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Inspection on 21/04/08 for St Ann`s Residential Home

Also see our care home review for St Ann`s Residential Home for more information

This is the latest available inspection report for this service, carried out on 21st April 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A resident that has lived in the home for 3 years said that they loved it and that they liked the home just as much as when they first arrived. The resident now had a new room, which had ensuite facilities, because they had asked the proprietor if they could change their room and he had arranged this for them. Another resident agreed that it was quite a nice place to live. A resident that had been admitted to the home on an emergency basis couldn`t praise the proprietor enough for the support that the proprietor had given the resident and for helping the resident cope with a traumatic event. Residents praised the care given by members of staff and one resident said that "staff are great, you can have a joke with them". Praise was also given to the manager and the deputy managers that were described as caring and approachable. A relative commented on the survey form that there are "extremely warm and obviously caring staff" and that they "make considerable efforts to arrange such events as birthday parties and other social gatherings". Another relative commented that they "find all the staff very friendly and caring". Particular emphasis is placed on training carers and the home is to be commended in respect of the achievement of NVQ qualifications by members of staff. Staff have opportunities not only to study for an NVQ level 2 qualification but to then progress to level 3 and level 4. Within the home there are a number of Eastern European members of staff and the home is able to offer support from members of staff that speak Polish and Russian. We saw that the home is currently translating key documents i.e. the service user guide and the statement of purpose into Polish.

What has improved since the last inspection?

At the random inspection in December all the statutory requirements identified in the key inspection in July had been met. Since the random inspection new carpets, tables and chairs and a new television have been purchased for the home. These have improved the appearance of communal areas and the facilities in the home.

CARE HOMES FOR OLDER PEOPLE St Ann`s Residential Home 125 Chalkhill Road Wembley Park Middlesex HA9 9AL Lead Inspector Julie Schofield Key Unannounced Inspection 08:45 21st April 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 St Ann`s Residential Home DS0000017440.V361409.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. St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Ann`s Residential Home Address 125 Chalkhill Road Wembley Park Middlesex HA9 9AL 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) 020 8908 2033 020 8904 2856 miclondon@yahoo.com Capital Investments & Devlp Ltd Monica Aurelia Luca Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 17 2nd July 2007 Date of last inspection Brief Description of the Service: The home is registered to provide personal care for up to 17 residents. At the time of the inspection there were 15 residents living in the care home and there were 2 vacancies. St Ann’s is situated close to Wembley Park underground station and main bus routes. It is also close to a parade of shops and to a supermarket. At the front of the home there is a large paved area for off street parking. (There are parking restrictions in the road immediately outside the home). Residents are accommodated in bedrooms on both ground and first floors and there are bathing and toilet facilities on both floors. Eight of the bedrooms have en suite facilities. There is a passenger lift connecting ground and first floor. Staff accommodation is situated on the second floor. The office, open plan dining and lounge areas and kitchen are situated on the ground floor and the laundry room is situated on the first floor. During the inspection, the proprietor said that the weekly fees charged vary between £450 and £550, depending on an assessment of the individual needs of the resident. The fees do not include the provision of personal items such as clothing or hairdressing. A copy of the statement of purpose is on display in the entrance hall and there is a notice informing visitors of access to the last inspection report by the CSCI. A copy of the report was produced. Information regarding the fees and the service provided may be obtained, on request, from the home. St Ann`s Residential Home DS0000017440.V361409.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. The inspection took over 2 visits to the home in April. The first visit took place on a Monday and started at 8.45am. It finished at 5.35pm. The second visit took place later in the week on a Thursday. It began at 8.55am and finished at 10.35am. During the inspection we spoke with the proprietor, the manager and deputy managers, members of staff and with residents. Records were examined and the care of a number of residents was case tracked, care practices were observed, a tour of the building took place and the preparation and serving of the midday meal was seen. The Annual Quality Assurance Assessment (AQAA) had been returned to us in October 2007 and during the inspection we checked for the evidence that was listed in the AQAA and discussed any queries that we had. Survey forms were distributed to the relatives of the residents in December 2007 and 5 of these were returned. We would like to thank everyone that gave assistance and comments during the inspection and thank those that took the time to complete and return the survey forms. What the service does well: A resident that has lived in the home for 3 years said that they loved it and that they liked the home just as much as when they first arrived. The resident now had a new room, which had ensuite facilities, because they had asked the proprietor if they could change their room and he had arranged this for them. Another resident agreed that it was quite a nice place to live. A resident that had been admitted to the home on an emergency basis couldn’t praise the proprietor enough for the support that the proprietor had given the resident and for helping the resident cope with a traumatic event. Residents praised the care given by members of staff and one resident said that “staff are great, you can have a joke with them”. Praise was also given to the manager and the deputy managers that were described as caring and approachable. A relative commented on the survey form that there are “extremely warm and obviously caring staff” and that they “make considerable efforts to arrange St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 6 such events as birthday parties and other social gatherings”. Another relative commented that they “find all the staff very friendly and caring”. Particular emphasis is placed on training carers and the home is to be commended in respect of the achievement of NVQ qualifications by members of staff. Staff have opportunities not only to study for an NVQ level 2 qualification but to then progress to level 3 and level 4. Within the home there are a number of Eastern European members of staff and the home is able to offer support from members of staff that speak Polish and Russian. We saw that the home is currently translating key documents i.e. the service user guide and the statement of purpose into Polish. What has improved since the last inspection? What they could do better: To assure residents that the administration of medication is safe and thorough two changes need to be put into practice. To avoid unnecessary confusion and errors medication must only be taken from the current blister cards. Before completing the medication round a check must be made of all blister cards to ensure that each relevant blister has been “popped”. One of the relative’s survey forms commented that residents should be able to go out of the home more and this needs to be discussed at a residents’ meeting so that a plan can be drawn up. To improve the general appearance in certain rooms/areas within the home so that they are pleasing to see and enjoyable to use some minor repairs are needed. Keeping electrical adaptor sockets in a safe position in a room would reduce a potential tripping hazard for the resident using the room and for anyone else coming into the room. St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 7 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. St Ann`s Residential Home DS0000017440.V361409.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 St Ann`s Residential Home DS0000017440.V361409.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The resident is assured of a service tailored to their individual needs by a comprehensive assessment process being carried out prior to admission. Standard 6 was not inspected, as the home does not offer an intermediate care service. EVIDENCE: Since the last key inspection 3 residents have been admitted to the care home. The case files were examined and 2 of the residents had been placed by a local authority. There was evidence that a pre-admission assessment had been St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 10 carried out by the manager and a deputy manager prior to the admission of the 2 of the residents to the home. The managers had visited the hospital or the care home where the residents were currently accommodated. There was information on file for these residents from the funding authority including social workers’ reports, care plans and FACE overview assessments. The third resident had been admitted on an emergency basis and a full admission assessment form had been completed. St Ann`s Residential Home DS0000017440.V361409.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Evaluating care plans on a regular basis ensures that changes in the needs of residents are identified and can be addressed and regular reviews of the placement confirm that the care home continues to be able to meet the individual needs of the resident. Residents’ health care needs are met through access to health care services in the community. The general well being of residents is promoted by assistance or support from staff in taking medication, as prescribed, however errors in the administration may compromise this. Residents said that their privacy and dignity is respected. EVIDENCE: St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 12 Four case files were examined. We saw that each one contained an initial care plan that was prepared on the basis of the pre-admission assessment and then a further care plan was developed after the initial review of the placement and after the resident had time to settle into the home. Care plans were comprehensive and there were detailed, informative and up to date monthly evaluations of the care plans. Care plans included risk assessments for pressure care, prevention of falls, mobility, nutrition, manual handling and specific risk assessments that were tailored to the individual needs of the resident. Risk assessments were subject to regular reviews. There was evidence of review meetings for the care plan and the placement being convened by both local authority and by the home. Residents and their representatives were invited to attend. Each of the relatives that completed a survey form agreed that the care home gave the support or care to the resident that the relative expected or had been agreed. The home provides care to some very elderly residents and at the time of the inspection one of the residents living in the home had recently celebrated their 107th birthday. One of the residents pointed to another resident that was walking past and told us that the other resident had been ill recently but that after a few days residents that were ill begin to look better. They said that this was due to the care and attention that they received from the members of staff. We saw on case files that residents had access to health care services. This included routine screening e.g. blood tests, preventative care e.g. flu jabs, out patient appointments and appointments with the GP, diabetic nurse, CPN, optician, dentist and chiropodist. Where necessary, a request for pressure relieving equipment has been made e.g. the provision of a special mattress for a resident. When the home was recently concerned about a resident losing weight the family and the GP were informed. The manager said that the home had changed its system of administering medication to residents and had introduced a monitored dosage system in January 2008. A new cupboard for controlled drugs had also been installed although no controlled drugs are prescribed for residents currently living in the home. The storage of medication was safe and secure. The records of the administration were up to date and complete. We saw that two blisters had not been opened on the cards. After an investigation the manager established that one of the blisters had been left unopened, as the member of staff had used medication from the previous card. (Medication had been unused when the resident went to hospital). The manager concluded that the second blister had not been opened due to an error on the part of the member of staff. Members of staff on duty confirmed that they had received medication training and attendance certificates were present on the staff files examined. One resident self medicates and we saw a risk assessment on the resident’s file. We spoke to 1 resident in the privacy of the resident’s room. They confirmed that they liked to spend time on their own and said that they were an “independent, private person”. They said that members of staff respected this St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 13 and that members of staff always knocked on the door and waited to be invited in before entering. All bedrooms are single bedrooms and when the resident sees their GP the consultation (and examination) take place in the resident’s room. When assistance with toileting is required it was observed that it was offered discreetly. A resident said that she prefers to be called by a name that is the recognised “shortened” version of her name and that this is the name that she is known by to her family and friends. Residents are able to make and to receive telephone calls in private. It was observed that residents requiring assistance with feeding received help from members of staff in a relaxed and friendly manner that maintained the dignity of the resident. St Ann`s Residential Home DS0000017440.V361409.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. With staff support, residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected. Residents are offered a varied and wholesome diet to maintain their well-being and which meets their cultural needs. EVIDENCE: Information about activities taking place locally was included in the most recent Newsletter, a copy of which was given to each resident. Information about the daily activities programme organised by the home is on display in the lounge and includes activities taking place in the home e.g. arts and crafts, dominoes or ball games and activities taking pace outside the home e.g. the St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 15 day centre, tea dance or walks in the community. One resident said that they sometimes took part in the quizzes that were arranged. The manager said that now the weather was brighter they were organising a trip to Kew Gardens and that many of the residents were showing an interest. A resident told us that as they had enjoyed an outing before Christmas and would like to take part in this one. Throughout the communal areas there are photographs of celebrations that have taken place in the home and these reflect the multicultural nature of the borough in which the home is situated. A resident said that they had enjoyed a good Easter and that it was always very nice in the home, “lots of celebrations and parties”. They said that the home celebrated all the festivals. When the home celebrated St Patrick’ s Day a group of dancers visited the home to entertain the residents. One of the residents enjoys singing, particularly singing hymns, and the manager said that the resident goes to church either with a family member or with a member of staff. There is also a church service in the home each week. The proprietor takes a resident that is Muslim to the mosque. In the entrance hall there was a notice for visitors, which set out the visiting times to the home. Residents said that the members of staff on duty make their relatives and friends welcome when they visit the home. Visits can take place in the privacy of the resident’s own room or in the lounge. A resident said that when their family visit the family take the resident out. If a resident does not wish to receive a visitor this wish is respected. A recent replacement of the carpet in the lounge/dining room and in the entrance hall and ground floor corridors involved residents in the decision making process. Carpet samples were shown to residents so that they could choose the colour that they preferred and residents told us that they had chosen the light biscuit colour to replace the old red carpet. Residents are also consulted about the content of menus and the choice of activities. The manager said that discussions about the content of the menus take place on a regular basis with residents and their suggestion of having homemade soups has been taken on board. During the inspection the midday meal was being prepared. It consisted of shepherd’s pie, potatoes and green beans. The dessert was treacle sponge with custard. An alternative was available if the resident wished. A resident said that the carer that cooks is excellent and that as the resident likes spicy food the cook “spices it up” for them. They said that portions sizes are good and that they have a roast dinner twice a week. The home follows a 3-week menu plan and a copy was available. The menu was varied and wholesome and an alternative to the main dish was listed or residents could have something else. The home provides meals for a number of diabetic residents and dishes for African Caribbean, Polish and Indian residents. A new resident that is Egyptian likes to cook for themselves. On St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 16 the day of the inspection the cook was preparing rice and peas for the African Caribbean residents. A recent visit by the Environmental Health Officer to inspect food hygiene standards in the care home resulted in “2 Stars”, which means “broadly compliant” in the scores on the doors initiative. St Ann`s Residential Home DS0000017440.V361409.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place to protect the rights of the residents. An adult protection procedure and training for members of staff in protection of vulnerable adults procedures help to promote and protect the welfare and safety of residents. EVIDENCE: A copy of the full complaints policy and a quick guide to the complaints policy were on display in the entrance hall, close to the visitors’ book. Both documents included information about how to contact other agencies that have an involvement in the process e.g. the CSCI and contained addresses and telephone numbers. There was also a Comments or Suggestions box by the visitors’ book for visitors to post their observations and a supply of forms that can be used for this are available. Complaints records were inspected. A resident had made four complaints in November 2007 about the heating and ventilation in the bedroom, the volume of the television etc. Details of the investigation and of relaying the outcome to the complainant were included in the records. (The main problems had been resolved when the resident had St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 18 been shown how to adjust the thermostat on the radiator to their satisfaction). Four complaints by residents about a new resident that was not sleeping at night had been resolved. The resident has now settled into the home and was calmer during the night. Four of the five relatives that completed a survey form confirmed that they knew how to make a complaint about the care provided, if they needed to. The fifth relative ticked that they couldn’t remember. We spoke with residents and they said that if there were something that they were not happy with they would speak to someone in the home. Staff attended protection of vulnerable adults training in 2007 (attendance certificates are on file) and the 2 members of staff that have started to work in the home in 2008 have been made aware of this in their induction training and will be attending a formal training course shortly. Two members of staff spoke with us about their training and they were able to explain their responsibilities in the event of an incident occurring or a disclosure being made. The manager has attended a protection of vulnerable adults training course designed for managers of care homes. The manager confirmed that there have not been any incidents or allegations of abuse since the last key inspection. The policies and procedures manual includes a copy of the protection of vulnerable adults procedures and the home has a copy of the local authority interagency guidelines in the event of abuse. The home also has policies in relation to handling residents’ monies and in relation to gifts and gratuities. St Ann`s Residential Home DS0000017440.V361409.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a home where the general standard of maintenance is good, although carrying out some minor repairs would assure residents of the continuation of pleasant and comfortable surroundings. Residents are assured of hygienic surroundings, as standards of cleanliness are good. EVIDENCE: Residents told us about changes to the home since the last key inspection. They said that there was a new dining table and chairs. There were new St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 20 carpets in the lounge, the hallway and stairs. One resident said that the carpet was “really lovely”. There was also a new and very large television in the lounge. We saw that there was a new patio table and chairs in the garden, ready for days when it is warm enough to sit outside. A tour of the premises took place and generally the upkeep of the home was good. Some minor repairs are needed. There are some water stains on the plaster in Room 12. Some of the plaster in Room 17 needs making good where it has bubbled due to a leak. Along the first floor corridor a section of the boxing around pipe work is missing. In the ground floor shower room the sealant around the toilet base needs replacing and a grab rail is missing. In the kitchen there was a gap between the edge of the tiles and the bottom of the cupboards and the trim on the edge of a cupboard door was missing. Residents said that they liked their bedrooms and one resident said that they were very lucky with the size of the room (large). During the site visit we saw that all areas of the home were clean and tidy and free from any offensive odours. Residents said that the home was kept clean. The manager said that most members of staff had completed a distance learning course over a 3-month period about infection control procedures. A new washing machine and tumble drier have been purchased for the laundry room. The room is on the first floor and access to the room does not involve carrying dirty laundry through any area where food is prepared, served or stored. St Ann`s Residential Home DS0000017440.V361409.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are assured of their needs being met through sufficient members of staff being on duty at all times of the day and the night. Residents benefit from care being provided by staff that have demonstrated their skills and understanding through NVQ training. The safety and welfare of residents is protected by recruitment practices that include all necessary checks and references. Residents are assured of competent members of staff supporting them by a programme of training for members of staff. EVIDENCE: At the start of the inspection a deputy manager and 2 carers were on duty and they were joined by the manager and the other deputy manager. (Deputy managers form part of the number of carers on duty each shift). One of the carers has a catering qualification and spent part of the shift preparing the midday meal. Three carers worked on the late shift with the manager still on duty at the beginning of this shift. There are 2 waking night staff and 2 St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 22 members of staff sleeping in but on call. The home has a domestic on duty each day. Staffing levels of 4 care staff on the early shift and 3 carers on the late shift are maintained throughout the week and are sufficient to meet the existing needs of the current residents. A resident said that all the members of staff are very nice. Looking at the names on the rota (deputy managers and carers) a discussion took place with the manager regarding NVQ qualifications. Of the 18 members of staff 3 members of staff have completed their level 4 qualification and 2 members of staff are currently studying for this. Two members of staff have completed their level 3 qualification and 6 members of staff are currently studying for this. Three members of staff have completed their level 2 qualification. One member of staff has a nursing qualification and one member of staff does not have an NVQ qualification. The personnel files of 4 members of staff were examined. These were for members of staff that had started to work in the care home after the last key inspection. We saw that each file contained an application form, proof of identity (passport details), 2 satisfactory references, an enhanced CRB disclosure and that the right to reside and work in the UK had been established, where necessary. Files also contained certificates for training courses attended. A discussion took place with the manager about training opportunities for members of staff. Each member of staff has an individual training profile. A copy of the training diary for the April to June 2008 was available. All members of staff have recently completed a distance learning course in relation to Equalities and Diversity over a 3-month period. Each member of staff has also completed food hygiene training. A new member of staff is in the process of doing induction training and we saw that the workbook met Sector Skills Common Induction Standards. St Ann`s Residential Home DS0000017440.V361409.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, 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager demonstrates her competence and commitment to a quality service for residents by continuing to develop her understanding, skills and knowledge through further training. Systems are in place to gather feedback on the quality of the service provided to enable the service to develop in ways that meet the changing needs of the residents. Systems are in place to safeguard the financial interests of residents. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents and regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager has completed her NVQ level 4 qualification. She has started a university course in the Management of Social Care and has competed the first part. (The course is beyond a level 4 qualification). Since the last inspection she has undertaken refresher training in safe working practice topics and has undertaken equalities and diversities training. She has attended training on the Mental Capacity Act and has attended a protection of vulnerable adults training course for managers. A copy of the most recent Newsletter (March 2008) was on display in the entrance hall and it included news of discussions with residents about the colour of the new carpet, taking up the residents’ suggestion of having home made soups on the menu and information about local activities that might be of interest to residents. We discussed what quality assurance systems were in place to enable the home to gain feedback on the quality of the service provided and to use this to inform the development of the service. An annual satisfaction survey form is distributed at the beginning of the year to relatives and friends of residents and to professional visitors to the home. The forms that had been returned were available and we saw some of the comments that had been made which included “excellent Christmas party”, the resident is “happy and well looked after” and “thank you for taking such good care of” the resident. There was a suggestion that residents might enjoy listening to old time music hall songs and a tape has been purchased so that these can be played. The home also holds staff meetings and holds residents meetings on a regular basis and these are both opportunities for comments to be made on the quality of care provided. The home assists 2 residents with their personal allowances and we looked at the records. These were up to date with a running total of the balance held. Details of all items of expenditure, with receipts, are kept. A record sheet is also kept when relatives leave money in the home for the resident’s use. These were seen and were satisfactory. Although the copy of the Employer’s Liability Insurance certificate that was on display in the home expired on the day of the inspection the proprietor provided a copy of the new certificate that would replace the one on display, the next day. Certificates to demonstrate that equipment and systems in the home were safe to use were seen. They included certificates for the lifts, the electrical installation, the Landlord’s Gas Safety Record, the fire extinguishers, the fire alarm system and the portable electrical appliances. There was a fire risk assessment and evidence of weekly fire alarm/smoke detector testing and regular fire drills. When talking with a resident we noticed that a 4-way adaptor, connected to 4 plugs with trailing flexes, was lying on the floor. We talked with 2 members of staff and they said that they had undertaken training St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 25 in safe working practice topics and that these are repeated on a regular basis. Attendance certificates are kept on the individual staff files. St Ann`s Residential Home DS0000017440.V361409.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 4 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 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 St Ann`s Residential Home DS0000017440.V361409.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 OP9 Regulation 13(2) Requirement To assure residents of a healthy lifestyle all medication must be given to a resident according to the dosage, times and frequencies advised by the GP. To assure residents that steps are taken to prevent errors occurring when medication is administered staff must only take medication from the blisters on the current monitored dosage card. To assure residents of more opportunities to take part in activities outside the home a plan must be drawn up after a discussion at a resident’s meeting. To assure residents of surroundings that are pleasing and smart the minor repairs in Rooms 12 and 17, the first floor corridor, the kitchen and in the ground floor bathroom must be carried out. To assure the resident and anyone that visits the resident’s bedroom that tripping hazards are eliminated any adaptors in DS0000017440.V361409.R01.S.doc Timescale for action 01/06/08 2 OP9 13(2) 01/06/08 3 OP12 16(2) 01/07/08 4 OP19 23(2) 01/07/08 5 OP38 13(4) 01/06/08 St Ann`s Residential Home Version 5.2 Page 28 use are positioned flush with the skirting board and not away from the wall. 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 OP16 Good Practice Recommendations That the manager reminds relatives during the review meetings of how to make a complaint about the care provided, if the relative feels the need. St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Contact Team Fourth Floor Caledonia House 223 Pentonville Road Harrow N1 9NG 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 St Ann`s Residential Home DS0000017440.V361409.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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