Key inspection report CARE HOMES FOR OLDER PEOPLE
Torkington House Creswick Road Acton London W3 9HF Lead Inspector
Robert Bond Key Unannounced Inspection 11th August 2009 10:00
DS0000027744.V377194.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 2 Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Torkington House Address Creswick Road Acton London W3 9HF 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) 0208 992 5187 0208 896 1196 torkington@greensleeves.org.uk www.greensleeves.org.uk Greensleeves Homes Trust Margaret Josephine Siriwardena Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Torkington House DS0000027744.V377194.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: 32 9th September 2008 Date of last inspection Brief Description of the Service: Torkington House was established in 1947 as a residential club for older people. It was later registered as a residential care home. The home is situated on a quiet street in Acton. There are no shops or services in the immediate vicinity, however Acton High Street is accessible by bus or car. The property is a large attractive detached Edwardian house, dating from 1899. The home had an extension built in 2005 and a further extension in 2008. The accommodation provision throughout is of a good standard. The home is registered to provide personal care for thirty-two older people. Torkington House is owned and managed by Greensleeves Home Trust who are a London based not for profit charitable organisation with a total of 16 homes throughout England. The home has a Registered Manager and a Deputy Manager. The fees range from £575 to £650 per week according to the assessed needs of the resident. Torkington House DS0000027744.V377194.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 was a key unannounced inspection that considered the key National Minimum Standards (NMS) as published by the Department of Health for care homes for older people. The previous CSCI inspection took place on 9th September 2008 and the report contained 9 requirements and 7 recommendations. The home submitted to us in advance of this current inspection a completed Annual Quality Assurance Assessment (AQAA). We also received completed quality assurance surveys from 21 residents or their relatives, 8 members of staff, and a pharmacist. The feedback was uniformly positive and contained phrases such as “Residents are pampered very well without losing their independence” and “The care and support from the staff is first class, there is always a friendly atmosphere.” On the day of the inspection we toured the home and met residents and staff, we interviewed the Manager and Deputy Manager, and we examined a range of records and files. Equality and diversity were considered throughout the process. Whereas we found that the cultural needs of the existing residents were being met, the home, and it appears Greensleeves Home Trust as a whole, does not yet routinely assess the cultural needs of residents and hence this aspect of social need is not formally addressed with the care planning system used at Torkington House. We assessed the home’s performance for 24 of the NMS, and found that 13 outcomes were fully met, and 4 expected outcomes were exceeded, whereas 7 outcomes were only partly met. This led us to make 9 requirements and 3 recommendations. At the time of our inspection, the home had three vacancies for residents, but was said to be fully staffed. The substantial extension building work had finished but the promised refurbishment of the top floor of the old building had not taken place. This part of the home continues to be physically substandard. What the service does well:
Prospective residents are assessed prior to admission to make sure that the home can meet their needs. The assessment includes religious needs. Detailed Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 6 individualised care plans are drawn up and residents or their representatives are involved in reviewing the content of the plans. Residents’ health care needs are comprehensively met and clear records of inputs from health care professionals are maintained. Good medication procedures are in place. Residents may stay at the home during their final days if they so wish. Staff care for residents in a courteous, gentle and professional manner, respecting their privacy and dignity. The feedback from residents is very good. The home provides a wide range of activities and a good variety of nutritious foods. Residents are regularly consulted about the wishes and choices. The home has an open visiting policy and visiting by relatives is encouraged. Robust procedures are in place for investigating any complaints received. All the staff undergo training in avoiding any type of abuse developing. Proper recruitment procedures are now in place. The home is well staffed and staff are well trained. Systems are also in place for quality assurance and health and safety monitoring. The home is well managed. Much of the home is newly built or refurbished and most parts of the building are very clean, tidy and hygienic. What has improved since the last inspection?
The new building work that was underway during the last inspection has now been finished to a high standard. As a result staff have a new kitchen, new laundry and new staff room. New catering, sluicing and laundry equipment has been purchased. A servery area has been installed. The garden area and associated plants, furniture and equipment are much improved. The Manager and Deputy Manager have both worked very hard to meet the requirements and recommendations that we made following the last inspection. Hence there have been a large number of improvements. The Statement of Purpose and Service Users’ Guide have been updated. Assessment forms and care plan forms have been revised and are stored on the computer. The religion and cultural background of residents are now always noted. Respite care records are now better maintained. Records of medication returned to the pharmacist now always show the strength. The weight of residents is now better recorded, and body charts are used more effectively. The use of medical and nursing abbreviations are avoided. The range of activities offered has been extended. Care staff are encouraged to lead activities when the part time activity co-ordinator is absent.
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DS0000027744.V377194.R01.S.doc Version 5.2 Page 7 Records of any complaints received and investigated have improved. The water pressure to hand washing basins has been adjusted. Recruitment interviews are now being recorded in writing, POVA First checks are being done earlier, and reference requests include the name and address of the referee. The working hours and days of some domestic staff have been changed in order to provide a better service. The Aged Care Channel is now used to assist with training staff. Domestic and administrative staff are going to attend the Safeguarding Adults training. What they could do better:
The home’s Statement of Purpose and Service Users’ Guide must be kept up to date, and should be dated to assist in this process. A full assessment of need should be completed and dated before a new resident is allowed to move in as the assessment is partly to determine whether the home can meet the resident’s needs. An assessment of cultural needs is an essential part of the social needs assessment, and hence the format in use must accommodate this aspect. As the process of creating a care plan is based upon what appears in the assessment, cultural needs if any are not appearing in care plans, and the format in use does not have a space for cultural needs. The home’s complaints leaflet does not give the contact details of the Care Quality Commission should a complainant want to contact us directly. The top corridors of the old building contain corridors, bathrooms and bedrooms that have not been refurbished and hence do not match the excellent standards achieved elsewhere in the building. Corridor carpets in this part of the building are particularly poor and must be replaced urgently. The dining room contains a large and noisy industrial style refrigerator that is out of place and is a disturbance to residents. Some residents’ beds were seen to be made up with thin and damaged blankets. The hot water supply needs adjustment in places so that residents are not able to access water that is potentially too hot. Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 8 Domestic staff need further training in the need to keep cleaning chemicals that come under the Control of Substances Hazardous to Health Regulations (COSSH) safe and away from residents. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The written information available to prospective residents is not currently fully up to date. It appears that residents sometimes move into the home without their needs being fully assessed in advance. Residents’ possible cultural needs are not been formally assessed as part of the admission process, or subsequently. The home does not offer intermediate care. EVIDENCE: We examined the home’s current Statement of Purpose and Service Users’ Guide. Neither document was up to date in that they did not make reference to the Care Quality Commission (CQC) which now registers and inspects the home. The contact details of the CQC should be quoted, particularly in the section about how to make a complaint. In addition, neither document was dated. Dating is invaluable in identifying the latest version of a document and helping to ensure that documents are kept under regular review.
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DS0000027744.V377194.R01.S.doc Version 5.2 Page 11 We examined three care files, one being for an established long-term resident, one for a recently moved in long-term resident, and one for a respite care service user. All three files contained detailed assessments of need for the individual residents. In the case of the new long-term resident the assessment was dated on the day she moved in as opposed to it being done in advance to assess whether the home could meet the person’s needs. In the case of the established long-term resident who moved in during 2004, an updated assessment had been completed this year. Although a revised assessment format is now being used, the form still fails to prompt the assessor to assess the possible cultural needs of the resident, despite this being a requirement we made at the last inspection. The previous requirement has therefore been restated. Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health, personal and social care needs are excellently set out in individualised plans of care, but the format does not encourage cultural needs to be recorded. Residents’ health needs are being met. Residents are well protected by the homes policies and procedures for dealing with medicines. Residents feel they are treated with great respect and their privacy is upheld. EVIDENCE: We examined three residents’ files, as described in the above outcome group. All three contained detailed individualised care plans using the home’s new computerised format, which is commended. The care plan for the established long-term resident was dated 7/11/08 but had been reviewed monthly. The
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DS0000027744.V377194.R01.S.doc Version 5.2 Page 13 care plan for the new resident was still hand-written after two months, pending it being typed into the computer. It had been signed and dated by the resident who had recorded her own views at the review held. This is also commended. Probably because cultural needs do not figure in the home’s assessment process, they do not appear either as a section in the care plan format. This was a requirement made at the last inspection we undertook. A revised requirement has therefore been made. It is however noted that the home does now record each resident’s religion and ethnicity within the personal details and profile at the front of each care file. Health and medication are sections of the care plans. One resident signed that she would be responsible for her own medication. The files contained weight charts completed monthly and showing any weight gain or loss. Body maps are used appropriately. A ‘malnutrition universal screening tool’ is also used. We examined a sample of the home’s medication storage and administration arrangements, including the records for returning unused medication to the pharmacist. No errors or omissions were noted. The home is commended for the use of photographs within the medication records to identify residents. We observed staff treating residents with great respect, knocking on their bedroom doors, and respecting their privacy and dignity. One resident told us, “This is a lovely home and we are well looked after.” A relative put on her survey, “The staff treat the residents with respect. The general atmosphere is a happy one.” Torkington House DS0000027744.V377194.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most residents said that the home meets their recreational and their food needs. A wide range of activities is provided. Residents’ choices are taken account of. EVIDENCE: The care plans we examined included life histories and a note of current interests. Activities are listed daily on a notice board, and something is advertised for every day. Recent outings include Kew Gardens, Richmond Park and Woburn. A garden party is planned. The Activity Co-ordinator works half time and this is three mornings and two afternoons. Care staff undertake additional activities. On the morning of our inspection, they were leading a dancing session. A hairdresser and a chiropodist visit the home. Residents were asked by survey what they thought about the home’s activities. They were asked ‘Does the home arrange activities that you can take part in if you want?’ 14 respondents answered ‘always’, 4 answered ‘usually’, and 2
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DS0000027744.V377194.R01.S.doc Version 5.2 Page 15 answered ‘sometimes’. One wrote ‘recreational activities’ in the section entitled ‘What could the home do better?’ The Church of England holds a monthly service in the home, and the Roman Catholics hold a two weekly mass. Adventists attend once a month. A local school visits the home twice a year to sing. Relatives and other visitors are encouraged. Residents meetings are held at which residents can express their choices concerning activities and food. We examined a food menu and noted the choices available. We also sampled the lunch (lamb casserole) and found it to be nutritious and tasty. The feedback from residents concerning the food was mostly positive but when asked ‘What could the home do better?’ one respondent replied “selection of food.” When asked ‘Do you like the meals at the home?’, 12 respondents said ‘always’, whereas 6 said ‘usually’, and 3 said ‘sometimes’. Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a robust complaints procedure in place but the leaflet informing residents and relatives about the process does not refer to the Care Quality Commission. Residents are well protected from abuse in that all staff receive the necessary training, and individual emergency evacuation plans have been developed for each resident. EVIDENCE: The Service Users’ Guide refers potential complainants to a leaflet entitled ‘Your suggestions, comments and complaints’. We asked for a copy and found that it did not refer to the CQC as the document had not been kept up to date. The document referred to the now defunct CSCI but it failed to provide the contact details for any one wishing to make a complaint directly, contrary to NMS 16.4 and the Care Home Regulations. We examined the home’s complaints register and found that no complaints had been recorded since before our last inspection. We examined the records of staff training in the Safeguarding of Adults. Care staff have been trained, and domestic and administrative staff are shortly to undergo this training, which is commended.
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DS0000027744.V377194.R01.S.doc Version 5.2 Page 17 We noted on the care files examined that risk assessments are undertaken concerning the potential of residents to fall, and on the ‘handling’ of residents. Each resident also has a ‘personal emergency evacuation plan’, which is commended. Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most parts of the home are very safe and well-maintained but the unrefurbished parts of the building are less so. Poor quality blankets were seen to be in use in some bedrooms. Most areas of the home are very clean, pleasant and hygienic, but the unrefurbished areas are not. EVIDENCE: Since the previous inspection, the new building work has been finished to an excellent standard. This includes the installation of new furniture and equipment, and the creation of a lovely garden area. We wrote in our last inspection report, “There is a marked contrast between the bedrooms, bathrooms and corridors in the old building and those in the
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DS0000027744.V377194.R01.S.doc Version 5.2 Page 19 existing new wing. Once the present works are complete, the management must consider how to improve the old parts of the building.” The Manager told us during this inspection that unfortunately the refurbishment of these original areas had not been done, nor had the work been programmed to be done. As a consequence, our previous requirement to replace ‘soiled and stretched corridor carpets’ had only been carried out on the ground floor and not in these upstairs areas. The Manager added that she now had authorisation to replace the upstairs corridor carpets and we were shown estimates for the work. The requirement has been restated however due to the very poor state of these carpets one year on. A recommendation is also made about the desirability of refurbishing, or taking out of use for residents, those parts of the building that have not been modernised. One item of new equipment that is incorrectly placed is a large and noisy stainless steel refrigerator currently sited in the dining room, and which must be relocated to a more appropriate place. We also noted two beds that were covered by thin and damaged hospital type blankets. The Manager said new blankets had been bought already and the old blankets should not have been used. The laundry and kitchen are new and are very clean and hygienic. The recently built part of the home and the refurbished part were also seen to be very clean and well decorated. The top floor area of the old building however was not so. Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ needs are well met by the good numbers and skills of the staff group. Domestic staff cover has improved. The extent of training provided is excellent. The home’s recruitment policies and practices are now satisfactory. Excellent raining records are kept. EVIDENCE: We examined the current staff rota which demonstrated that four care staff plus a senior carer are on duty each day, and when the home is full, three care staff are on duty at night, which is commended. The rota also showed that domestic staff are now rostered for weekend duties. 77 of the care staff have NVQ level 2 awards in care. Senior staff and the Manager have recently completed the level 3 awards in Palliative Care, which is commended. We examined two staff recruitment files. The first concerned an employee who started work on 22/07/08. All references were in order but the Criminal Records Bureau certificate was dated 08/10/08. The file contained an invoice from the ‘umbrella organisation’ that took up the CRB request which
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DS0000027744.V377194.R01.S.doc Version 5.2 Page 21 demonstrated that a POVA First disclosure had been paid for by Torkington House. However no record of the POVA First clearance was on the file. The worker should not have been allowed to start work without a POVA First clearance. The Manager telephoned the umbrella organisation who responded that they had the clearance, and that they would post it on to the home. The second file was for a worker who started on 21/01/08. In this instance, a POVA First clearance was on the file but it was dated 31/01/08. The Manager said it was company policy to allow someone to start work in this circumstance provided a risk assessment was undertaken and the worker did not work alone. As this is contrary to Regulations, a check was made with Greensleeves Homes Trust by the CQC Provider Relationship Link person, and the Trust denied that this had been company policy. The home’s CRB and POVA First arrangements have now changed in that the checks are now sought directly by the home, and an umbrella organisation is no longer used. Hence no requirement is made concerning failings that are now historical. We examined the staff training records which were well maintained. Details of induction training appeared on individual files. Use is made of a television channel, Aged Care Channel from Australia, which is commended. Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed, to the benefit of the residents and staff. Good quality assurance processes are in place. Residents’ financial interests are well safeguarded. The staff are well supervised. The health and safety of the residents are sufficiently promoted in most instances. EVIDENCE: The Manager has achieved the Registered Manager’s Award and has been successful in meeting the great majority of the requirements and recommendations we made at the last inspection. A number of other improvements have also been achieved during this period. She is ably assisted by her Deputy Manager who is undertaking a similar management qualification.
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DS0000027744.V377194.R01.S.doc Version 5.2 Page 23 Quality Assurance is achieved by regular visits and reports by the Area Manager, and by the use of questionnaires sent out to residents and relatives by the head office of Greensleeves Homes Trust. The Manager has plans to help set up a ‘Relatives and Friends Circle’ which will further aid the consultation process. The home only holds money for two residents now. We checked the records and amount of cash held and found it to be correct. The additional expenses for the other residents are dealt with by sending invoices to relatives. We noted supervision records that indicated staff were receiving professional supervision at the correct frequency. In terms of health and safety, we found that the hot water supply to wash hand basins in two out of three bedrooms checked was slightly too hot, being at 44 degrees Centrigrade. We also found bleach lying unattended in a domestic’s trolley left on a landing, and ‘sanitiser’ in an unlocked bathroom cabinet. Positively, however, we found the nurse call bell system working and quickly answered, first aid boxes to be full and regularly audited, the gas appliances, water supply and the lift to have safety certificates in place, and a record of window opening restrictor checks in place. Torkington House DS0000027744.V377194.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 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 4 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 2 17 x 18 4 2 x x x x 2 x 3 STAFFING Standard No Score 27 4 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 3 x 2 Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes 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 OP1 Regulation 6 Requirement The registered person must keep the Statement of Purpose and Service Users’ Guide under review and revised so that they are up to date. The assessment of prospective residents must include their cultural needs. THIS IS A RESTATEMENT AS THE REQUIREMENT HAS NOT BEEN MET WITHIN THE TIMESCALE PREVIOUSLY SET OF 01/10/08. The care plan format must include space to record any assessed cultural needs of the resident. The home’s complaints procedure leaflet must include the name, address and telephone number of the Care Quality Commission. Soiled and stretched corridor carpets must be replaced. THIS IS A RESTATEMENT AS THE REQUIREMENT HAS NOT BEEN MET WITHIN THE TIMESCALE PREVIOUSLY SET OF 01/01/09. Timescale for action 01/10/09 2. OP3 14 01/10/09 3. OP7 15 01/10/09 4. OP16 22 01/10/09 5. OP19 23(2)(d) 01/10/09 Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 26 6. 7. 8. OP19 OP24 OP38 23 16 13 9. OP38 13 The industrial style refrigerator must be relocated away from the residents’ communal dining area. Good quality blankets must always be used when making residents’ beds. The hot water supply available to residents must be adjusted so that it does not exceed 43 degrees Centrigrade. The home must comply with the COSSH regulations concerning the protection of residents and safe storage of cleaning chemicals. 01/10/09 01/10/09 01/10/09 01/10/09 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 OP1 OP3 OP19 Good Practice Recommendations The Statement of Purpose and the Service Users’ Guide should both be dated. Except for emergency admissions, a full assessment of need for new prospective residents should be completed before admission. That Greensleeves Home Trust consider whether it is appropriate to continue providing substandard accommodation in unrefurbished parts of the building. Torkington House DS0000027744.V377194.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission London Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk
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