Care Home: Westfield Residential Home Limited

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What the care home does well People are well assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm, due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication very well and staff are trained in medication administration. People experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected.They are encouraged to maintain contact with family members and friends and enjoy visits from them any time of the day, and they are encouraged to exercise choice and control over their lives. People enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. They are confident their complaints will be listened to and acted upon. People are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service`s policies, procedures and practice under the safeguarding adults systems. They experience a safe, clean and well-maintained environment. A sufficient number of care staff work in the home on each shift to meet the assessed and changing needs of people. The manager runs the service in the best interests of the people that live there, safeguards their financial interests, and maintains their health, safety and welfare. The home is well protected in respect of health and safety and fire precautions etc. What has improved since the last inspection? The manager now provides people with a written confirmation that the home can or cannot meet their assessed needs shortly after their needs have been assessed. The manager has now made the complaint procedure more accessible to everyone by ensuring it is displayed around the home and in people`s rooms. The manager has made sure weekly fire equipment tests have been resumed and are recorded. What the care home could do better: The service make sure all documents relating to assessments etc. are dated at the time of compilation or signing, so that people know when their needs were assessed, and for authentication. The service could make the medication administration system safer by discussing with the pharmacist the need for a second seal on the cassettes. The service could make sure all staff receive regular up-dated training in safeguarding adults issues, preferably from an external source, so that staffare competent in dealing with safeguarding issues and people are confident they are being protected. The service could encourage more staff to undertake qualifications, so that a minimum of 50% care staff have the recognised or equivalent award, and so that people know they are being cared for by a qualified and skilled workforce. The service could make sure there are two signatures obtained for any transaction of money held in safe keeping for people that live in the home, so they are confident their finances are being protected. The service could undertake to have a legionella test carried out on the stored hot water, so that people are confident their health and welfare are being promoted and protected. CARE HOMES FOR OLDER PEOPLE Westfield Residential Home Limited 16 Carr Lane Willerby Hull East Yorkshire HU10 6JW Lead Inspector Janet Lamb Unannounced Key Inspection 20th November 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000046005.V355383.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. DS0000046005.V355383.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westfield Residential Home Limited Address 16 Carr Lane Willerby Hull East Yorkshire HU10 6JW 01482 651760 01482 659355 jeff@redmore1.karoo.co.uk 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) Westfield Residential Home Limited Mrs Suzanne Barbara Cross Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22) of places DS0000046005.V355383.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2006 Brief Description of the Service: Westfield House is a care home that is owned by a local private company. It is situated in a residential area of Willerby, in the East Riding of Yorkshire and is close to local amenities, i.e. shops, hairdressers, public houses, a chemist and a post office. The home is close to a bus route. Information about the home is provided to people and others in the home’s statement of purpose and service user guide. Fees paid range from £360.00 to £420.00 per week and there is an additional charge for hairdressing, private chiropody, toiletries, newspapers and magazines. On the day of the inspection there were 22 people accommodated at the home. The home is a large traditional house that has been converted and extended to provide accommodation for 22 older people. There are 20 single bedrooms and 1 shared room. Communal accommodation is provided in a lounge, conservatory and dining room. Access to all areas of the building is facilitated by the use of ramps and stair lifts. There is a pleasant, easily accessible garden to the rear and car-parking facilities are available at the front of the building. DS0000046005.V355383.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of Westfield Residential Home took place over a period of time and involved sending a request for information, the annual quality assurance assessment (AQAA) to the home in September 2007 concerning people that use the service and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information in early October 2007 and survey questionnaires were then issued to a selection of people in the home, their relatives and GPs. Surveys were also sent to other health care professionals with an interest in people’s care, to social service departments commissioning people’s care and to the staff working in the home. The information obtained from surveys and that already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 20th November 2007 to test these suggestions, and to interview people living there, staff, visitors and the home manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed, along with a selection of bedrooms. Two people were interviewed, the manager, administrator and registered provider were asked for information and documents and files were inspected along with some records and other information held. Some of the routine of the day was observed and several visitors were seen going about their business. What the service does well: People are well assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm, due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication very well and staff are trained in medication administration. People experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. DS0000046005.V355383.R01.S.doc Version 5.2 Page 6 They are encouraged to maintain contact with family members and friends and enjoy visits from them any time of the day, and they are encouraged to exercise choice and control over their lives. People enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. They are confident their complaints will be listened to and acted upon. People are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service’s policies, procedures and practice under the safeguarding adults systems. They experience a safe, clean and well-maintained environment. A sufficient number of care staff work in the home on each shift to meet the assessed and changing needs of people. The manager runs the service in the best interests of the people that live there, safeguards their financial interests, and maintains their health, safety and welfare. The home is well protected in respect of health and safety and fire precautions etc. What has improved since the last inspection? What they could do better: The service make sure all documents relating to assessments etc. are dated at the time of compilation or signing, so that people know when their needs were assessed, and for authentication. The service could make the medication administration system safer by discussing with the pharmacist the need for a second seal on the cassettes. The service could make sure all staff receive regular up-dated training in safeguarding adults issues, preferably from an external source, so that staff DS0000046005.V355383.R01.S.doc Version 5.2 Page 7 are competent in dealing with safeguarding issues and people are confident they are being protected. The service could encourage more staff to undertake qualifications, so that a minimum of 50 care staff have the recognised or equivalent award, and so that people know they are being cared for by a qualified and skilled workforce. The service could make sure there are two signatures obtained for any transaction of money held in safe keeping for people that live in the home, so they are confident their finances are being protected. The service could undertake to have a legionella test carried out on the stored hot water, so that people are confident their health and welfare are being promoted and protected. 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. DS0000046005.V355383.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 DS0000046005.V355383.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): 2 only. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People’s individual and diverse needs are well assessed so they are confident needs will be met. They receive sufficient written information in the form of a statement of purpose and a service users guide so they can decide if the home is the right place for them. EVIDENCE: Discussion with people that use the service and the manager and viewing of documents held in files, with people’s permission, reveals the systems for assessing prospective people to use the service is clear and well followed. It is documented and involves the assessing of individual’s diverse needs and transferring that information into a care plan. DS0000046005.V355383.R01.S.doc Version 5.2 Page 10 People spoken to are aware of the files held on them and remember the assessment of their needs being carried out by both the social services department and the home manager. Files contain such assessment documents and the manager confirms the process for admission. Documents show that assessment is undertaken with full consent of either the person receiving the service or their relative, in cases where they are not able to understand, in the form of signatures. There is an assessment form that considers 16 areas of need – from mobility to medication, to eating, to socialising and to such as sensory aids etc. to name a few. There is a one-page form that states an individual’s needs have been assessed and the home can or cannot meet those needs. The form also asks people if they require a lock to their room or a locked facility in their room, in which case they should agree to an assessment being done in these areas as well. Assessment of needs carried out by the management is thorough. Documents seen tend to have a lack of dates on them however. There is also a lack of copies of the placing authority community care assessment document on file. These need to be kept in the files belonging to people and must be obtained from the placing local authorities. There are no people ever admitted to the home for intermediate care, so standard 6 is not applicable. DS0000046005.V355383.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. People who use the service receive good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have their health and social care needs well documented in care plans, so they are confident all their needs will be met. They have good opportunities to self-medicate or their medication needs are well managed, and they enjoy good levels of privacy and their dignity is well maintained, so they are confident their overall quality of life is good. EVIDENCE: Discussion with two people, the manager and viewing of case files for three people with their permission, where possible, and viewing of medication administration record sheets, reveals people have their personal and health care needs well recorded in a care plan and have those needs well met. People spoken to are very satisfied with the help and support they receive to maintain their personal and health care. One said, “I’m happy here. I don’t DS0000046005.V355383.R01.S.doc Version 5.2 Page 12 need any help with personal care, but if I did I would be looked after discreetly.” Another said, “This is a wonderful place, nothing is too much trouble.” Diary notes show the care and support people receive and reviews of care plans show how changes in needs are to be dealt with. People spoke of seeing their GP when they choose, of having their medication looked after for them and of visits from the physiotherapist and chiropodist etc. They are very satisfied with the health care professional involvement. Comments from health care professionals in surveys state the home takes good notice of advice given, the staff are interested in people’s conditions and promoting their good health, and that the home provides very individual support and care. Records held in files show individuals’ health history, their nutritional screening, their weight, risk assessment documents, and key-working notes as well as management notes and monthly summaries. There are also records of GP visits, hospital appointments, letters stating medication reviews have taken place, peoples’ medical cards, and letters for such as arranging influenza vaccinations. All areas of personal and health care needs are well documented and there is evidence they are being well met. There is a medication administration procedure, a robust medication administration ‘trail’ and good storage for medicines. There is a locked cupboard in one of the corridors that contains a locked medicine trolley and a medicine fridge. The Nomad monitored dosage system is used, but it only has the one set of security seals on it. A recommendation is made for there to be another seal put in use, to prevent the outer case from being opened. The manager took action on this quickly and began discussions with the local pharmacist. MAR sheets are satisfactorily completed. There are people receiving controlled drugs, which are further locked in a cash register in the trolley. A separate record is maintained for these, but administration sheets are also signed. Staff receive training in medication administration and evidence is available in their training files. Where some have not had updates on training for some time it is recommended this be undertaken and refreshed – one file showed training in this area was last done in June 2004. Those people spoken to are quite satisfied with the levels of privacy and dignity experienced in the home. There were no comments in surveys or during interviews that gave cause for concern. Comments are all positive, and time spent observing interaction between people and staff reveal every consideration for people’s dignity and wellbeing is made. DS0000046005.V355383.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People enjoy flexible routines, good contact with relatives and friends, good opportunities to be self-determining, and highly satisfying food provision, so they are confident their daily lives and social activities meet their expectations. EVIDENCE: Discussion with people, staff and the manager and viewing of information and individual diary notes reveal people have good opportunities for being entertained or passing the time of day and for indulging in healthy eating. There is an activities plan available and there are things to do throughout the day. People spoke of having been out to a show in Cottingham, having taken part in a clothes sale in the home and having played bingo on a regular basis. On the day of the site visit people were sitting in the lounge and joining in with a quiz, which seems to be quite popular. Later in the day entertainers arrived DS0000046005.V355383.R01.S.doc Version 5.2 Page 14 to play music and sing many of the old time songs and popular songs of the 60’s and 70’s. People were also dancing along to the singing. There were also several visitors to the home and two people were taken out for the afternoon by one of their relatives. Relationships with family and friends are encouraged and very well maintained. Diary notes show evidence of visitors, outings and activities that people join in with. These are done very much at the will and wishes of people that live in the home. People spoken to were asked about the arrangements for maintaining their finances, and everyone said they were quite satisfied with having their relatives in control of their money. People are happy to hold a small amount on their person or to have it in the safe keeping of the office. Where money is held in the home there is an individual running balance held on record and transactions in/out, signature of staff etc. It is recommended in standard 35 in the section on Management and Administration that two signatures be obtained for all transactions on behalf of people, where they do not sign themselves. Information received from people living in the home, viewing of the menus and a brief discussion with the manager reveals people are very satisfied with the food provision and enjoy a variety of healthy meals. They are consulted daily on the choices of the day and these are recorded for the cook to prepare food as appropriate. One person said, “The food is beautiful, no problems. The staff ask us each day what we want. ____ is a marvellous cook. We had a turkey dinner yesterday, and it is scampi and chips today.” Another said, on leaving the dining room, “I have thoroughly enjoyed my dinner though I can’t remember what I had.” Then she remembered on being prompted about the scampi. The kitchen is clean, tidy and well organised and satisfactorily equipped. Diary notes show evidence of nutritional screening, menu choices and special diets required. DS0000046005.V355383.R01.S.doc Version 5.2 Page 15 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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People make use of informal complaint processes and systems and have all issues dealt with appropriately and they do not need to make formal complaints, so they are confident their concerns are dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: Discussion with people living in the home, the manager and the provider and information taken from surveys reveals people and their relatives know how to make a complaint and to represent themselves, but have had little cause to. There are policies and procedures and records held for complaints and for handling allegations or concerns. The manager uses these effectively to achieve solutions for people when they are feeling disadvantaged. One person was able to discuss directly the conversation she had with a staff member that upset her and lead to the staff member being dismissed. The manager and provider confirm this was the case. Action was appropriately taken and deemed satisfactory by the complainant. DS0000046005.V355383.R01.S.doc Version 5.2 Page 16 Staff are aware of the procedures to follow and know where to find the home’s policies and procedures manuals. There is a good ethos amongst the staff group that is lead by the manager, that shows they are open to suggestions for improvement, consider complaints to be a means of helping the service move forward with improvements, and that people’s views should be listened to. Staff have been trained in handling people with challenging behaviour as well as in safeguarding adult’s issues, but safeguarding training was done some time ago. Where possible all staff should undertake a refresher in this with an external organisation, the local authority or the Safeguarding Adult’s Board, etc. New staff are required to read the safeguarding adult’s folder in place and to understand the policy on abuse, to gain some knowledge of the area. One person said, “Yes I feel safe here, I have my own room. If I have any complaints I would go straight to the manager and can report things further, depends on what it is.” Relatives and health care professionals speak of the manager and staff always putting people first and considering their every need. Records of complaints and allegations made are held but only the complaint record has an entry, there having been no allegations or incidents for some time. This has been dealt with appropriately and quickly. DS0000046005.V355383.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have a well-maintained, safe, clean and comfortable environment in which to live, so they are confident they have a good home. EVIDENCE: Discussion with people and the manager and viewing of a selection of rooms and the communal areas of the home reveal the house is very well maintained, clean and comfortable. The home is suitable for its stated purpose of providing care and accommodation to older people and meets the legislative requirements of other organisations, as well as the Commission’s. DS0000046005.V355383.R01.S.doc Version 5.2 Page 18 Handrails are provided in en-suites according to individual need, there isn’t a passenger lift to the upper floor but there is a stair lift, and plans are in place to include some extension work with a passenger lift as well. The provider intends to extend the property to include two new single rooms and thereby reduce the double room in the main house. The garden to the rear is extremely pleasant and well maintained and has a ramp and rails for access to those with poorer mobility or that use wheelchairs. Maintenance of the house internally and externally is very good. People spoken to are satisfied with the cleanliness of the home and their rooms. Those seen are very personalised. The laundry is away from the kitchen and has separate access. It meets the Water Supply (Water Fittings) Regulations 1999 and provides sluicing and hand washing facilities. There are laundry assistants employed. Staff have infection control policies to follow, have access to strategically placed disinfecting hand gel, and have done infection control training. Both standards in this section are met. DS0000046005.V355383.R01.S.doc Version 5.2 Page 19 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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People are cared for by well-recruited, welltrained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy a good service of care. EVIDENCE: Discussion with the manager, viewing of rosters and using information from the home to determine the Residential Staffing Forum figures shows the home is sufficiently staffed in terms of staffing hours provided per week. Forum figures require 411.27 hours for 2 high, 12 medium and 8 low dependency people. According to the roster for week commencing 19/11/07 the home provides 402.5 care hours per week. This is a shortfall of 8.77 hours per week, but because there is a full time manager in the home each week day and between one and two housekeepers working each day then the cover is sufficient to meet the needs of people. Of the seventeen care staff employed seven have achieved NVQ level 2. There are three of the seven staff that have also achieved level 3 and a further staff member that has only done level 3. This gives the home 47.5 of care staff DS0000046005.V355383.R01.S.doc Version 5.2 Page 20 with the required qualifications. Efforts need to continue to ensure the 50 target is achieved. There is a recruitment and selection policy and procedure in place and practice is good. Staff files viewed with their permission show evidence of identification, criminal records bureau checks, references undertaken, and all of the homes recruitment documentation. Systems are robust and protect people living in the home. Staff are a long-standing group of workers, with only a couple newly appointed to their posts. The manager confirms the recruitment process and that staff are well vetted for their roles. Staff undertake induction and foundation training and attend courses as are appropriate. Certificates of attendance line the walls in one of the corridors. The home also regained the Investors In People Award in June 2007. DS0000046005.V355383.R01.S.doc Version 5.2 Page 21 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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People live in a home that is well run and in their best interests, where good systems are in place to determine the quality of the service. Their financial interests are safeguarded and their health, safety and welfare are well promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: Discussion with people and the manager and viewing of documents and records reveal people and the staff benefit from a well run home. DS0000046005.V355383.R01.S.doc Version 5.2 Page 22 The manager has the NVQ level 4 Registered Manager’s Award and is a qualified Registered Mental Nurse. She has 25 years caring experience, 9 of which are in a managerial role, some of these at Westfileds, and she constantly strives to improve her own knowledge and understanding of the care business for the benefit of improved services. She maintains her National Midwifery Council (NMC) Personal Identification Number (PIN) by undertaking reading and attending training. There have been no changes to the systems for quality assuring the service provided in the home since the last inspection. These were not assessed on this inspection, but the manager explained the home usually carries out people, relative and staff surveys. The home has the East Riding of Yorkshire Council quality development scheme awards – part one and two, and carries out monthly audits of which records are kept of the outcomes. There is a quality assurance file in place for each year containing the evidence of the systems and monitoring in place. People spoken to say they are satisfied with the arrangements for handling of their finances. Family members have control of finances for most people, but the manager holds a small amount in safe keeping for some of them, which is regularly balance checked and has individual recording documentation. Two sheets were seen and they record money in/out, reason why and the balance. They only show one signature though and it is recommended that where the person receiving the money is not the owner of it then two signatures are required for all transactions. One person said, “My daughter deals with my finances, I am very happy with that. I don’t have any held in the office.” Discussion with the manager, provider and viewing of documents shows the home is well maintained and the health, safety and welfare of people and staff are promoted and protected. Areas sampled during this site visit are fire safety, lifting equipment and water temperature controls and safety of cleaning materials. There are fire procedures and policies in place, a fire risk assessment document (last reviewed 15/10/07), and evidence of fire training (04/05/06) and a Fire and Rescue Service inspection (Jan 02). Annual fire training is now due and has been arranged for December 2007, and it is over five years since a visit was made by the local fire department, but this is not the home’s responsibility – it being determined by the fire department on a risk basis. Weekly fire equipment checks are carried out and two-monthly drills are held, and both are recorded appropriately. The home has fire safety signage and exits are kept clear. There is no passenger lift in the home at the moment, but there is a stair lift and this is regularly maintained in line with the manufacturers requirements and those of the insurance company. There is also a bath hoist and mobile hoists. Pickering’s Lifts last maintained these and the stair lift 08/11/06. DS0000046005.V355383.R01.S.doc Version 5.2 Page 23 Certificates of maintenance are available for viewing. The manager is aware of the need to remind Pickering’s that maintenance is now due. Hot water outlets within the home are fitted with thermostatic control valves and staff undertake checks on water temperatures. There is no record of there having been a legionella test carried out on the hot water storage tank, and so this is recommended for action. All cleaning products used in the home have safety leaflets and are used according to dilution instructions in line with the Control of Substances Hazardous to Health Regulations 1988. No products were seen left unattended and staff in the laundry were following safe practices. DS0000046005.V355383.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 4 X 3 X 3 X X 3 DS0000046005.V355383.R01.S.doc Version 5.2 Page 25 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 DS0000046005.V355383.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP2 Good Practice Recommendations The registered provider should make sure all documents relating to assessments etc. are dated at the time of compilation or signing, so that people know when their needs were assessed, and for authentication. The registered provider should request that a second seal be put into use on the Nomad medication cassettes, so that the removable inner cannot be tampered with, and people know their medication is stored safely. The registered provider should make sure all staff receive regular up-dated training in safeguarding adults issues, preferably from an external source, so that staff are competent in dealing with safeguarding issues and people are confident they are being protected. The registered provider should encourage more staff to undertake qualifications, so that a minimum of 50 care staff have the recognised or equivalent award, and so that people know they are being cared for by a qualified and skilled workforce. The registered provider should make sure there are two signatures obtained for any transaction of money held in safe keeping for people that live in the home, so they are confident their finances are being protected. The registered provider should undertake to have a legionella test carried out on the stored hot water, so that people are confident their health and welfare are being promoted and protected. 2 OP9 3 OP18 4 OP28 5 OP35 6 OP38 DS0000046005.V355383.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000046005.V355383.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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