Inspection on 01/08/05 for Abbeyfield Connors House

This inspection was carried out on 1st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Abbeyfield Connors House 24/10/06

Abbeyfield Connors House 17/02/06

Abbeyfield Connors House 19/03/05

Abbeyfield Connors House 23/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Connors House Craddock Road Canterbury Kent CT1 1YP Lead Inspector Jenny McGookin Announced 01 & 02/08/05 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Connors House Address Craddock Road, Canterbury, Kent, CT1 1YP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01227 769774 01795 784290 The Abbeyfield Medway Valley Society Mrs Jacqueline Dawn Wood Registered Care Home 40 Category(ies) of Care Home for Older People, 39, persons with a registration, with number Physical Disability, 1. of places In July 2004 the Home was registered to provide Dementia care for up to 20 residents. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The registration for the one person with a physical disability is limited to the person whose date of birth is 21/08/1940. In July 2004 the Home was registered to provide Dementia care for up to 20 residents. Date of last inspection 19/03/05 Brief Description of the Service: Connors House is registered to provide accommodation and personal care for 40 older people, one of whom may have a discrete physical disability. The Registered Provider is Abbeyfields Medway Valley Society, which is a charitable organisation, and is responsible for overseeing the operation of the Home. Mrs Wood is the Registered Manager, and is an employee of the Registered Provider. This is a predominantly single storey building, which was purpose built by Kent County Council in the 1980s. It transferred to Abbeyfield Medway Valley Society in 2000. The residents’ accommodation is arranged in two wings, each comprising two units, on the ground floor – Holly, Evergreen, Ash and Cedar. The Holly and Evergreen units are used principally to accommodate service users with cognitive impairment; and the Ash and Cedar units are for physically frail elderly people. Each pair of units shares a lounge/dining room, which has its own kitchenette facility, toilets, bathrooms and a suite of bedrooms. There is also a communal conservatory area and courtyard garden facilities. There are in total 32 single occupancy bedrooms, and four bedrooms which can be shared. All areas of the home are linked to a call bell system which is designed to assist service users to summon help should it be needed. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which was used to introduce the new inspector to residents and the staff; to check progress with matters raised from the last inspection (March 2005); and to reach a preliminary view on other aspects of the day-to day running of the home. The inspection process took just over fourteen hours, spread over two days, and involved meetings with three residents, six relatives, seven staff (representing the direct care side, care, housekeeping and catering) and the deputy manager and the manager. The inspection also involved an examination of comment cards from thirteen residents, fourteen relatives / visitors, a range of records and policy documents and the selection of three residents’ case files, to track their care. Seven bedrooms were inspected for compliance with the National Minimum Standards, and the inspector also checked some communal areas. Interactions between staff and residents were observed throughout the day. What the service does well: What has improved since the last inspection? Some progress had been made with matters raised for attention by the last inspection, and record keeping is more systematic and properly accountable. Staff present as generally very self-motivated, notwithstanding the extra Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 6 pressures attributed to providing cover while recruitment checks await completion. 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 contacting your local CSCI office. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5, 6 1. The home has a combined Statement of Purpose and Service User Guide but this document does not provide Service Users and prospective Service Users with all the information they need to make a decision about moving into the home. 2. There are contracts governing each placement between the home and the resident, or their representative, and these contain all the elements recommended to protect residents’ interests. 3, 4. Prospective residents are assessed prior to admission to establish the extent to which their needs can be met by the home, and how potential risks will be managed. Service users and their relatives are generally very content with the way they are supported by the home. 5. Prospective residents, or their representatives, have the opportunity to visit the home before proceeding with the admission and there is a trial stay to further inform their choice. 6. The home does not provide intermediate care. EVIDENCE: Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 9 There is a combined Statement of Purpose and Service User Guide, which usefully describe the facilities, services and principles of care but a number of elements listed by this standard were not there. Feedback on the day of this inspection indicated that the decision to apply to this home was influenced largely by its locality (i.e. close to where the resident or their friends or relatives lived), by previous contact (e.g. respite placements, as visitors or through attending the day centre sharing the same site) and by personal recommendation, although relatives also confirmed having received public information produced by the home. There are contracts governing each placement (whether self funded or funded by a third party). These comprehensively cover all the elements listed by this standard, and the provision of explanatory notes ensures residents’ interests are understood and protected. The home carries out a standardised preadmission assessment, underpinned by a scoring assessment process and the prospective resident or representative is invited to visit the home. The residents and relatives were generally able to confirm this process, though, with one or two exceptions, the residents did not visit the home themselves, either because they trusted the judgement of their representatives or because they had already gained a positive impression of it. Each resident is offered a four weeks’ trial stay, and although the relatives confirmed this, most residents come into stay in practice. On their admission, the home draws up a care plan within the first two days, which is reviewed monthly or as required, and it also carries out further assessments of the residents. The home does not provide intermediate care. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 7. The assessment and care planning processes cover a range of health and personal care needs, as well as some social care needs 8. The home is served by a range of healthcare professionals, to promote good health and has generally adequate facilities for privacy. 9. The home has policies and procedures for dealing with medication, but some matters were raised for attention in respect of record keeping, to further safeguard the arrangements. 10. Residents confirmed that staff treat them well, and that their privacy is respected. Observed interactions between staff and residents were respectful during this inspection. EVIDENCE: The “Pre-Admission Assessment” covers a wide range of health, personal care and social care needs (e.g. contacts, relationships, interests, hobbies, religious and cultural needs) as well as the residents’ feelings about coming into a residential care home. This process is underpinned by risk assessments and is judged a holistic approach. The residents spoken to did not recall the Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 11 admission process but all the relatives spoken to were aware there were care plans and being asked a lot of questions about the residents’ care needs. Less clear, however, was the extent to which social care needs were followed through following admission, or the extent to which residents or their relatives were involved in formal reviews, though each relative confirmed they were in practice being kept up to date. With four exceptions, all the bedrooms in this home are single occupancy, which means personal care and treatments can be given in privacy. Shared rooms have screening between the beds to afford their occupants some privacy. However, in two rooms seen, the hand basin area is not screened off. This effectively means privacy is not assured. Feedback from the almost all the residents confirmed that their privacy was respected and that staff generally treated them well, though in one case this was said to be sometimes not the case. The home accesses a range of healthcare professionals, but the contract states that residents would need to pay for any personal equipment / services such as chiropodists, dentists, opticians, complementary therapists and hairdressers not covered by the NHS. The resident or their representative is also liable to pay for any abnormal amounts of personal care / supervision / monitoring. The home has benefited by input from undergraduate Occupational Therapists on work placements and is strongly recommended to look for more opportunities for such input, so that the home can continue to optimise its capacity to meet the needs of the residents. There is no Loop system for the hearing impaired. Nor are there large print documents, tapes or Braille other than can be provided by the Mobile Library. The arrangements for medication were partially inspected on this occasion, and some matters in respect of record-keeping were raised for attention. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 12. The residents are generally very content with their lifestyles in this home, and the home has been able to match their expectations. This home offers a range of activities inside and outside the home. 13. There are open visiting arrangements, and the home is well placed for access to local shopping outlets. 14. There is choice and control over most aspects of daily routines. Personal care is offered in a way, which generally protects residents’ privacy and dignity. 15. The meals in this home are generally very satisfactory, offering both choice and variety and catering for personal preferences. Residents can also opt to eat where they eat and at different times. EVIDENCE: Residents were not able to give many examples of any particular interests and hobbies being actively promoted by the home. However, records showed that Occupational Therapists on a recent fixed term work placement had provided a range of recreational and therapeutic sessions, which staff also reported finding instructive in respect of their own direct care of residents. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 13 Staff and records indicated said there were occasional walks and trips out, colouring sessions, card and board games, discussion groups. There are also larger scale events such as a Strawberry Tea and barbecue, theatre visits and seasonal festivities. The home is serviced by the local Mobile Library, which can provide large print books and tapes. Most residents and their representatives indicated that they were generally content with the residents’ lifestyles in this home, though a few wished the home would organise more. Further work placements from Occupational Therapists or the introduction of an Activities Co-ordinator would be of benefit. The combined Statement of Purpose / Service User Guide commits the home to regular church services, and to arrange visits by clergy on request. However, there was no specific information for prospective residents on local religious resources or services to the home. The home has open visiting arrangements, and feedback from residents and relatives as well from questionnaires received from fourteen relatives / visitors invariably confirmed that they were always made welcome whenever they visited. The daily routines are as flexible as healthcare needs will allow. Residents confirmed that they can choose when to get up and go to bed. The chef has a hotel catering background and has been with this home for nine years. In that time she has built up a reputation for exemplary catering and kitchen management standards, and is now being used to audit and support other homes in the group. The meals sampled during this inspection were judged expertly cooked and well presented, and feedback from most residents confirmed their satisfaction with their meals – in a couple of cases this aspect of the home was identified as a key strength. Residents were observed being assisted by staff in a respectful and unhurried way. There is a 5-week menu cycle for summer, winter and intermediate seasons, but this is applied flexibly and there are always hot and cold options as well as a wide range of other options. Food can be kept chilled or ready plated for heating up at other times to suit residents’ personal preferences. Some residents have diabetic diets, and these can be catered for - the menus highlight these options in red so that residents can be supported to make choices for themselves. Because the dementia unit is relatively new, the chef is currently developing menus for the residents there. She even makes her own lollypops from Ensure and fresh fruit juices for clients who can’t swallow easily, to suck on. Most residents have soft food rather than liquidised. But where residents require pureed food, the components of each meal are liquidised and Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 14 presented separately so that they can enjoy their discrete colours, taste and smells but one previous resident wanted her meals pureed together and this was provided. The chef is looking into providing moulded food, lunch boxes, and snacks around the building so residents can help themselves. There is a range of adapted cutlery and crockery – examples include thick handled and curved cutlery, plates to keep food warm, beakers (some with two handles and spouts), retainer plates. The home gets all its food provision fresh from local outlets, and is keeping records of the meal options actually consumed by individuals, as required. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 16. There is a complaints procedure readily available, and residents feel that any complaints they had would be listened to and acted on. The home relies on staff, or the residents’ families and friends to raise issues and represent the interests of the less able residents. 18. Residents feel well cared for and safe there is a policy on adult protection. Staff expressed a commitment to protect residents from abuse, but would benefit from information on the role and powers of the CSCI. EVIDENCE: The home’s complaints procedure is discreetly displayed in each bedroom, and describes the process and timeframes involved, in general compliance with the provisions of Regulation 22. It also gives the CSCI as an option at any stage. Feedback questionnaires from residents and their relatives, and conversations with residents during this inspection, confirmed that almost all of them knew who to talk to if they had a complaint and felt safe. The home has recently registered with a new independent advocacy service so it is too early to judge the effectiveness of this. In the meantime, the home relies on staff, or the residents’ families and friends to raise issues and represent the interests of the less able residents. There is a policy on abuse, and the manager is conversant with all the available sources of advice and the agencies, which need to be involved and the need to take a multidisciplinary approach to strategy meetings, to ensure a timely and cohesive approach. Staff expressed a commitment to protect residents from abuse. Less clear, however, was their knowledge of the role and powers of the CSCI. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 16 Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26 19, 25. The layout of this home is generally suitable for its stated purpose, and residents and their relatives confirm this is an attractive and homely place to live. Records confirm it is being maintained and regularly inspected for safety. 20. Residents have a choice of communal areas, and furnishings tend to be domestic in character. There are homely touches throughout. 21. The number of communal lavatories and washing facilities has not been judged sufficient for the number of residents but they are generally accessible to bedrooms and communal areas. None of the bedrooms has en-suite facilities. 22. There is a range of equipment and adaptations to support residents and staff in safety in their daily routines and to maximise residents’ independence. 23, 24. Most residents have access to the privacy of their own bedrooms and can personalise them with their own possessions and items of furniture. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 18 26. The home is generally well maintained and all areas inspected were free of any unpleasant odours. EVIDENCE: The layout of this home is generally suitable for its stated purpose and well maintained and decorated. Access to all area is good and there are handrails. Some matters were raised for attention on this occasion. The home provides adequate communal space (i.e. two lounges in each unit, plus a conservatory and quiet room and dining areas) for each resident. All furnishings within the communal areas are domestic in character and of good quality, suitable for the service users needs. All areas seen were clean, well maintained and in satisfactory decorative order, accepting the corridor in the Holly Unit is already scheduled to be redecorated and re-carpeted. All areas are linked with a call bell system. Specialist equipment includes special mattresses, raised toilet seats, grab rails and corridor rails, and hoists. The list is not exhaustive but there were, however, no Loop systems in the communal areas for residents using hearing aids. There did not appear to be adequate discreet storage for wheelchairs and walking frames as some areas within communal rooms were a bit cluttered. There are 32 single bedrooms, which are all at least 10 square metres – none of these has en-suite facilities. There are four double rooms, each providing 20sq.m of usable floor space (i.e. in excess of the National Minimum spatial Standard), with screening between beds for privacy. However, none of the shared rooms has en-suite facilities and the sink area in the two double bedroom inspected did not have screening, which is judged insufficient. Seven bedrooms (including two double rooms) were inspected on this occasion and all were well maintained and in satisfactory decorative order. Each room had been personalised with the residents’ possessions and, in some cases, pieces of their own furniture and there were homely touches throughout. Electrical equipment brought in by residents is being given visual checks to start with, followed by proper PAT tests – this is judged potentially hazardous. The bedroom doors were lockable and in almost all cases there were also lockable facilities. However, when assessed against the National Minimum Standards the bedrooms did not have all the furniture and fitments required. Non-provision must in each case be justified by properly documented consultation or risk assessment. The outlook from some bedrooms was featureless (lawn and fencing) and would benefit by positive focal features such as ornamentation or landscaping. There are eight communal toilets, one shower room and four communal bathrooms in the home so that residents have some degree of choice and most Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 19 toilets are within easy reach of bedrooms. There are no en-suite facilities in the rooms occupied by the residents. Some matters are raised for attention. Separate sluicing facilities are provided. One facility was selected for inspection on this occasion and judged in need of redecoration, in order to maintain impermeable surfaces capable of being easily cleaned. Clinical waste is appropriately managed – there are weekly collections under contract by a private company. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 27. The numbers and deployment of staff are intended to meet the needs of residents, although the layout of the home and persisting delays in CRB clearance are testing the team’s capacity to do this. 29, 30. The home’s recruitment and training processes are designed to meet and protect the needs of the residents. Staff feel well invested in. EVIDENCE: The manager described the following staffing arrangements. From 7am till 2pm, and from 2pm till 9pm – one should expect to see three care staff in Holly and Everygreen, and two care staff in Ash and Cedar. There is one senior care staff in overall charge throughout the daytime. From 9pm till 7am – 3 waking night care staff plus I senior sleeping on site but on call There is an extra ½ hour for overlap between shifts so the dementia unit is not left unattended and to facilitate handover. There are dedicated staffing hours for household and catering duties. This effectively means there is overall a ratio of only one member of care staff to every eight residents during the waking day, and the layout of the units disperses them widely. Feedback questionnaires from 12/14 relatives/visitors indicated they felt there were sufficient staffing levels but several sources raised this as an area requiring improvement during the inspection, and will require regular review. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 21 Records and staff confirmed a systematic recruitment process, designed for consistency and that recruitment is subject to satisfactory references, proof of identification and CRB checks etc, in line with required practice. However, delays in obtaining CRB clearance is reported to be putting off otherwise good candidates, and staff morale is reportedly being tested by the need to cover shortfalls. The recruitment of a number of staff predates the National Minimum Standards but more recent recruits have benefited by the introduction of a detailed Induction Pack, based on the TOPSS model, followed through in all cases by a comprehensive training programme and top-up “Awareness Sessions” designed to promote the skills mix of the team. Eleven staff now have NVQ Level 2 accreditation which equates to 25 i.e. not yet compliant with National Minimum targets. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36, 37 31, 32. The Manager’s qualifications and experience as described are appropriate to her role as registered manager. Residents, relatives and staff have confidence in her leadership qualities. Less clear was the impact of the registered provider organisation. 36. Staff have ready access to line management on a day-to-day basis. But there needs to be one-to-one formal documented supervision in full compliance with National Minimum Standard 36, to ensure residents are in safe hands at all times. 37. Staff have access to a comprehensive range of policies and procedures and considerable progress has been made with the systematising of records, most notably personnel files. Residents’ records will require further work and some need to be better secured against loss or disarray. EVIDENCE: Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 23 The Registered Manager has the skills and knowledge necessary to enable her to manage the operation of the Home effectively. All the feedback from residents and relatives indicated there was confidence in her leadership. All sources expressed satisfaction with the care and most residents said they did not feel the need to be any more involved in decisions about the running of the home than they already were. There are clear lines of accountability within the home and staff report that inhouse line management is accessible. However, supervision sessions tend to be given to groups of staff. The frequency of formal documented one-to-one supervision sessions is not in most cases compliant with the National Minimum Standard. Less clear, moreover, was Abbeyfield Medway Valley Society’s compliance with it’s duty to carry out inspection visits of its own at least once a month (Regulation 26). There were gaps in the records seen, and this was attributed to a clerical error, which has been rectified. Reports have traditionally been held on site, but are now being routinely submitted to the correct CSCI office. Some staff feel the registered proprietor could be more appreciative of their efforts to maintain staffing levels. Building maintenance records were not inspected on this occasion, but there is a dedicated maintenance staff member who said day-to-day work was logged in the House WorkBook, to ensure standards are maintained. Some matters were raised for attention. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 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 4 COMPLAINTS AND PROTECTION 2 3 2 3 3 2 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 2 x x x x 2 2 Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 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. Standard OP1 Regulation 4, 5, 6 & 1 Requirement The combined Statement of Purpose and Service User Guide must be amended to comply with all the elements of National Minimum Standard 1, and associated Regulations Medication Administration Records. The allergies section needs to be routinely addressed. Any codes used to indicate irregularities in medication administration, need to be detailed on the flip side The following matters are raised for attention as precautions against the risj of accident: All radiators need to have guards. All handbasins need to have thermostatic control. The plugs used to maintain the fish tank in one corridor require an external socket as they are a hazard for passing wheelchairs. Action plan / justification for non-provision to be submitted. Bathroom in Ash Unit. Ceiling is stained. Skylight is stained and cracked Electrical equipment brought in by residents must be PAT tested Timescale for action 31 12 05 2. OP9 17 Immediate and ongoing 3. OP19 13 30 11 05 4. 5. OP21 OP24 13 13 30 11 05 Immediate and Page 26 Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 6. OP24 16(2) 7. 8. OP24 OP24 16(2) 13(4) 9. OP26 13(4) 10. OP36 18(2) before usage as a precaution against the risk of accident All bedroom furniture and fittings must be routinely checked for compliance against the National Minimum Standards. Nonprovision must in each case be justified by properly documented consultation or risk assessment Bedroom 1. The resident wants the wardrobe re-positioned Bedroom vanity units. The edges and corners are sharp and need to be guarded as a precaution againts the risk of injury. Sluice areas must be maintained in good decorative order, in order to maintain impervious surfaces capable of being easily cleaned. There needs to be one-to-one formal documented supervision in full compliance with National Minimum Standard 36, to ensure residents are in safe hands at all times. ongoing Immediate and ongoing 30 11 05 31 10 05 Immediate and ongoing Immediate and ongoing 11. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care Planning reviews should routinely record who participates in each case; include the recorded views of resident and/or their representative, and any unmet needs, so that anyone authorised to inspect them can evaluate their ownership. More attention could be given to exploring each resident’s interests, aspirations and social needs in a practical way Adult Protection training should include information on the role and powers of the CSCI H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 27 2. OP18 Connors House 3. 4. 5. 6. OP19.3 OP21 OP21 OP22 7. 8. 9. 10. OP22 OP24 OP26 OP37 The installation of positive features / focal points is recommended for stretches of lawn overlooked by bedrooms to make them attractive Communal WCs. Sliding doors are recommended for transfers Bathrooms should have provision for clothes and personal effects Consideration should be given to providing discreet storage areas for wheelchairs and frames in communal areas so as not to detract from their homeliness or clutter the areas A Loop system is recommended for lounge areas, for residents with hearing aids, subject to assessment by suitably qualified persons There should be screening around sink areas in double rooms to ensure privacy for personal care Sluice areas should have either wrist or elbow mixer taps on sinks, and diffusers over ceiling lights Residents’ records will require further work to systemmatise them, and some need to be better secured against loss or disarray. Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Connors House H56-H05 S23364 Connors House V230933 010805 Stage 4.doc Version 1.40 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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