Inspection on 03/10/06 for 87 Rectory Road

This inspection was carried out on 3rd 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

87 Rectory Road 14/07/09

87 Rectory Road 07/08/08

87 Rectory Road 14/11/07

87 Rectory Road 23/03/06

87 Rectory Road 26/09/05

87 Rectory Road 31/01/05

87 Rectory Road 15/06/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Rectory Road (87) 87 Rectory Road Pitsea Essex SS13 2AF Lead Inspector Mr Trevor Davey Key Unannounced Inspection 12:40p 3rd October 2006 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 Rectory Road (87) DS0000036721.V313062.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. Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rectory Road (87) Address 87 Rectory Road Pitsea Essex SS13 2AF 01268 583634 01268 584347 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) MCCH Society Limited Mr Francis Anthony Winn Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (7) Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To accommodate the five service users under the age of 65 years who have a diagnosed mental disorder (excluding learning disability or dementia). To accommodate the seven service users over the age of 65 years, who have a diagnosed mental disorder (excluding learning disability or dementia). 23rd March 2006 Date of last inspection Brief Description of the Service: 87, Rectory Road provides accommodation, nursing care and support for twelve residents who have severe and enduring mental health illness. The home is a purpose built property on two floors in a mainly residential area of Pitsea, within close proximity of local shops and has transport links to Basildon and Southend-on-Sea. All bedrooms are single with en-suite facilities and a passenger lift is provided to all levels. There is a communal bathroom on both floors and a large lounge/dining room on the ground floor with a separate activities room. Residents are able to access a large garden/patio area and on site car parking is available. The home has the use of a vehicle for transporting residents. The current rate of fees as stated in the Service Users Guide, is £1080 per week. Additional charges are made for hairdressing, chiropody, holidays, toiletries and activities. Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit took place over a period of 7 hours. The visit mainly focused on the progress the home had made since the last inspection and covered all Key standards. As the age range of the majority of residents falls within the older person category, the Older Person National Minimum Standards have been used for the basis of this inspection. The Registered Manager and deputy were attending a management meeting at the Provider’s Central office but were available in the home later during the site visit. Management, staff, residents and visitors were spoken with during the site visit. Their comments and contributions received were helpful in assisting the Inspector to compile this report. In addition, Case tracking took place using some of the personal care records and other official records within the home were also assessed. Letters had also been sent out to health care professionals requesting feedback of the service provided by the home. In addition, responses from a survey which had been conducted with residents and families by the home, were also taken into account. The feedback which had been received was complimentary and positive regarding the standard of care provided. The inspection also took into account previous information submitted by the Register Manager including the completed Pre- inspection questionnaire. What the service does well: From conversations with residents, staff, visitors to the service and observation during the site visit, the variety and scope of social/leisure experiences of residents has improved which meets individual interests and aspirations and this is supplemented by effective group activities. These include music therapy which has encouraged residents to express themselves as well as communicating and interacting better with each other as a group. The activities organiser together with the staff team have consulted with residents to arrange holidays and regular leisure activities in the local community which have taken individual preferences into account. Some residents who were at one time reluctant to go out, now regularly visit and have greater involvement in the local community and also enjoy holidays which are arranged in accordance with individual needs and expectations. The home consults with residents and relatives to obtain feedback of the service provided by arranging meetings and using questionnaires. Comments received included appreciation that residents had been given more opportunity for social involvement since being in the home compared with the time when they were in hospital. One such comment which was included in the Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 6 Registered Provider s annual report stated, The best thing I do is go to the post office to draw my own money out and go to do shopping for my own clothes. Staff were also said to be supportive and always made visitors feel welcome. Community Psychiatric Nurses have also commented that they have noted that there is a wide range of activities which are organised for residents. The management have also set themselves the task of reviewing and developing the service and have begun to evaluate what they do and the delivery of care, by involving residents and other people involved with the home. Care plans and risk assessments are detailed with staff encouraged to work together as a team. The home is good at identifying potential skills and training needs of staff and ongoing courses are arranged for staff to attend. What has improved since the last inspection? What they could do better: A requirement from the last three inspection reports for contracts specifying terms/conditions, including the costs of services provided by the Funding Authority and other items which are the responsibility of the resident, has not been met. It is of concern to the Inspector that this issue is still outstanding although raised over twelve months ago and that the rights of residents, or their representatives, to be provided with information as to the amount and method of payment of fees, has still not been addressed (as required by regulation 5(1) of the Care Homes Regulations). Not all the medication administrative records were being maintained in accordance with guidance issued by the Royal Pharmaceutical Society. This Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 7 included some details of medication which had been transcribed on to the M.A.R. sheets without staff signatures. Some health and safety issues had not been addressed regarding the security of hazardous substances and clinical waste which could be assessable and a danger to residents. Checks also need to be maintained to ensure that food being stored in the fridge/freezer is properly covered and dated in accordance with food hygiene regulations. 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. Rectory Road (87) DS0000036721.V313062.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) Rectory Road (87) DS0000036721.V313062.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 to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Quality in this outcome area is good. Pre-admission assessment details for care/health needs had been completed to give staff suitable information to determine whether the needs of potential residents could be met by the home. The process of providing each resident with a contract/terms and conditions which identifies the cost and responsibility of services provided, has not been completed which means specific financial information is not available to users of the service. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 10 Pre-admission assessment information was available which included hospital admission sheets, which contained personal information, history and background assessment. Details relating to psychiatric/medical history as well as activities of daily living were also included. Comments were recorded from the Occupational Therapist where appropriate, including moving and handing assessments. Other information including mental health support networks were available. As part of the admission process, management are also involved in visiting potential residents and transitional arrangements are made for visits to be made to the home to establish suitability of environment as well as providing opportunity to meet other residents. The Inspector spoke to residents who had been admitted this year and care plans together with risk assessments had been drawn up. Residents spoke about the opportunities they had been given for taking part in swimming and visiting local shops with members of the staff team since being admitted to the home. The Manager advised the Inspector that although discussions had taken place regarding the need to clarify the costs of services together with terms and conditions for residents, these had not been finalised. Residents or representatives acting on their behalf, are entitled to know the financial charges involved for providing services in the home as well as who is responsible for meeting these costs. This must be addressed by the Registered Provider and the Commissioning Authorities involved with a view to providing written contracts/terms and conditions to residents. The home does not provide intermediate care. Rectory Road (87) DS0000036721.V313062.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 to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. The care and health needs of residents were being met appropriately which had been set out and agreed in a plan of care with any necessary risk assessments. Where appropriate, other healthcare professionals were involved in this process. Policies and procedures in relation to the administration of medication were not always being followed in accordance with the guidance and good practice laid down by the Royal Pharmaceutical Society. Residents are treated with respect and individual privacy is upheld. Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 12 This judgment has been made using available evidence including a visit to the service. EVIDENCE: Case tracking took place in respect of three residents and other personal care records were also looked at. Written information was easy to follow and clearly set out different aspects of care and support which had been identified. This was supported by care plans and risk assessments as to how appropriate and safe support should be provided and who should be involved. Monthly valuations take place and some of the risk assessments on file included mobility and risk of falls, socialising in the community, wheelchair use, promoting continence and minimising verbally and physically abusive behaviour. It was not always clear whether monthly valuations had taken place for all residents as some dates had been omitted. In one case the latest evaluation date had been recorded in April 2006. Records of health appointments and ongoing daily reports were available. The management of the home have begun an evaluation of the care services provided which started in August 2006 and the intention is that this exercise will be undertaken to involve residents on an individual basis. The Inspector observed medication as this was being administered to residents. It was noted that there were instances where medication prescription details had been transcribed on to the medication administrative record sheets but these had not been supported by two staff signatures. One resident had been administered Atenebol at 11 a.m. but this had not been signed for on the M.A.R. sheet. It was also noted that Ibrufen syrup had been prescribed for one resident three times per day and this was last given on the 10th of September 2006 and the M.A.R. sheet had been endorsed outstanding (O/S). There was no reference as to why this had been discontinued although a member of staff advised the Inspector that a repeat prescription had been requested and was probably still awaited. It was not always clear whether protocols had been completed for medication be taken as required. There must be clear guidance for staff as to the symptoms and reasons when medication should be given as required in the absence of any clear prescription dosage instructions. Where changes in prescribed medication take place, doctors must confirm in writing or by fax any new instructions. A review of the administration of medication in the home should take place to ensure safe procedures are followed by all staff to minimise the risk of errors occurring which could affect the well-being of residents. Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 13 Staff were observed interacting with residents appropriately at all times in a caring, professional and supportive role whilst at the same time, providing support for personal needs which respected individual dignity and privacy. Feedback from surveys carried out by the home from relatives was positive and recognised the good quality care and support provided to residents. Rectory Road (87) DS0000036721.V313062.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is excellent. The home provides an activities/recreational programme to meet individual preferences, social, cultural and religious needs. Meals take account of residents’ choice. Relatives and friends are encouraged to have active involvement with the home. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 15 A variety of social and leisure activities are provided for residents on a regular basis which take into account individual needs and interests. The home has increasingly focused on stimulating and involving residents which has been matched with appropriate staff support. The Inspector spoke with the activities organiser who has a key role, together with other members of the staff team, in arranging regular visits and contacts within the local community. This includes swimming, visits to shops, leisure centre and the local market. Records/reports were available showing activities and places of interest visited by residents. Individual diaries had also been introduced which included entries by residents themselves in which they shared their experiences. One of the residents told the Inspector how she enjoyed writing in her diary which staff helped her with. Some residents who at one time were reluctant to leave the home, now regularly go out and have formed good links within the local community. Special holidays are arranged taking individual preferences into account and where necessary, risk assessments had been completed covering mobility issues and transport arrangements. Some of the residents talked about their holiday experiences and how staff accompanied them on local outings and visits to places of interest. The home also has its own vehicle which is used regularly. The home has been good at responding positively to feedback received from surveys carried out with relatives and residents. An example of this was the benefit it would be to residents if holidays were arranged on a one-to-one basis and for these to be focused on particular past interests. Arrangements are now made for two members of staff to accompany individual residents to places which have facilities available to meet the needs of residents. This included a holiday cottage with a swimming pool. In addition, the local swimming pool have assisted staff in providing special assistance and facilities for wheelchair users. During the inspection, nine of the residents were taking part in a music therapy session which take place on a weekly basis. The Inspector spoke to the music therapist who said that these sessions had resulted in residents learning to listen, interact and communicate better with each other. Residents were now able to express themselves more clearly as a result of being involved in this group exercise as well as sharing and co-operating with one another. Other in-house activities included painting and crafts, board games, karaoke, cards and Dominos. Most of the activities are held in the main dining room/lounge but residents are able to spend time in their rooms if they so wish and a smaller activities room is available should residents wish to use this as a quiet area. Plans are being considered to provide a small extension to provide an alternative lounge area. Residents are involved in selecting menus allowing for individual preferences and meals provided, had been recorded. Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 16 From conversation with residents, staff, observation and records available, the home was able to demonstrate that the quality of life and experience of residents, had improved in accordance with their expectations and identified needs. Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. There is an established complaints procedure in place. Staff had an understanding of the reporting procedure for the prevention of harm of vulnerable adults, ensuring that the safety of residents in the home is of paramount importance. This judgment has been made using available evidence including a visit to the service. EVIDENCE: The complaints procedure is set out in the Service Users Died and since the last inspection, there had been no recorded complaints. Staff spoken to, had a clear understanding and knowledge of prevention of vulnerable adult reporting procedures and a copy of the policy and whistle blowing procedure is available in the home. Training records over the last twelve months show that staff have attended courses on adult protection awareness. Rectory Road (87) DS0000036721.V313062.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 ,20,24,25 &26 Quality in this outcome area is good. Residents live in a homely environment which is clean and hygienic. Ongoing maintenance and servicing of equipment takes place but some areas of the home were not secure which could pose a risk to the safety and well-being of residents. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 19 The premises of the home were clean and hygienic. Bedrooms were individually identified by the name of the occupier and were personalised with ornaments, pictures and photographs as well as other personal possessions. Individual accommodation was spacious, fit for purpose with ensuite facilities. Other communal bathrooms with mechanical aids and toilets were also available. Protective radiator surfaces and window restrictors had also been provided. The sluice and laundry doors on the ground floor were unlocked and inside, cupboard storage was not always secure which left contaminated ‘sharps’ containers accessible to residents had they gained access to this area. Other cleaning materials and substances had not all been secured in lockable storage. A soiled/clinical waste bin was exposed as the top was missing which could pose a risk to the health of staff or residents should they enter this area. These issues were raised with the management as part of the feedback during the inspection. Liquid soap, paper towels, disposable gloves and aprons together with disposal facilities, were available throughout the home for the use of staff. The pre-inspection questionnaire submitted by the home, indicates that services and equipment have been checked within agreed timescales and appropriate safety certificate issued. Rectory Road (87) DS0000036721.V313062.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. The number and skills of staff on duty together with supervision, is sufficient to meet and support the needs of residents. Recruitment and training procedures are in place to ensure residents are protected and staff are competent to their jobs. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Staff rotas were available and the normal provision of staff allows for one qualified registered mental nurse and four support workers to be available for the early shift and one qualified nurse and three support workers for the late shift. In addition, the manager and/or deputy are available supernumerary Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 21 and a cook and domestic are also employed for five hours per day Monday to Friday. Two staff are on a ‘awake’ duty at night which includes a qualified registered mental nurse. Arrangements have been made with the Registered Provider and the Provider Relationship Manager of the Commission for Social Care Inspection, for recruitment records to be checked at the Central office in Maidstone every six months. The Registered Provider notifies the home once recruitment checks have been completed for new members of staff ( including Criminal Record Bureau procedures). At the time of inspection, there was one Criminal Record Bureau check outstanding which the home is chasing up. The home is aware that members of staff cannot work unsupervised until the C.R.B. process has been completed. Staff spoken to, confirmed that training is always available and a record of courses completed was made available for inspection. Courses completed include personal hygiene and infection control, medication administration and other courses planned include dealing with challenging behaviour, person centred planning and first aid. Rectory Road (87) DS0000036721.V313062.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. The Registered Manager and team, operate the home in the best interests of residents. Staff are properly supervised and measures are in place to ensure the health, safety and welfare of residents at all times. Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 23 This judgment has been made using available evidence including a visit to the service. EVIDENCE: Good communication systems are in place involving senior management and the staff team. Some of the staff team were spoken with and supervisions take place every month which is seen as a positive exercise . Training needs are identified and staff are encouraged to enrol for courses as part of their ongoing staff development. At least 50 of the staff team have obtained N.V.Q. Level 2 or above. The home has demonstrated its willingness to improve the service provided by liaising with relatives and residents and obtaining feedback from surveys as well as holding meetings every six months. The Inspector was advised that the manager and deputy are available after these meetings to meet with individual relatives to discuss issues or ideas relating to the ongoing development of the service. The procedures for recording financial transactions relating to the personal allowances of residents, have been improved and a sample check was made by the Inspector. Receipts were also available and the staff team check balances of monies each day. Two staff signatures are recorded for transactions and where possible, the resident concerned is also a signatory. Regular monitoring inspections of the home are undertaken by the Responsible Individual and reports are submitted to the Commission for Social Care Inspection as required by Regulation 26 of the Care Homes Regulations. Rectory Road (87) DS0000036721.V313062.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 x 2 2 3 3 4 x 5 x 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 ENVIRONMENT Standard No Score 19 3 20 2 21 x 22 x 23 x 24 3 25 2 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 3 34 x 35 3 36 x 37 x 38 3 Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 25 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. Standard OP2 Regulation 5(1) Requirement The Registered Person must produce a contract terms/conditions which identifies the costs of services provided by the Funding Authority and for items which are the responsibility of the service user. (Schedule 4 also refers). (Previous timescales of 31/10/05, 01/12/05 & 01/06/06 not met). Timescale for action 01/12/06 2. OP9 13(2) 3. OP20 23(2) The Registered Person shall 15/11/06 make arrangements for the recording, handling, safekeeping, and administration and disposal of medicines received into the care home in accordance with guidance issued by the Royal Pharmaceutical Society. 30/11/06 The Registered Person shall having regard to the number and needs of the service uses, ensure that the physical design and layout of the premises to be used as the care home meets the residents needs. This is in reference to the need to create DS0000036721.V313062.R01.S.doc Version 5.2 Page 26 Rectory Road (87) an alternative quiet/lounge area for the benefit of residents. (previous timescale of 31/03/06 not met). 4. OP25 13(3)(4) 15/11/06 The Registered Person shall ensure that all parts of the home to which service users may have access, is secure and free from hazards to their safety and so far as reasonably practicable, free from avoidable risks. Any unnecessary risks to the health or safety of service uses must be identified and so far as possible eliminated. This applies particularly to the laundry and sluice areas. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rectory Road (87) DS0000036721.V313062.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 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. 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