Inspection on 10/01/06 for Alver Bank

This inspection was carried out on 10th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Alver Bank 07/11/06

Alver Bank 12/08/05

Alver Bank 20/01/05

Alver Bank 16/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Alver Bank Alver Bank 17 West Road Clapham London SW4 7DH Lead Inspector Ms Rehema Russell Unannounced Inspection 09.30 10 January 2006 th 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 DS0000022717.V269180.R01.S.doc Version 5.0 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. DS0000022717.V269180.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Alver Bank Address Alver Bank 17 West Road Clapham London SW4 7DH 0207-627-8061 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 Salvation Army Ms Malgorzata Lipnicka Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (0) of places DS0000022717.V269180.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th August 2005 Brief Description of the Service: Alver Bank is a home for older people owned by the Salvation Army Housing Association and managed by the Salvation Army Social Services. It is located in an historic listed building set in large, landscaped grounds. Within the same grounds and adjoining the home, there is a sheltered housing complex, as well as independent flat and a community centre. The home is situated between Brixton and Clapham and has good transport links. It offers some parking at the front and side of the home and on street parking. There is accommodation for 27 older people, all in single rooms. The ground floor has two lounges, the treatment room, two offices, the dining room, the kitchen, a few bedrooms, several toilets and bathrooms, and access to the gardens and grounds via stairs or a ramp. The first floor has the majority of bedrooms, several bathrooms and toilets, a shower room and a kitchenette. There is a passenger lift to the first floor which is shared by the sheltered housing block that adjoins the home. There are landscaped gardens to the front and rear of the property. The home and grounds are fully wheelchair accessible. DS0000022717.V269180.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon of 10th January 2006. The registered manager was on annual leave and the inspection was facilitated well by the deputy manager. The inspector toured the premises, spoke to several residents, a visiting relative, a senior care assistant and the catering manager, observed staff interaction with service users and service users activities, and looked at documentation and records. At the time of the inspection there were 25 service users at the home, with two vacancies. What the service does well: What has improved since the last inspection? What they could do better: The inspector was very pleased to learn that one of the previous outstanding requirements, that the home provides a designated hairdressing room, was in the process of being implemented. However, two requirements related to providing aids/adaptations for bathrooms and one related to staff being provided with terms and conditions remain outstanding and two new requirements arose at this inspection. These related to the maintenance of external CCTV security cameras and to the timely implementation of the annual gas safety check. DS0000022717.V269180.R01.S.doc Version 5.0 Page 6 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. DS0000022717.V269180.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection DS0000022717.V269180.R01.S.doc Version 5.0 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 the following standard(s): 1, 3 and 6 Prospective residents have the information they need to make an informed choice about the home and an assessment of need is undertaken prior to admission. The home does not admit residents solely for intermediate care. EVIDENCE: There had been no changes to these three Standards since the previous inspection. The comprehensive and easily understood brochure, Statement of Purpose and Service Users’ Guide had not changed and they continue to provide all of the information required by regulation, including residents’ views of the home. The home continues to carry out a full assessment of need before residents enter the home. Prior to admission, the home obtains the community care services assessment of need and any other relevant specialist reports and reviews. On this basis and information observed and obtained on internal assessment and trial visits, a dependency profile is compiled. This profile is the home’s internal assessment. The resident’s care plan is devised from this and the community care assessment. The home continues to update the dependency profile monthly. DS0000022717.V269180.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7, 8, 9, 10 and 11 Residents’ individual health and personal care needs are laid out in care plans. The full range of healthcare specialists and facilities are employed to meet residents’ needs. Residents are safeguarded by the medication storage, administration and recording systems at the home. Residents feel they are treated with respect and their privacy is upheld. Funeral plans are in place to ensure residents’ wishes are met. EVIDENCE: The care planning system at the home had not changed since the previous inspection. All care plans are signed by the manager/senior care assistant/key worker and also by the resident unless this is not feasible. Care plans are also signed by relatives where this is appropriate. Each care plan has between 6 – 10 components which cover areas such as the mobility, health, communication, financial and behavioural needs of the resident. Each component clearly describes the need and how it is to be met. There is no specific component for social needs as residents are given a full choice on whether to socialise and to join in with the activities at the home and this would only be listed if it presented as a mental, emotional or behavioural need. Monthly reviews are held via the updating of the dependency profile. Formal six monthly reviews are held and recorded, and there is evidence that relatives DS0000022717.V269180.R01.S.doc Version 5.0 Page 10 are invited to attend these. A second care file for each resident is kept in the treatment room. This has a detailed medical profile and records of doctor and other specialist appointments. These files show that the full range of healthcare specialists is accessed for residents, either by the specialist visiting the home or by residents being escorted and transported to external appointments. A third care file is kept locked in the manager’s office. This file has information on financial matters, medical records and contract issues and other matters that it is not necessary for health or care workers to access. In this way, residents’ confidentiality is safeguarded. In regard to medication, the policy at the home is for only senior care assistants to administer medication, and this had not changed since the previous inspection. There are currently no residents who are able to selfmedicate. There is a separate treatment room at the home in which staff and visiting professionals administer personal healthcare needs. This facilitates residents’ privacy and dignity. Staff were observed to approach residents respectfully and to offer personal care discreetly and sensitively, and residents spoken with confirmed that their privacy and dignity is respected and safeguarded by staff. Prior to the previous inspection the home had written to the families of all residents to enquire about their wishes in regard to illness, dying and death. Only 10 responses had been received but from these responses, and discussion with the resident where feasible, comprehensive plans had been written to cover the events of illness, dying and death. DS0000022717.V269180.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 12, 13, 14 and 15 Residents’ social, cultural, religious and recreational needs are facilitated. Residents are encouraged and supported to maintain contact with family, friends and the local community, and to exercise choice and control over their lives. A varied, nutritious and wholesome diet is provided in pleasant surroundings and a convivial atmosphere. EVIDENCE: A large range of individual and group activities are on offer inside and outside the home. There are two large lounges. One is equipped with television, fish tank and objects of interest. The other is a quiet lounge, with no television but with books, music and a budgerigar. This lounge is used for the optional morning prayer meeting and for craft activities in the afternoon. Residents are free to choose which lounge they wish to utilise, how often and when, and on the day of inspection it was noted that some residents had changed the usual lounge that they stayed in. The deputy explained that this had given rise to some disruption between certain individuals but this had been managed well by staff and a ‘truce’ arrived at. Inside the home, a range of activities such as darts, sing-a-long, arts and crafts, board games, quizzes and seasonal activities are offered. A list of daily activities for the week is kept on the notice board in the main hallway (opposite the two lounges) and the specific activities for the day are also written up on the large notice board outside the dining room. The home has its own transport and this is used to take interested DS0000022717.V269180.R01.S.doc Version 5.0 Page 12 residents shopping or on day trips. Two of the residents spoken with mentioned enjoying the outings that they had been on. These included Christmas shopping, shopping trips to big centres in Lewisham, Wandsworth and Surrey Quays and summer days trips such as Kew Gardens. Outside events are also held in the home grounds, such as garden parties and fetes celebrating various religion’s feastdays and celebrations. Although the home is run by an organisation of a particular Christian faith, residents of all or no faiths are welcome and services and clerical visits for different denominations are arranged according to individual resident’s wishes. The home also ensures that it meets the cultural needs of residents – currently there is a resident from a Caribbean background who is being provided with suitable food and activities, according to his personal choice. The catering manager has ensured that there is a Caribbean meal weekly and has found that the majority of other residents now enjoy this meal too. In addition, Caribbean alternatives are available at other times and the catering manager is currently redesigning the menu records to ensure that these alternatives can be recorded when they are chosen. Verbal evidence from residents showed that residents are encouraged and supported to maintain contact with family and friends. On the day of inspection the inspector spoke privately with a service user and her relative who visits regularly. They confirmed that visitors are always made welcome at the home and are offered tea and can also partake in meals at the home. Many examples were given and observed of residents’ being encouraged and supported to make choices and exercise control over their lives. A drinks machine has been installed in the main reception area that provides hot drinks such as tea, coffee and chocolate. Although hot drinks are available from staff all day the machine enables residents to get a drink for themselves and therefore to feel more independent. There are also cold water dispensers throughout the home for the same reason. Residents confirmed that they can get up and go to bed at times of their own choosing, and were observed to go freely about the home as they pleased. A few chose to stay in their rooms during the morning/afternoon, and all bedrooms seen were personalised according to individual choice. Two examples of advocacy information being given to residents in appropriate situations were given and all personal information was kept private and secure. Residents are offered a varied and nutritious menu. They have a choice in regard to both the main meal and the desert, and a jug of cold drink is available on each table for self-service, with a hot drink offered after the meal. Residents spoken with confirmed that they liked the meals offered and could also get snacks and drinks outside mealtimes. One resident express dissatisfaction with the food but this was because he wanted specialist vegetables, such as New Jersey potatoes and Savoy cabbage. The inspector spoke with the catering manager/chef who confirmed that it would not be feasible to offer such specialities as part of the every day menu. However, she DS0000022717.V269180.R01.S.doc Version 5.0 Page 13 was just preparing new menus which would include having potatoes in many other forms rather than mashed (e.g. croquette, chips, sauté etc.) and told the inspector that a dietician had been consulted about the menus. Apart from breakfast, lunch and supper, residents are also offered drinks and a snack mid morning, mid afternoon and later in the evening. A full range of medical diets is provided, such a diabetic and liquid as appropriate. The inspector sampled the vegetarian option on the menu that day, home-made macaroni cheese, and found it very tasty. DS0000022717.V269180.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 16 and 18 Complaints are listened to, taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: The home has a clearly written complaints procedure that is fully explained in the Statement of Purpose, which is provided to all residents. A copy of the Salvation Army Housing Association complaints procedure is also displayed on the notice board in the main hallway, where it is easily accessible to residents and visitors. The requirement arising from the previous report in regard to the document stating that complainants can approach CSCI and providing CSCI contact details had been implemented. The resident and her relative spoken with were both aware of how to make complaints but said that they found the manager and deputy very approachable in regard to any problems they may have and had not had to make any complaints. There had been no new complaints since the previous inspection, at which it had been found that complaints received in the last year had been investigated in a thorough and timely manner and had been appropriately resolved. Verbal evidence from staff showed that verbal and physical aggression from service users is understood and dealt with appropriately. The home has the appropriate policies in place to respond to suspicion of abuse. The home’s own abuse policy is comprehensive and the home also keeps a copy of the local authorities’ procedure and of the policy document “No Secrets”. DS0000022717.V269180.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 19, 20, 21, 22, 24, 25, 26 Residents have access to safe, comfortable, attractive and well-maintained indoor and outdoor communal facilities, but on the day of inspection some of the external CCTV cameras were not in working order. Aids and adaptations are provided throughout the home and service users’ own rooms are safe, comfortable and personalised. The home is clean, pleasant and hygienic throughout. Although the home has an appropriately number of bathrooms, several are not suitable for residents’ needs and therefore restricts their choice, dignity and comfort. Hairdressing facilities are inadequate and also restrict residents’ dignity, privacy and comfort. EVIDENCE: The home has several indoor communal areas, including two large lounges, a large dining room, two offices and a large furnished reception area. It therefore has sufficient space to facilitate the variety of social, cultural and religious activities that are offered and to provide private space if residents do not wish to entertain visitors in their own bedrooms. All communal areas are DS0000022717.V269180.R01.S.doc Version 5.0 Page 16 decorated, fitted and furnished to a high standard and are attractive and comfortable. The reception area is attractive and comfortable. It has been provided with seating facilities, ornamentation and a good quality drinks machine, so that residents are able to sit comfortably in the area and to observe and take part in the social life and comings and going in the home. There is also a kitchenette on the first floor where residents can make drinks for themselves or their visitors if they wish. There are large, landscaped and well maintained grounds that are accessible to all residents, including wheelchair users and those with restricted mobility. The grounds and entrances to the home have external CCTV cameras for security purposes but on the day of the inspection several of the cameras were not in working order, which potentially comprised the safety of the home. The Registered Provider must ensure that all of the CCTV cameras are maintained in working order. Bedrooms throughout the home were seen. Although they vary is size, they are all comfortable, well furnished and fitted, and all are personalised according to individual residents’ choices and preferences. All bedrooms had personal possessions, some had private telephone lines, music and television, and some were locked by the resident when not occupied. One service user, who has a lot of hobby materials and is visited regularly by grandchildren, told the inspector that she would prefer a larger bedroom, and the deputy manager said that this would be facilitated. Aids and adaptations are present throughout the home. There are grab rails throughout, ramps leading out from the front and back entrances to the home and gardens, two Parker baths and a walk/wheel in shower, and various bed aids and adaptations as required. However, three bathrooms require aids/adaptation adjustments in order to ensure that the independence needs of residents are met and these are referred to below. The laundry room has recently been fitted with very up to date washing and drying machines and the laundry person reported that they, and the ironing machine provided, were easy and convenient to use and provided good quality laundering. The kitchen was also well provided for and was well organised and maintained and clean and hygienic throughout. The home has four bathrooms (with toilets), one shower room and two additional toilets on the first floor. It has three toilets and two bathrooms (with toilets) on the ground floor. These are conveniently sited for communal areas and bedrooms and are sufficient in numbers for the 27 residents at the home. However, only two of the upstairs bathrooms and the upstairs shower room are suitable for the needs of the residents of the home and hence the other four bathrooms are not currently used. This is because the baths in these four bathrooms are too low for residents to step in and out of. This therefore restricts independence and choice. Residents can only access the two bathrooms which have Parker baths and the disability shower room. In addition, the controls in the disability shower room cannot be used by DS0000022717.V269180.R01.S.doc Version 5.0 Page 17 residents when they are sitting down and therefore independence, choice and privacy are restricted as it is necessary to have staff assistance in order to use the shower. Furthermore, as there is no hairdressing room at the home, residents sit in the first floor lift area and corridor to have their hair done and one of the only two bathrooms that is useable is used by the hairdresser for hair washing. This is not conducive to privacy or dignity and further restricts choice for residents wishing to bathe. The lack of suitable bathing and hairdressing facilities was made subject to requirement in the previous report and although there had been no progress at the time of the inspection, at the time of writing this report the inspector was informed that certain works were about to start imminently. These works are the conversion of one ground floor bathroom to a hairdressing room, the provision of a new sluice, and the provision of better ventilation in the laundry room. The Salvation Army Housing Association, who will be carrying out the above works, informed the inspector that the previous requirements in regard to providing electronically self-operated chairs in two bathrooms does not fall under their responsibilities as these are not permanent fixtures. Three of the four previous bathroom requirements are therefore repeated in this report, and these should be addressed by the Salvation Army Social Services. These requirements are for electronically self-operated chair hoists to be provided for the remaining ground floor bathroom and for the first floor bathroom, and for the controls in the disability shower room to be lowered so that residents seated in wheelchairs are able to operate these independently. The home is suitably and adequately lit, heated and ventilated, with central heating throughout, all radiators fitted with low surface temperature covers and proper water temperature and thermostatic controls. On the day of inspection there were no offensive odours in the home and the home was clean and hygienic throughout. DS0000022717.V269180.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 Standards 27 and 28 were assessed at the previous inspection. Staffing numbers and skills mix are sufficient to meet the assessed needs of residents and staff are suitably trained to ensure that residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policy and practices but not all staff have signed to accept their terms and conditions of employment. Staff are trained and competent to do their jobs. EVIDENCE: Standards 27 and 28 were assessed at the previous inspection and were both found to be met, with Standard 28 found to be exceeded. There had been no changes to the care staff cover or to the percentage of care staff trained to NVQ Level 2 since the previous inspection and so these two Standards continue to be met. The Registered Provider operates a robust recruitment policy and procedure and suitable procedures are followed to ensure the safety and protection of residents. These procedures had been checked at the previous inspection and found to be met and there had been no new members of staff since that inspection. However a requirement had arisen from the previous two inspection reports that the Registered Person ensure that all staff have signed and accepted terms and conditions of employment and that copies of these are held on their personnel files. At this inspection a random check revealed that although some progress had been made, there remained some files where terms and conditions were not signed and evidenced. This requirement has DS0000022717.V269180.R01.S.doc Version 5.0 Page 19 now been outstanding since March 2005, which is a poor reflection on the management of the Registered Provider. The staff training file was examined and evidenced that each member of staff had an individual training record. All staff undertake all required basic training during induction, such as food hygiene, lifting and handling, first aid, fire training and health and safety. They then receive at least 3 days training per year, which covers relevant subjects such as dementia, report writing, activities and hearing loss. Senior care staff spoken with confirmed this and were happy with the amount and quality of the training provided by the Registered Provider. DS0000022717.V269180.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38 The Registered Manager is suitably qualified, competent and experienced to run the home and residents benefit from the management approach at the home. Residents’ views are regularly sought, both formally and informally, to ensure that the home is being run in their best interests. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are generally promoted and protected but the annual gas safety inspection had not taken place and this could potentially jeopardise the safety of the home. EVIDENCE: There has been no change to the positions of manager and deputy manager at the home since the previous inspection. The registered manager of the home is a registered nurse, has NVQ Level 4 in Management, a qualification in geriatric nursing and is a NVQ assessor. She has several years senior management experience and in addition is beginning a Bachelor of Science degree in health and social work. The deputy manager has NVQ Level 3 in DS0000022717.V269180.R01.S.doc Version 5.0 Page 21 customer services, is undertaking NVQ Level 4 in management, has a City & Guilds qualification in advanced management for care and has several years experience of care and management with the client group. Both managers have a thorough understanding of the needs and conditions of elderly people and a detailed knowledge and understanding of the personalities, interests and needs of individual residents at the home. Verbal evidence from residents, relatives and staff indicated that there is an open, positive and inclusive management style at the home, and that all three groups of people find the manager and deputy approachable, empathetic and supportive. At the previous inspection, verbal and written evidence indicated that the home has effective quality assurance and monitoring systems which are based on seeking the views of residents, visitors and external specialists. Views are sought informally on a daily basis and formally using residents’ surveys, the comments book and the complaints procedure. Residents’ views are sought by survey two months after admission to the home and then annually. Residents meetings are held bi-monthly and the Registered Provider carries out monthly visits and its own annual inspections. In addition, two residents’ surveys are held each year on behalf of the Salvation Army Housing Association in regard to their tenancy rights. These systems had not changed since the previous inspection. There are six service users for whom the home manages their personal allowances. The records, receipts and balances of these were seen, spot checks of balances were undertaken, and all were found to be in good order. Financial records are detailed and thorough, each transaction signed by both the resident and the deputy manager, and all receipts are retained. Regular health and safety checks are carried out and recorded at the home and the storage of hazardous substances, regulation of water temperatures and accident and incident recording were all found to be in good order. The fire book showed that regular fire drills and fire point tests are undertaken. The inspector was told that fire drills are carried out at varying times of the day and night, which is good practice, but the times are not currently recorded and it is recommended that this is done from now on. On the day of the inspection it was found that the annual gas safety inspection check was overdue by 4 days and the maintenance person undertook to expedite this. The Registered Provider must ensure that annual gas safety checks are undertaken in good time and must provide evidence of the overdue check being undertaken. DS0000022717.V269180.R01.S.doc Version 5.0 Page 22 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 4 2 2 X 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 DS0000022717.V269180.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP21 Regulation 13(4)(c) 23(2)(n) Requirement The Registered Person must ensure that CCTV cameras are maintained in working order. The Registered Person must ensure that the controls in the disability shower room are positioned so that they can be operated independently by residents whilst in wheelchairs. The Registered Person must ensure that as self-operated electronic chair hoist is provided for the ground floor and first floor bathrooms. The previous timescale of 30/04/06 has not yet passed. The Registered Person must ensure that all staff have signed and accepted terms and conditions and that copies are held on their personnel files. Previous timescales of 31/03/05 and 30/10/05 have not been met. The Registered Person must ensure that annual gas safety inspection checks are undertaken on time. Evidence of the current overdue annual DS0000022717.V269180.R01.S.doc Timescale for action 30/04/06 31/07/06 3 OP22 23(2)(n) 31/07/06 4 OP29 19 31/03/06 5 OP38 13(4) 31/03/06 Version 5.0 Page 24 inspection must be supplied to the Commission. 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 OP38 Good Practice Recommendations The Registered Manager should ensure that the time of day/night of fire drills in recorded. DS0000022717.V269180.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022717.V269180.R01.S.doc Version 5.0 Page 26 - 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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