an activities questionnaire that is given to people who use the service when they have settled into the home. This asks people if they like Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 15 outdoor activities such as gardening, walking etc; indoor activities such as bingo, guest speakers, games etc; trips out to garden centres, theatre etc; health and beauty such as a manicure and pedicure. This is to be commended. On the day of the visit the inspector joined an exercise class. During the session some comments made to the inspector about the activities provided in the home include, “There is a good variety of activities“ and “I don’t want a lot of activities and you are not forced to join in, which I like.” People taking part in the exercise class enjoyed the class and expressed their enjoyment to the facilitator on the day. Service users spoken to said they enjoy various activities and examples given to the inspector include bingo, keep fit, hairdressing, cards, a quiz and day trips out. Activities are advertised on a notice board in the entrance hall. The home has employed an activities coordinator on a part time basis. The home provides a diverse range of needs for people who use the service. Examples of involvement in the home by local community groups and individuals are visits by a mobile hairdresser, various visiting entertainers and a weekly church service. Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. Family and friends are invited to participate in some of the social event organised. One person spoken to said, “I have a lovely room and I was able to bring some of my own furniture which makes it seem more like home”. People who use the service have a good level of autonomy. During the visit people were seen to go out when they wished, stay in their room, receive visitors throughout the day. There is a residents committee which meets monthly. Minutes are kept of these meetings and were looked at by the inspector. Topics recently discussed have included the food and menu changes, entertainment and outings and a fish supper. It is pleasing to see that issues raised are acted upon and recorded in the minutes. People who use the service are offered three meals a day, with the main meal being served at lunchtime. The menus cover a four weekly rotating system. A choice of main meal is available, and on the day there was a choice between vegetable lasagne or salad. The choice for the following day was chicken nuggets and chips or pork fillet in mushroom sauce. One person said “the food Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 16 is always good. There are one or two disasters but on the whole the food is nice”. Lunch was observed and was found to be relaxed, unrushed and well organised. The meals were attractively presented and plentiful. One person said “the lasagne was nice”. In discussions with service users it was confirmed that meals are always of a high standard and there are sufficient snacks and drinks available throughout the day. Nutritional screening was observed in care plans with regular monthly weights being recorded of people who use the service. Tickford Abbey DS0000015073.V357893.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. There are policies and procedures in place to protect people who use the service from harm and the home has an effective complaints procedure to ensure that people who use the service or their representatives are listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home uses corporate policies regarding complaints and Safeguarding Adults from Abuse. The complaints procedure is outlined in a leaflet which is on display in the home. The procedure outlines the timescales for action at various stages and informs the complainant of their right to complain to the Commission for Social Care Inspection. The home has a dedicated book for the recording of complaints and the registered manager said that the home has not received any complaints since the previous inspection. The Commission has received no complaints about this service. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. The registered manager is aware of the POVA register and would submit staff for inclusion if it became necessary. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 18 The home uses the Milton Keynes policy regarding Safeguarding adults and the organisations own policy in conjunction with this. This includes guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. The Commission has details of one safeguarding adults refferral and this was seen to have been dealt with within timescales and refferred to the appropriate authorities. This outcome of the referral was concluded as unsubstaniated. Training records demonstrate that care staff are up to date with Protection of Vulnerable Adults and this forms part of their induction. The home does not routinely manager monies on behalf of people who use the service. The registered manager does not act as appointee for any service users. Tickford Abbey DS0000015073.V357893.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, 20, 21, 22, 25 and 26. Quality in this outcome area is good. The home provides a safe, well maintained and clean environment providing people who use the service with an attractive and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Tickford Abbey is set in picturesque and tranquil landscaped grounds that back onto the River Ouse. The centre of Newport Pagnell is nearby and is convenient for shops, pubs and other local amenities. There is space for parking to the front and rear of the home. The home is an older building, built in 1891, and a part of the home is listed. An extension was added to the home in the 1970’s. The accommodation is over three floors and access to all levels is via a passenger lift. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 20 The home has twenty-five single bedrooms, seventeen of which have en-suite facilities. There are three double rooms that also have en-suite facilities. The front entrance of the home includes the manager’s office and two seated areas which is welcoming and homely. Communal space consists of three lounge areas and a large spacious dining room that are set in a homely and attractive fashion. The internal decoration of the home is of a good standard and there are personal touches around the home such as flowers, plants, books and pictures. The registered manager said that there is a five year programme of redecoration and refurbishment in place. Windows and doors are due to be replaced in the next phase of this programme. The kitchen is clean, spacious and well looked after and achieved four stars following the most recent inspection from the environmental health agency. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. All radiators have low temperature surface covers and are thermostatically controlled. Emergency lighting is provided throughout the home. Hot water control valves are fitted to all hot water outlets accessible to service users. Laundry facilities are small but sufficient for current demand, and sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. Tickford Abbey DS0000015073.V357893.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 good. The staffing numbers and skill mix is satisfactory and staff training is sufficient and up to date to ensure that people who use the service benefit from staff who are who are competent to do their job. Recruitment procedures are undertaken to ensure staff have the right skills and competencies to support the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs twenty care staff and the home’s staff rota demonstrates that there are adequate numbers of staff on duty at all times to ensure the needs of the service users are always met. This includes sufficient numbers of ancillary staff. The registered manager is extra to these numbers. The registered manager and the deputy manager maintain an out of hours on call system. There are no staff working in the home who are aged under 18 years of age and there are no members of staff under the age of 21yrs left in charge of the home. The home continues to support staff on NVQ training and information supplied to the Commission before the inspection indicates that fourteen care staff have Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 22 completed NVQ level 2 or above and a further four staff are working towards this qualification. Following the previous report a requirement was issued for a process of named supervision for new staff appointed under POVA first arrangements until an enhanced CRB certificate. It is pleasing to see that this has been complied with. A random selection of staff files were made available for inspection purposes, including those most newly recruited. All files looked at contain the necessary documentation as detailed in schedule 2. There is evidence that all staff CRB checks had been obtained. However several of these are dated 2003 and 2004 and it is recommended that these are renewed. The home does not employ any volunteers. There is an induction programme in place which care staff attend to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. Care staff have access to a varied and comprehensive training programme, and staff records demonstrate that staff are up to date with mandatory training. This includes fire safety, moving and handling techniques, basic food hygiene training and core skills training. There is specialist training available for staff, an example of this is Alzheimers training, bereavement and death, sight awareness, catheter care and dementia and challenging behaviour training. Staff confirmed that there are regular staff meetings held monthly. Staff spoken on the day of the visit said that the manager is approachable and supportive and there is a good range of training available. Tickford Abbey DS0000015073.V357893.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. The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is a first level registered general nurse (RGN) and has completed the registered managers award. She has a diploma in the care of older people and as an NVQ assessor. The registered manager is experienced in the care of older people and has been the manager of Tickford Abbey for over eight years. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 24 The registered manager reports to an external line manager who carries out her supervision monthly and undertakes monitoring visits on behalf of the provider. Training undertaken by the registered manager in the previous twelve months includes advanced medicines, Infection Control, train the trainer for moving and handling, and three monthly managers training with the organisation. During the visit the inspector looked at satisfaction questionnaires that had been sent out to individuals who use the service and other stake holders to the home. These were sent out in 2006. The registered manager said that new questionnaires had recently been sent out. The inspector was told that the organisation sent out Quality Assurance surveys annually and the home sends out questionnaires on a six monthly basis. Service users spoken to on the day on the visit spoke about the residents committee and how most problems can be solved at these meetings. There is a folder containing compliments and thank you letters, mainly from the relatives of service users. Monthly monitoring reports were looked at for the past five months and they follow a detailed format that shows speaking with staff and people who use the service is a regular feature of the visits, plus good practices such as examining a sample of individuals money and staff training records. The manager does not undertake the role of appointee for any service users. The home does not generally manager monies for people who use the service, however for one individual the home collects their pension which is a long standing arrangement and is overseen by a solicitor. Secure facilities are available for the safekeeping of valuables if required. A range of health and safety checks are in place at the service and carried out on a daily, weekly or monthly basis. One requirement was issued following the previous inspection for health and safety matters to be thoroughly addressed in the kitchen. These must include good practice in labelling food products stored in the fridge and regular cleaning of insectocutors. It is pleasing to see that during this inspection this has been complied with. The fire risk assessment was looked at and is fully completed and is dated 26/01/08. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 25 The last visit by the fire authority was in June 2007 and no recommendations were made during this visit. Evidence of mandatory health and safety training demonstrates that staff are up to date with this training. Service reports are in place for the maintenance of hoists and the lift. There are service certificates PAT testing dated 21/10/07 and legionella dated 18/12/07. There are systems in place for water chlorination and kitchen hygiene. COSHH sheets are up to date and accurate. The inspector looked at Infection Control guidelines that are available for all staff. Tickford Abbey DS0000015073.V357893.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 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 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 X X 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 X 3 X 3 X X 3 Tickford Abbey DS0000015073.V357893.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. 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 OP7 OP7 OP29 Good Practice Recommendations It is recommended that the care plans contain further detail to ensure the care needs of people who use the service can be met. It is recommended that the daily notes, contained within the care plans, contain further detail. It is recommended that Criminal Records Bureau checks are renewed if they are dated 2003 and 2004. Tickford Abbey DS0000015073.V357893.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Tickford Abbey DS0000015073.V357893.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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