Inspection on 25/07/05 for Anne Residential Home (1)

This inspection was carried out on 25th July 2005.

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

Anne Residential Home (1) 12/06/07

Anne Residential Home (1) 22/08/06

Anne Residential Home (1) 31/01/06

Anne Residential Home (1) 04/11/04

Anne Residential Home (1) 09/12/03

Similar services:

Spinney (The)

Queen Elizabeth House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Anne Residential Home (1) 80 Coombe Lane west Kingston Upon Thames Surrey KT2 7AD Lead Inspector Barry Khabbazi Unannounced Inspection 25 July 2005 9:30am 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. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Anne Residential Home (1) Address 80 Coombe Lane West, Kingston Upon Thames, Surrey, KT2 7AD 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) 020 8942 8378 020 8942 3861 Mrs Kystyna Gordon Care Home 4 Category(ies) of Old Age (4) registration, with number Dementia - over 65 (4) of places Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 19 January 2005 Brief Description of the Service: Anne Residential Home 1 is a two-storey building set back from a main thoroughfare connecting Kingston and New Malden. There are few amenities within walking distance but Kingston town centre is a few minutes drive away by car.The home is registered for 3 adults aged over 65 years of age who have Dementia. Two bedrooms are located on the ground floor, the third is located on the first floor and accessed via a set of stairs.Staffing of Anne Residential 1 is provided to ensure that, in addition to the manager, there is one staff member per shift on duty at the home. At night, one member of staff sleeps in at the home and is available on-call if needed. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was un-announced and started at 8.30 a.m. The inspection took place over three and a half hours. The inspector was able to speak to all the residents on this occasion and observe breakfast. Feedback from residents at this inspection was all positive. During this inspection the manager/owner was interviewed. Records, and care plans and the building were examined, as were all the residents’ bedrooms. What the service does well: What has improved since the last inspection? The missing section of the fence in the rear garden has now been replaced. The staff vetting procedure is now much improved and now meets the National Minimum Standards. This should help protect the residents from undesirable staff. Thermostatic mixer valves have now been fitted to the hot water outlets in the bath and the shower to ensure the hot water temperature does not exceed 43 degrees Celsius to avoid scolding. Hot water temperatures are now recorded daily to ensure that the maximum temperature at the point of delivery does not exceed 43 degrees Celsius to avoid scolding. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 6 Risk assessment are now completed in relation to the mobility of each service user to ensure that the mobilization needs of the resident regarding aids/adaptations are met 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. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.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 Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.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) 3 The initial assessment covers all the elements of Standard 3. This will ensure a detailed and relevant assessment of a resident’s individual needs and a better understanding of needs by staff. EVIDENCE: Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 9 The home uses ‘Standex’ medical assessment forms, which while being comprehensive from a clinical perspective, do not cover any social needs. However other assessment documents are completed in addition to these, and together they cover all the elements required under Standard 3.3, and in particular a history falls, oral health, mobility, social interests, religious and cultural needs and carer and family involvement and other social contacts. Standard 6 does not apply to this home as this home does not provide rehabilitation with a view to returning to the community. The home has a Statement Of Purpose and Service Users Guide all in the same file. Although Standard 1 was not fully assessed on this occasion, the inspector did suspect that there were a few omissions in the Statement Of Purpose and Service Users Guide, for example the new Standards require room sizes etc. The registered manager was asked to check this during her usual annual updating of these documents so that this Standard can be examined for compliance in more detail at the next inspection. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.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, and 10. Care plans are much improved and are now more holistic and also cover social care needs. This should improve how well staff, particularly new staff, know a resident’s needs. Residents’ personal care needs and physical and emotional health needs are met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is also well managed to ensure maximised good health. EVIDENCE: The home uses ‘Standex’ medical Care plan forms, which while being comprehensive from a clinical perspective, do not cover any social needs. However, other documents are completed in addition to these, and together they cover all the elements required under Standard 7. There are currently no residents with a pressure sore at this home. Pressure sore avoidance procedures include 2 nursing beds and air pressure mattresses, hygiene and regular toileting, nutritional and fluid monitoring and Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 11 supplements where required {see also meals}, and activities to promote mobility. Residents remain registered with their own family General Practitioner whenever it is practicable to do so. The owner stated that a chiropodist visits the home approximately once every six weeks at no charge to service users although private services are also available. Medication records were up to date. Medicines are currently stored in a cupboard attached to the wall in each individual’s bedroom. Residents can self medicate subject to a risk assessment. Staff were observed to interact with service users with respect and dignity and demonstrated a good relationship with them. This was confirmed through discussions with residents. Personal care needs were addressed promptly, and in a fashion that maintained the respect and dignity of service users. Residents’ life story books are produced to exercise and maintain memory. Relatives are encouraged to and do maintain contact with the home and other residents following the death of the resident concerned. Residents are not being weighed on a monthly basis. The following recommendation is now therefore set: Residents should be weighed on a monthly basis. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.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, and 15. The home’s policies support visits to the residents from relatives and friends. Residents are provided with opportunities to remain part of the local community and are able to take part in appropriate activities. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. The daily routines and the home’s policies promote the residents’ choice and rights, to ensure equality and that all rights are enjoyed by all residents. EVIDENCE: The routines of daily living and activities are made as flexible as possible, for example there is no set bed time or getting up time. The home has links with other similar services in the area and residents are encouraged to maintain social contact with their peers through open mornings in the home. Individual activities also occur and events and birthdays are also celebrated. The owner/ registered manager provides transport, if required, to enable residents to undertake visits to places of interest locally. Residents are encouraged to receive visitors at all times. Community interaction includes the local town centre’s resources and shops. Residents are able to attend church should they wish to do so. The owner reported good relationships with neighbours. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 13 The home is run in a manner that promotes choice and independence and this was confirmed through residents’ comments, policies, and observation. The home does not take responsibility for the control or administration of any residents’ finances. Residents can bring in their own possessions and furniture if they wish and this was observed in their rooms, which had been individualised. Residents can take meals, and particularly snacks, at times and places to suit them and have a choice of meals and alternatives. Menus were examined and were nutritiously balanced with at least 5 portions of fruit/vegetables per day and appropriate protein and carbohydrate contents. Many fresh meals are prepared including fresh soup. Breakfast was observed on this occasion and a choice of cooked and cold food was observed to be chosen. The owner manager is a Dietician and provides meals that are very well balanced nutritionally and contain specific higher areas of nutrition when poor health requires. This has had positive outcomes for the residents’ health and speed of healing, for example in the case of pressure sores. The residents confirmed that meals at the home are pleasant and enjoyable. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 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 standard(s) 16, and 18. Complaints are generally managed well which should ensure that residents’ and relatives’ concerns are listened to. The home’s policies and procedures generally help protect residents from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: The home has not received any complaints over the last 24 months. The complaints procedure was clear and contained all the elements required including a written maximum response time of less than 28 days and details of how to contact the Commission. The home has a copy of the local Adult Protection procedure. The home also has a Whistle Blowing Policy and an Abuse Policy. There is a Gifts Policy and the wills policy does indicate that staff are precluded from being involved in the making or being the beneficiary of a residents’ will as required under this Standard. The home does not handle any residents money and there are lockable spaces in residents rooms and a safe for secure holding of valuables. Restraints policies were not available for inspection. The following requirement is now set. The home’s restraints policy must be sent in to the Commission and all staff must be aware of this policy and its guidance. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 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 standard(s) 19, 25, and 26. The home is in very good condition externally and internally, and is well decorated in a homely fashion and very well maintained. This creates a pleasant environment that promotes the residents’ dignity and emotional wellbeing. Most areas of the home are safe but more work needs to occur to fully confirm the residents’ safe environment. The home is particularly hygienic and clean, homely and comfortable; this environment therefore promotes a pleasant environment, the residents’ health, and emotional well-being. EVIDENCE: The home appeared to be in good condition externally and was well decorated in a homely fashion inside. This home is very well maintained and clean. At this unannounced inspection, it was reassuring to see that the home was as particularly clean and hygienic. This home is maintained to a high level of cleanliness. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 16 The last inspection report contained a requirement for the missing section of the fence in the rear garden to be replaced. This has now occurred and this requirement is now met. The last inspection report contained a requirement for thermostatic mixer valves be fitted to the hot water outlets in the bath and the shower to facilitate regulation of the hot water temperature so that it does not exceed 43 degrees Celsius. This has now occurred and this requirement is now met. The last inspection report contained a requirement for the home to record hot water temperatures daily and ensure that the maximum temperature at the point of delivery does not exceed 43 degrees Celsius. This has now occurred and this requirement is now met. The home did not have the bacterial analysis’ testing results available for inspection. The following requirement is now therefore set: The ‘certificate of bacterial analysis’ testing results are to be sent in to the Commission First floor windows were not fitted with window restrictors. The following requirement is set to address this: The need for window restrictors must be risk assessed. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 17 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, and 30. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency. The staff vetting procedure is now much improved and now meets the National Minimum Standards fully. This should help protect the residents from undesirable staff. Induction and foundation training to National Training Organisation’s specifications is now in place. This should create a more highly trained workforce. EVIDENCE: The home is managed and run on a day-to-day basis by the owner/manager, with assistance provided by staff. In addition to the registered manager’s hours there is a total of 35 care staff hours per week. The owner/manager lives locally and is therefore available in case of emergency. Agency staff are currently not used. The last inspection report contained a requirement for the home to retain the criminal records bureau checks on staff on site and make them available for inspection. These were available at this inspection as were all the other vetting documents required under this Standard. The requirement is now therefore met. Criminal record bureau checks, proof of identity and references were available for inspection and met the required standard in files sampled. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 18 All staff are previously known to the owner/manager and are have been in post for some years. Induction and foundation training to National Training Organisation’s specifications is now in place. However existing staff are long term staff and there have been no new staff yet to do the induction training. This Standard will therefore need to be assessed once a new staff member starts. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 19 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) 33, 35, 36, and 38. The home has implemented a quality assurance system and an annual development plan, with both involving residents. This should ensure that the home is run in a way that involves the residents and a way that is in the best interests of the residents. Residents’ financial interests are safeguarded by the home’s policies, practice and lack of involvement Only limited progress has been made with regards to the frequency of recorded staff supervision. This could affect the quality of the work that staff do. Although health and safety policies and procedures do generally protect the residents, further checks need to be done to ensure that the electrical appliances are safe. EVIDENCE: Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 20 Quality assurance tools currently include residents and relative questionnaires, and a complaints system. These quality assurance tools have been pulled together into an internal quality assurance system, which includes this information in the home’s annual plan where appropriate, and then provides a system of feedback and review involving the residents in the form of resident meetings. This should allow open measuring of achievement in improving quality. It is seen as good practice that the home does not manage any residents’ money and it is to be commended for pursuing alternative solutions. The last inspection report contained a requirement for risk assessment be completed in relation to the mobility of each service user and that this assessment should detail the mobilisation skills of the service user, and any aids/adaptations needed. This was available at this inspection ands this requirement is now therefore met. The last inspection report contained a requirement for notes of supervision sessions to be recorded and held on individual staff filles. This has started but has not yet been fully implimented. The existing requirement will remain in force untill fully met. All of the health and safety policies and procedures relevant to this Standard have been seen to be present. Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets were available and these substances were all locked away. All of the procedures and testing of systems required in Standard 38 were also present except for the Portable Appliance Testing certificate. The following requirement is set to address this: The Portable Appliance Testing results must be sent in to the Commission. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 21 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 2 x 2 Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 22 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 18 Regulation 13 Requirement The homes restraints policy must be sent in to the Commission and all staff must be aware of this policy and its guidance. The ‘certificate of bacterial analysis’ testing results are to be sent in to the Commission The need for window restrictors must be risk assessed. Notes of supervision sessions should be recorded and held on individual staff files. The Portable Appliance Testing results must be sent in to the Commission Timescale for action 1/11/2005. 2. 3. 4. 5. 25 25 36 28 13[3][4] 12 18 (1) a 12 1/11/2005. 1/11/2005. 1/11/2005. 1/11/2005. 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 8 Good Practice Recommendations Residents should be weighed on a monthly basis. Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 23 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Anne Residential Home (1) G53 S13405 AnneResdential1 V241646 250705 stage4.doc Version 1.40 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!