Inspection on 25/07/07 for Abbeyfield Rogers House

This inspection was carried out on 25th July 2007.

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

Abbeyfield Rogers House 23/08/06

Abbeyfield Rogers House 03/01/06

Abbeyfield Rogers House 06/06/05

Abbeyfield Rogers House 13/12/04

Abbeyfield Rogers House 29/07/04

Abbeyfield Rogers House 29/03/04

Similar services:

Ridgemount

Wingham Court

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

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

CARE HOMES FOR OLDER PEOPLE Abbeyfield Rogers House Drewery Drive Rainham Gillingham Kent ME8 0NX Lead Inspector Jenny McGookin Key Unannounced Inspection 09:55 25th & 26th July 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyfield Rogers House Address Drewery Drive Rainham Gillingham Kent ME8 0NX 01634 262266 01634 261374 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) The Abbeyfield Kent Society Lucy Josephine Dixon Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That one service user under the age of sixty five (65) may be accommodated at any one time 23rd August 2006 Date of last inspection Brief Description of the Service: Rogers House is a modern purpose built home for the care of the elderly; it located in a residential area within easy walking distance of local shops. The home is currently registered for the care of 41 older people. Accommodation is in 37 single and two shared bedrooms, all of which have en-suite facilities or a dedicated toilet close to the room. All bedrooms are fitted with a call bell system and a telephone and TV point. There are 5 day rooms and a large conservatory opposite the main entrance. The home has 5 assisted bathrooms, assisted toilets and has an 8-person lift providing access to all 3 floors. The current fees for the home range from £459 (Local Authority funded) to £490 (privately funded) per week. Additional charges may be made for additional or specialist care, clothing, outings and entertainment, and personal or luxury items such as hairdressing, chiropody, toiletries and newspapers. Information on the Home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose and Service User Guide. The e-mail address for this home is: rogers@abbeyfieldkent.org Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on two site visits, the first of which was unannounced and the second (the following day) was by prior arrangement. These site visits were used to inform this year’s key inspection process; to check progress with matters raised from the last inspection (August 2006,) given the timeframes had run their course; and to review findings on the day-to day running of the home. The inspection process took fifteen and a half hours, spread over the two days. It involved meetings with two groups pf three service users over lunch (representing residential and day care provision) and a number of staff representing a range of functions of the home - the Assistant Home Manager; two senior carers, the Administrative Assistant (who is also the home’s activities co-ordinator); the cook and maintenance man as well as a visiting NVQ Assessor. The Registered Manager was off site on other duties on both days. Although the Commission had issued feedback questionnaires for distribution to service users, relatives and visiting professionals, only one form was submitted in time for the issue of this draft. The others will be used to inform the Commission’s intelligence in due course. The inspection also involved an examination of records, and the selection of three residents’ case files, to track their care. Personnel files were examined, and interactions between the staff and residents were observed throughout the day. Four bedrooms, selected at random, were checked for compliance with the National Minimum Standards on this occasion, along with some communal areas. What the service does well: Although this home was built something like sixteen years ago, it has a number of design features, which would be judged exemplary even by today’s standards. This is a home, which clearly intended to be able to anticipate the changing needs of its elderly service users from start to finish. And it has accomplished this discreetly, without compromising on the quality of furniture and fittings that combine to make this property also very homely. People are genuinely proud to live and work there. This service has significantly more strengths than weaknesses. It provides good evidence of strong and consistent management, delivering good outcomes for people, and uses its resources well. An examination of previous Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 6 inspection reports will show a sustained track record. Where weaknesses have emerged, the service has recognised them and managed them well. The staff team is competent, well-trained, supported and well deployed. There are clear policies and standards to guide working practice. The systems for assessment, monitoring, reviewing and recording are robust to promote the welfare and safeguard people who use the service. This home is viewed positively by its stakeholders. There are good links with the local community and an open culture. 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 Abbeyfield Rogers House DS0000028736.V345726.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. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 1, 2, 3, 4, 5, 6 Whilst prospective residents and their representatives have access to much of the information needed to decide whether this home will meet their needs some shortfalls in the documentation need to be addressed. Prospective residents can feel confident that their needs will be properly assessed and that they will be supplied with a contract which clearly tells residents about the service they will receive. This home does not provide intermediate care. EVIDENCE: There is an Information pack for prospective residents, which contains a Service User Guide and a range of loose-leaf documents, usefully describing a range of facilities, services and service principles. The intention appears to be Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 10 to cover all the elements of this standard in the combination of documents. However, there was no overall contents page to help the reader navigate through the documentation, or checklist to ensure all the intended contents were present. This is recommended. This pack will, moreover, require further attention to provide all the information prescribed by the National Minimum Standard, so that prospective residents or their representatives can be confident they have all the information they need to reflect on, in order to make an informed decision. This matter has been reported back to the home separately. At the time of these site visits, the Assistant Home Manager was in the process of compiling an admission checklist, which will include the issue of the Information pack and the question of whether other languages or formats were warranted. This is judged diligent practice, as no residents showed any recognition of its contents. A checklist would compensate for residents not being able to recall this with any accuracy. When asked, residents said that the decision to apply to this home was in practice influenced more by its locality (i.e. close to where they or their relatives lived), and by the home’s reputation, than by any public information produced by the home itself. There was good evidence of preadmission assessments, which routinely takes any assessments carried out by funding authorities into account. And there was anecdotal evidence of prospective residents (where able) or their representative visiting the home before the admission, to meet the staff and other residents. A trial stay of one month is available. All the residents spoken to said they were very happy with the choice of home. On their admission, the home carries out further assessments and risk assessments. The home can demonstrate its capacity to meet the needs of residents. See section on “Environment”; the section on “Health and Personal Care” for a description of services provision; and the section on staffing for information on deployment and training. This home does not provide intermediate care. Should the home provide rehabilitation and/or convalescence, all the elements of National Minimum Standard 6 will apply Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. 7, 8, 9, 10 Residents can be confident that the health and personal care which they receive is based on their assessed individual needs. Residents can be confident that the principles of respect, dignity and privacy are put into practice. EVIDENCE: Three residents’ files were selected for case tracking on this occasion, to represent the latest admissions (i.e. over the past year). The format of the care plans used by this home properly identify a range of health and personal care needs in the first instance, and these are intended to be supplemented by daily reports, assessments (including risks) and records of contact with healthcare professionals. Records confirmed that care plans and assessments are subject to in-house monthly reviews thereon – though often in these cases under inspection, with little or no change. This was judged Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 12 surprising, given the adjustments new admissions would need to make. Some of the instructions to staff would have generic application and would not necessarily single out one resident’s individual’s needs from another. Nor was there any record of attempts to actively pursue the residents’ emotional needs or interests; or to establish any unmet needs. These elements will all require attention, to ensure a more holistic approach. Training in person-centred planning might be of benefit. Less clear, however, was compliance with the National Minimum Standard in respect of formal multi disciplinary reviews (except those led by funding authorities), to reflect changing needs. Records need to better evidence the home taking a lead in this. It was not clear, moreover, to what extent residents or their relatives / representatives are actively engaged in the care planning process, except in respect of reviews carried out by funding authorities. None of the residents spoken to on this occasion showed any recognition of the process, though they did recall being asked questions about their care initially, and on a day-to-day basis thereon, and did confirm that they are generally very appreciative of the level of care given. The residents’ health is monitored regularly. And records confirm they have access to a range of medical services, according to need. Residents would need to pay for chiropody, podiatry, physiotherapy, specialist, additional treatment or medication themselves. Feedback from healthcare professionals indicates there has been a high incidence of urinary tract infections. The home’s management have taken the view that is because they discover UTIs at an early stage due to their robust monitoring processes, working in conjunction with the local GP. All staff are reported to be regularly receiving training in ‘Just Add Water’ and are reminded to encourage residents to drink regularly. This is recorded on their training matrix. The home uses the Monitored Dosage System of medication, over a 4-week cycle. The home has its own policy on medication, but also has ready access to the Royal Pharmaceutical Society Guidance on medication and directories on drugs, for reference. There were no gaps of anomalies in the medication administration records seen on this occasion. Staff are trained to administer medication. The home’s Medication trolleys are kept properly secured when not in use. With two exceptions, all the bedrooms in this home are single occupancy, which means health and personal care can be given in privacy. Feedback indicated that the daily routines are generally as flexible as healthcare needs and staffing levels will allow. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 12, 13, 14, 15 Residents are able to exercise choices over their daily life style, and social activities and can keep in contact with family and friends. Residents can be confident that the social, cultural and recreational activities offered by the home will meet their expectations. Residents can be confident that they will receive receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: Residents were not able to give many examples of any particular interests or hobbies being actively promoted by the home, but the home has a lively activities programme (showing events every morning and afternoon / evening) based initially on individual assessments, and the home’s administrative assistant also works as their activities co-ordinator. Examples of activities include: Bingo, sing-alongs, arts and crafts sessions (supported by a team of volunteers), quiz and card games, films and slide Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 14 shows, games and exercises to music. There are hairdressing sessions, manicure and cosmetic sessions. Seasonal events are celebrated, such as Palm Sunday, April Fools Day, Easter and Christmas. Shopping events are brought on site (e.g. clothing, Body Shop products) and there are periodic outings to a local shopping or garden centre. The home has its own stock of DVDs, videos etc and there are entertainers. The home has a Loop system in one of its lounges, for use with hearing aids. Religious preferences are properly identified as part of the initial assessment and care planning process. There are services on site and at St Matthew’s Church, which is sited at the front end of the Abbeyfield Rogers site, and there is a Chaplaincy service readily available to residents. In each case, individual and group services can be arranged. Residents can choose when to go to bed or get up, and what to do during the day, but tend in practice to have their own fairly set routines. They were observed being supported to make choices and decisions during the day of this inspection. One lady comes in to lead Motivation sessions to try to encourage residents to build up their confidence to try things. Residents are able to have visitors at any reasonable time. The home is reasonably well placed for links with the local community (see also section on “Environment”). All the bedrooms have telephone points. Residents can have lines installed in their own bedrooms, at their own expense. Unless other arrangements have been made, residents receive their mail unopened. Catering needs are properly identified as part of the preadmission process and updated or amended thereon. There is a five-week cycle of menus. This is traditionally drawn up by the cook in consultation with staff giving direct care, and alternatives are always available. Records are maintained of the options chosen by individuals, as required, and special provision is made for individual preferences, and residents with swallowing problems e.g. early-stage dementia. When asked, the cook said she hadn’t had specialist training for the elderly or dementia (this is strongly recommended), but had been able to experiment with different dishes to good effect. The inspector joined residents for lunch on both visits and judged the meals well prepared and well presented. The residents confirmed this was representative, and that alternatives were readily available. The pace was unhurried and congenial. The dining area provides pleasant settings but residents can choose to eat elsewhere. One recess in a first floor balcony has been a popular spot for breakfasts and snacks in the good weather. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 16, 17, 18 Residents can be confident that their complaint will be addressed properly since they have access to a robust and effective complaints procedure. Residents can feel confident that they are protected from abuse and will have their legal rights protected. EVIDENCE: This home has a clear complaints procedure, which is in the Information Pack given to prospective residents and available on request. It will require amendment to take account of the new inter-agency arrangements, once they become publicised. The home keeps a register of complaints, as required, and access to its contents is restricted to those properly authorised. The range of complaints registered was judged a realistic reflection of communal living, and there was good evidence of the home’s responses. Residents and their representatives can have confidence that the home’s culture is to take concerns and complaints seriously. The home has information on independent advocacy services on display but families and friends tend in practice to be relied on to provide this. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 16 The home has procedures to ensure that service users are safeguarded from abuse in all its forms, and staff confirmed their commitment to challenge and report any incidences of abuse, should they occur. In the event, this has not been warranted. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. 19, 20, 21, 23, 24, 25, 26 Residents benefit from living in a home in which the physical design and layout have been well thought through and it provides residents with a safe, wellmaintained and comfortable environment, which encourages independence. EVIDENCE: This home is in Wigmore, close to Rainham and Gillingham, with all the community and transport links that implies. There are local shops and a library, and a larger shopping precinct with a superstore a short distance away. The nearest train station is Rainham, and there is a bus route, which stops at the end of Drewery Drive. On-site car parking facilities are good (up to seven vehicles at a time), and there is unrestricted kerb-side parking along Drewery Drive. Measures are in place to keep the premises secure against Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 18 unauthorised access, without infringing on the residents’ freedom of movement. The layout of this home is judged generally very suitable for its stated purpose; it is accessible, safe and well-maintained. Comfortable temperatures and lighting levels were being maintained throughout. The residents have a good choice of communal areas (which includes five lounges), and they are each spacious. The furniture tends to be domestic in style and of good quality, and there were homely touches everywhere. And several areas have benefited from re-carpeting and/or refurbishment, with more in prospect. All corridors and doorways are wide enough to allow the passage of wheelchairs and mobility aids; and there is a spacious shaft lift and staircases to access all floors, so that residents can move about as independently as possible. All areas are linked with a call bell system. Specialist provision is in place but it is not overly conspicuous and includes hand and grab rails, raised toilet seats, push and lever operated door handles, doors which can be lifted off their hinges in an emergency, and lifting equipment, including hoists. This list is not exhaustive. The home was clearly designed to maintain its capacity to meet the emerging needs of its residents and best practice standards. It’s designer is to be commended. This home is currently registered to provide care for up to forty-three residents, and although two bedrooms are registered as double rooms, all are currently being used for single occupancy. Two bedrooms on the top floor have exclusive use of bathrooms directly opposite their doors, but all the rest have their own en-suite facilities. So that residents can be assured of privacy. Four bedrooms were inspected on this occasion, and judged well maintained and personalised. In terms of their furniture and fittings, moreover, they showed a sound level of compliance with all the provisions of the National Minimum Standards. All the bedrooms have telephone points, and television points - and all are linked to a call system facility. And there are five communal bathrooms (with assisted or Parker baths) and seven communal WCs i.e. all reasonably close to bedrooms and communal areas. All the maintenance records seen were up to date and systematically arranged. A few matters were raised for consideration or attention, on this occasion, accepting the refurbishment plans are ongoing. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 27, 28, 29, 30 The care of residents is enhanced because staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. EVIDENCE: This home’s staffing arrangements are designed to ensure that (excluding the manager) there are always at least five care staff on duty, plus a senior, during the mornings and four care staff, plus a senior during the afternoons. There are additional staff to cover peak periods (8-11am and at afternoon tea time). At night there are always two waking staff from 9.30pm till 7.30am. The home has ready access to a bank of flexi staff. In the absence of the manager there is always someone in charge, with an oncall system as a back up. Team working has been identified as a key strength. Staffing rotas were submitted to the Commission to confirm this arrangement, and there have been no concerns raised with the Commission about the home’s capacity to maintain these staffing levels. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 20 An examination of three personnel records, selected at random, confirmed feedback from staff, that this home has a systematic recruitment process to comply with the key elements of the standard. Staff also confirmed that there is a generally sound level of investment in mandatory training (e.g. moving and handling, medication, food hygiene, First Aid and Health and Safety, COSHH and infection control) to keep the service users safe. Some specialist training such as dementia care was identified as a further training need, so as to anticipate the emerging needs of one or two residents. At the time of issue of this draft, information was not available on the overall level of NVQ accreditation, but a visiting NVQ Assessor expressed her satisfaction with the progress being made. All her candidates were said to be on target to obtain accreditation by their due date. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 31, 32, 33, 34, 35, 36, 37, 38 The home is run for the benefit of residents in that the management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: There are clear lines of accountability within the home and the Abbeyfield organisation; and staff and residents have reported that in-house line management is invariably accessible and supportive. Less clear, however, was compliance with the National Minimum Standard for the frequency of formal, documented staff supervision sessions (matter raised by the last inspection). This will require attention. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 22 Abbeyfield has been generally able to evidence compliance with its duty to carry out formal documented inspection visits at least once a month (Regulation 26) though there were some gaps. All the current residents are white British. Five are male – the rest are female. All the staff are currently female because this is what residents have reportedly said they wanted. Information on ethnicity of staff was not available by the time of issue of this draft. Records confirm there are periodic group meetings with the residents and relatives to discuss the running of the home, and there have been quality assurance initiatives (including questionnaires) every year as well as a range of auditing exercises, to evaluate the home’s performance against its stated aims and objectives. The home makes provision for the proper storage and accounting of personal effects and small sums of pocket money. There is a summary development plan for the current financial year but it needs to reflect local provision and resources – and to link with its quality assurance initiatives and auditing arrangements, to obtain full compliance with this standard. The views of service users and feedback from other stakeholders will be crucial to the success of this. The home’s property maintenance certificates seen were up to date. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 18 3 4 4 4 3 3 3 4 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 3 3 Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP1 Good Practice Recommendations There should be a system for ensuring the Information Pack meets all the provisions of this standard And is available in a language or format to meet the individual needs of prospective residents and/or their representatives. Care plans should clearly single out one resident’s needs from another’s. And they should more actively: • evidence the active participation of interested parties, most notably the residents • pursue the residents’ emotional needs • offer specialist interventions e.g. to the individual with dementia • establish any unmet needs. These elements should be attended to ensure a more holistic approach. Specialist training in catering for the elderly or dementia is DS0000028736.V345726.R01.S.doc Version 5.2 Page 25 2 OP7 3 OP15 Abbeyfield Rogers House 4 5 OP16 OP19 strongly recommended, so as to anticipate the emerging needs of one or two residents. The home’s complaints procedure will require amendment to take account of the new inter-agency arrangements, once they become publicised Building. The following matters are raised for attention or consideration: • Recommend consideration be given to installing handrails from lounge areas into garden. • Fly screen on external door to kitchen requires repair or replacement (catches on clothes) • Fridge temperatures may require attention to maintain compliance with legal / recommended temperatures. • The heat extractor in the catering area may need adjusting • The catering area may benefit by the provision of a chiller room. • Toilet seat on 2nd floor requires securing. • Temperature of clinical room may require review – tends to get too warm, despite fan and extractor fan. • The installation of a sports channel on the home’s communal TV has been suggested. Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Abbeyfield Rogers House DS0000028736.V345726.R01.S.doc Version 5.2 Page 27 - 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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