Inspection on 16/10/06 for 40 Fir Tree Road

This inspection was carried out on 16th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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.

Other inspections for this house

40 Fir Tree Road 26/08/08

40 Fir Tree Road 16/07/07

40 Fir Tree Road 01/11/05

40 Fir Tree Road 05/04/05

40 Fir Tree Road 20/09/04

40 Fir Tree Road 24/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Fir Tree Road (40) 40 Fir Tree Road Banstead Surrey SM7 1NG Lead Inspector Joseph Croft Unannounced Inspection 16th October 2006 10:00 X10029.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 Fir Tree Road (40) DS0000013494.V316095.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 and Care Homes for Adults 18 – 65*. 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. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fir Tree Road (40) Address 40 Fir Tree Road Banstead Surrey SM7 1NG 01737 379242 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) www.c-i-c.co.uk. Community Integrated Care Mrs Judith Eleanor Conteh Care Home 8 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (5), Physical disability (2), of places Physical disability over 65 years of age (4) Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to 3 (three) residents aged 47-64 years. Up to 5 (five) residents aged over 65 years. Of the 3 (three) adults with learning disabilities (LD) accommodated, 2 (two) may have an additional physical disability (PD). Of the 5 (five) older people with learning disabilities LD(E) accomodated, 4 (four) may have an additional physical disability PD(E). 1st November 2005 Date of last inspection Brief Description of the Service: The home is registered as a care home only within the service user category: Learning disability (LD) and Learning disability over 65 years of age. The home is registered to accommodate a maximum of seven Service Users. Community Integrated Care manages the home. It is a large detached house with extensive grounds to the front and rear and is situated on a busy main road, near to Banstead centre.40 Fir Tree Road aims to provide a safe and homely environment that enables Service Users to develop to their maximum potential and where they are treated with dignity and respect. Service Users are very much an integral part of the homes operation despite their profound disabilities. The home provides a good standard of accommodation to its Service Users. The weekly fees range from £1040 to £1120. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection using the Inspection for Better Lives process for the year 2006/2007. This key inspection ensured that all the core standards of the National Minimum Standards for Older People were considered. This inspection was unannounced therefore staff and residents were not informed in advance of the inspection being carried out. This inspection was conducted by Mr J Croft on the 16th October 2006, and took seven and a half hours, commencing at 10:00 hours and concluding at 17:35 hours. The inspection process included a tour of the premises, sampling of residents’ care plans, risk assessments, staff training records and staff recruitment files; other documents sampled included policies and procedures, staff duty rota, menu, medication and records of medicines. Discussions took place with the manager and staff. Due to the complex learning needs and levels of understanding, the inspector was not able to have in depth conversations with residents; however, the inspector did meet all residents and, through the use of minimum language and support from staff on duty, the inspector was able to ask some residents about the home. Observations of practice and staff interaction with residents were observed during the inspection. There are currently eight residents living at the home. During discussions residents were able to convey they are happy living in the home, that the food was good and they liked the activities offered. Residents’ bedrooms had their personal belongings such as televisions, pictures, and family photographs. Discussions took place with staff on duty at the time of the inspection. Staff were knowledgeable about residents’ care plans, their likes and dislikes, and how to support them. Feedback was provided at the end of the inspection to the manager. The inspector would like to thank the staff and residents for their cooperation during the inspection. Seven requirements were made during this inspection. What the service does well: Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 6 Prospective residents are provided with information about the home to enable them to make an informed choice. The arrangements for assessing needs are satisfactory ensuring the aspirations and needs of residents can met at the home. Staff support residents in a dignified and respectful manner. Residents are able to make choices in accordance with their abilities and are provided with a balanced diet in pleasant surroundings and in an unhurried way. The home has a complaints system to enable residents and their families to raise concerns. Staff having knowledge and understanding of adult protection issues protects residents. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with information about the home to enable them to make an informed choice. The arrangements for assessing needs are satisfactory ensuring the aspirations and needs of residents can be met at the home. EVIDENCE: Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 10 The home has a Statement of Purpose that is dated October 2005, which is currently being reviewed by the manager. Each resident’s file contained a copy of the Service Users Guide, and included a widget symbol format of the home’s complaints procedure. The manager stated that residents have been offered this document to keep in their bedroom, but unfortunately they do not have the capacity to understand the importance of this document, and therefore returned it to the manager. Three care files were sampled, each contained a pre-admission assessment from care managers. Assessments sampled included information in regard to family contact, personal care, support networks, physical health, mental health, employment, education, leisure, accommodation, manual handling, finance, ethnicity, and care support required. The initial assessments were used to form the basis of the residents’ care plans, which identified the actions that carers should follow to assist an individual living at the home. Due to the complex needs of residents, it was not possible to ascertain their experience of moving into the home. The home has an Admissions Policy that provides the procedures to be followed when referrals are made to the home. This clearly states that assessments of needs and an in-depth history of the potential resident must be obtained from their care manager, and that two to three visits to the home must be arranged prior to the prospective resident commencing their placement. The manager stated the home does not offer intermediate care. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported in a dignified and respectful manner. Residents are protected by a medication policy; however, accurate records of medication received are not fully complete. EVIDENCE: Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 12 On the day of the inspection three care plans were sampled as part of the tracking process. Information in the care plans included their personal care needs, nutrition, mobility, incontinence, moving and handling, mental stimulus and how the general care needs of individual residents are to be met. It was noted that care plans had not been reviewed on a monthly basis by staff, nor had residents or their representatives signed them. A requirement has been made in regard to these. Individual risk assessments were in place and included risks on falls, moving and handling, the environment and daily activities. These were signed by residents and reviewed on a regular basis. The inspector viewed evidence that statutory annual reviews had been undertaken. Residents were not able to engage in conversation about their care plans. During discussions, staff were able to give an account of the content of care plans for the residents with whom they key work, and were aware of the need to review care plans. Staff stated they support residents to make choices about themselves, the activities they like to do and the food they would like to eat. Records of decisions and activities attended by residents are maintained in their care plans and the daily records kept by the home. Health care needs were recorded to ensure residents receive the health care services to meet their needs. There was evidence that residents’ optical, dental and chiropody needs are met; records of these were maintained on individual care files. Where appropriate, occupational therapists, dieticians and speech therapists would be involved in residents’ care. Records of residents’ weights were maintained, and any variation to weight would be discussed with the GP. During discussions, the manager stated that none of the residents currently suffer with pressure sores. The District Nurse visits on a regular basis, and as and when required, and offers advice and training in regard to pressure sores. Residents attend the GP surgery, but if they were unable to, then the GP would see them in the privacy of their own bedrooms. The home follows the Community Integrated Care (CIC) Medical Policy and Procedure. The manager stated only staff that are trained administer medication. Four staff training records sampled evidenced they had attended training in regard to medication. None of the residents are able to self-administer their own medication. The home uses the Lloyds’ blister packs and Medication Administration Records sheets (MAR) for recording medication. Medical records sampled provided evidence that accurate records of medicines dispensed are clearly maintained, however, it was noted that there was not a total recorded on the MAR sheet for one particular prescribed medication. A requirement has been made in regard to this. The home maintains records of medicines returned to the Pharmacist. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 13 A Controlled Drug register is maintained in the home, and two members of staff sign each record. It was noted that controlled drugs were stored in the drugs trolley. It is strongly recommended that all Controlled Drugs are stored in a Controlled Drugs cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The manager stated that the Lloyds pharmacist visits the home to view medication records and offer advice. Evidence of the last visit undertaken by the pharmacist was viewed to have taken place on the 22nd September 2005. It was brought to the attention of the inspector that one resident has Diabetes that is controlled through medication and diet. However, the manager stated staff had not received training in regard to this medical condition since 2000. A requirement has been made that the registered person must ensure all staff working in the care home receive training on all aspects of the medical condition of Diabetes. During discussions staff stated residents have access to a telephone in the home, and calls can be taken in private. Residents receive their mail, but require the support of staff to read and understand the contents. Staff also stated they respect residents privacy and dignity through knocking on bedroom doors, addressing each by their first names, and provide personal care in private. All residents have their own bedrooms. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices in accordance with their abilities and are provided with a balanced diet in pleasant surroundings and in an unhurried way. EVIDENCE: Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 15 The manager stated that residents take part in a variety of activities that include going to the theatre to watch musicals and other shows, and visiting the local community. This was confirmed during discussions with staff who also stated they take residents to the local fish and chip shop, local fast food outlets, as well as trips further away on weekends when possible. Staff stated that they take some residents on the local bus into nearby towns. Evidence of these activities were recorded in individual care files, these were viewed during this inspection. Other activities included attending day centres, hydrotherapy and aromatherapy. Due to residents’ complex needs activities are chosen on a daily basis, and residents require one to one support. Care files of residents used in the sampling provided evidence that their religion is that of Church of England. During discussions staff stated they had taken residents to the local church to attend Sunday services. This is in accordance with the home’s Statement of Purpose where it states under the philosophy of care that residents’ racial, religious and cultural needs will not lead to discrimination, and opportunities for religious observance would be provided. The manager stated some residents have family contacts, but for those residents who do not have any family, arrangements for advocates from Surrey Advocacy have been established. There are no restrictions on visits to residents, unless the resident concerned states that they do not want to see visitors. During the tour of the premises, it was observed that residents had their own personal belongings in their bedrooms. The menus were viewed during this inspection. The manager stated that residents choose the week’s menu at weekends, and food is bought fresh from the local supermarket. The food stores were viewed, and found to be appropriately stored with a good supply of food. The menus included balanced and varied meals with meat, fish, pasta, fresh vegetables and fruit. Each meal is recorded for every resident. During discussions staff stated residents are provided with drinks and snacks throughout the day. Lunch was observed to be a relaxed, unhurried occasion with four members of staff supporting residents. Some residents were able to indicate to the inspector that the meal they were eating was nice. Four residents were observed to have liquefied meals that were presented in an appropriate manner. The home maintains daily records of the fridge, freezer and cooking temperatures. On the day of the inspection the kitchen was clean and tidy. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service . The home has a complaints system to enable residents and their families to raise concerns. Staff having knowledge and understanding of adult protection issues protects residents. EVIDENCE: The Commission For Social Care Inspection Surrey Local Office has not received any complaints in regard to this home since the previous inspection. The home has a Complaints Policy and Procedure that includes time scales and the Commission For Social Care Inspection Surrey Local Office contact details. A copy of the complaints policy was displayed on the notice board in the entrance to the home, and the Service Users Guide contains a copy with widget symbols to enable residents to understand the contents. The manager stated there have not been any complaints made during the time she has managed the home. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 17 During discussions staff stated they would make complaints to the manager or, if not satisfied, would contact the area manager. The home had a Protection of Vulnerable Adults Policy and Procedure that was dated March 2003. The manager stated the policy has been updated, but was waiting for it to be returned from head office. The manager stated she would forward a copy to the Commission For Social Care Inspection Surrey Local Office once it has been approved. The manager informed the inspector that the home does have a copy of the Surrey Multi – Agency Procedures of February 2005, but was unable to produce a copy as a member of staff who is undertaking the NVQ training had borrowed it. Sampling of staff training records evidenced that nine staff had attended Protection of Vulnerable Adults training. During discussions, staff were able to give an accurate account of the procedures to be followed in the case of abuse, and they would not hesitate taking their concerns to the Commission For Social Care Inspection if they did not feel they had been appropriately dealt with. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. EVIDENCE: Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 19 On the day of the inspection the home was found to be clean, tidy and free from offensive odours. The home has grab rails and adaptations such as mobile hoists and bathing aids in place to support residents to maintain their independence. There were five bedrooms on the first floor and three on the ground floor. Bedrooms were spacious, brightly decorated and appropriately furnished. Residents had their own possessions that included television, video, music appliances and family photographs. Due to their complex needs, residents are not able to have a key to their bedrooms. The home’s communal areas were spacious and decorated and furnished to a very good standard. Residents have access to all communal parts of the home. No safety hazards were evident within the communal and private space areas. Toilet and bathing facilities were of a very good standard and offered adequate privacy for the residents. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the home’s recruitment policy; however, the home must ensure all recruitment files contain the necessary information. EVIDENCE: The staff duty rota was viewed for the week of the inspection. This evidenced that there were four staff on the early shift, three on the late shift and two waking night staff. The home employs one housekeeper who attends to the domestic duties. During discussions staff stated they felt there were enough staff on duty for the week days, however, they felt it would be an advantage to have more than Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 21 three staff on each shift at the weekends to enable external activities to be undertaken every weekend. A good practice recommendation has been made that the manager reviews the staffing arrangements for weekends. The manager stated that the home does not employ any staff under the age of twenty-one years. The home employs eleven care staff, of which five hold the minimum of NVQ level 2 and above. One member of staff is due to compete the NVQ level 3 which will mean the home would achieved 50 of staff who are trained to the minimum of NVQ level 2 and above. The home follows the Community Integrated Care recruitment policy and procedure. Three staff files were chosen at random to sample. One staff file did not contain an application form or two written references. An immediate requirement has been made in regard to this, to which Community Integrated Care has responded. There was evidence in the care workers files sampled that they are supervised on a regular basis. All newly appointed staff undertake an induction programme. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 23 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home; however, some issues in regard to training must be addressed to ensure the safety and welfare of the residents is maintained. EVIDENCE: The manager stated she has sixteen years experience in care work with Older People with Learning Difficulties and Physical Disabilities. The manager holds the NVQ level 3, and is currently undertaking the Registered Managers Award (RMA). The manager stated that Community Integrated Care undertakes the annual Quality Assurance surveys for residents, staff, family and advocates. However, they were not available at the home to view during the inspection. A requirement has been made that the registered person must ensure a copy of the quality assurance report is kept at the home for inspection purposes. Monthly staff meetings are held at the home, minutes of these meetings were evidenced. The manager stated that residents do not have monthly meetings due to their low levels of understanding, but they are consulted on a daily basis in regards to choices. The money of residents who were part of the tracking process was examined; monies kept by the home balanced with the records maintained. Four staff training files were sampled during this inspection. This provided evidence that staff had not received the entire mandatory training as stated in the home’s Statement of Purpose, or training in regard to Infection Control. A requirement has been made in regard to these. The home uses the Community Integrated Care Policies and Procedures, some of which have been commented on under the appropriate standards. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature, fridge and freezer recordings, specialist beds and wheelchairs were regularly checked. Fir Tree Road (40) DS0000013494.V316095.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 3 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X 37 X 38 2 Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? 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. 2. Standard OP7 OP7 Regulation 15 (2) (a) 15 (1) Requirement The manager must ensure all care plans are reviewed on a monthly basis. Residents and/or their representatives must sign their care plans, or the reasons for not signing must be recorded. The Medication Administration Records must have records of the quantities of prescribed medicines received. The registered person must ensure all staff working in the care home receives training on all aspects of the medical condition of Diabetes. All recruitment files must include a completed application form and two written references. The registered person must ensure a copy of the quality assurance report is kept at the home for inspection purposes. The registered person must ensure staff receive all mandatory training, and training in regard to Infection Control. Timescale for action 16/11/06 16/11/06 3. OP9 13 (2) 07/11/06 4. OP9 18 (1) (a) (c) (i), 13 (2), 12 (1) (a) 19 (1) (b) 24 (2) 16/11/06 5. 6. OP29 OP33 16/10/06 11/11/06 7. OP38 18 (1) (c) 16/11/06 Fir Tree Road (40) DS0000013494.V316095.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. 2. Refer to Standard OP9 OP27 Good Practice Recommendations It is strongly recommended that ALL Controlled Drugs are stored in a Controlled Drugs cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The manager should review the staffing arrangements for the weekends to ensure there are enough staff on duty for external activities to take place. Fir Tree Road (40) DS0000013494.V316095.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Fir Tree Road (40) DS0000013494.V316095.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. Re-publishing this information is in breach of the terms of use of that website. 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