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 31st January 2006 9:30am 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 Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 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. Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 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 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) 020 8942 8378 020 8942 3861 Mrs Krystyna Gordon Care Home 4 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (4) of places Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th July 2005 Brief Description of the Service: Anne Residential Home 1 is a single-storey building set back from a main thoroughfare connecting Kingston and New Malden. All the bedrooms are therefore on the ground floor. There are few amenities within walking distance but Kingston town centre is a few minutes drive away by car. The home is registered for 4 adults aged over 65 years of age who have Dementia. 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. The home is a short distance from the owners other care home. There continues to be an emphasis on integration between the service users from the owners other home. Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. All of the Commission’s service user and relative surveys received to date have only provided positive comments about this home. Where shortfalls have been identified, these are of a minor nature and the manager has proven committed to fully meeting requirements and standards. The key Standards identified throughout this report were all assessed at the last inspection, which was the main inspection for the year. Please see that inspection report for a full audit of all the key Standards. This unannounced inspection therefore focused on following up on previous requirements and any new issues arising. During this inspection all of the residents were met and the manager/owner was interviewed. Records, and care plans and the building were also examined. What the service does well: This home is in a bungalow and all rooms are therefore on one level which provides better access to service users with restricted mobility. 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. This is a home for older people where the residents experience a caring family like environment. All the residents have commented that they like living in the home, and like their rooms, meals and how they are treated. 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. 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. This home is very well maintained and clean. At this and the last unannounced inspection, it was reassuring to see that the home was as particularly clean and hygienic. Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 6 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
Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 7 contacting your local CSCI office. Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 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 Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. EVIDENCE: Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 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 the following standard(s): 8 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. EVIDENCE: The last report recorded that the residents were not being weighed on a monthly basis. The following recommendation was then set: Residents should be weighed on a monthly basis. This had occoured bt the time of this inspection and this recommendation is therefore now met. Evidence of good practice presented under standard 8: . Residents’ life story books are produced to exercise and maintain memory. All the residents have commented about liking living in the home, and liking their rooms, meals and how they are treated. Evidence of good practice presented under standard 11: . Relatives are encouraged to and do maintain contact with the home and other residents following the death of the resident concerned.
Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 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): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. Details of previously identified good practice that are referred to elsewhere in this report are however included below. EVIDENCE: Evidence of good practice presented under standard 15: . 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. All the residents have commented about liking living in the home, and liking their rooms, meals and how they are treated. Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 12 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): 18 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 last inspection report recorded that the restraints policies were not available for inspection. The following requirement was then 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. This has not occurred and the requirement therefore remains. Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 13 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): 25 Most areas of the home are safe but more work needs to occur to fully confirm the residents’ safe environment. EVIDENCE: The last inspection report recorded that the home did not have the bacterial analysis testing results available for inspection. The following requirement was then set: The ‘certificate of bacterial analysis’ testing results are to be sent in to the Commission. Although this had been sought, the water has not been tested yet. The requirement will remain until fully met. The last inspection report recorded that the first floor windows were not fitted with window restrictors. The following requirement was then set: The need for window restrictors must be risk assessed. This had not occurred and this requirement remains in force. Evidence of good practice presented under Standard 20: This home is in a bungalow and all rooms are therefore on one level which provides better access to service users with restricted mobility
Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 14 Evidence of good practice presented under Standard 26: 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. Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 15 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): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. EVIDENCE: Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 16 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): 36 and 38. 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. Health and safety policies and procedures do generally protect the residents. EVIDENCE: The last inspection report recorded that Standard 36 requires the home to record supervision sessions and that these sessions should occur 6 times per year, and although supervision sessions were occurring these were not being fully recorded. The following requirement was then set: Notes of supervision sessions must be recorded and held on individual staff filles. This had not occurred yet and this requirement therfore remains in force. Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 17 The last inspection report also recorded that all of the procedures and testing of systems required in Standard 38 were 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. This had occurred and this requirement is now met. Evidence of good practice presented under Standard 32: This is a home for older people where the residents experience a caring family like environment. All the residents have commented about liking living in the home, and liking their rooms, meals and how they are treated. Evidence of good practice presented under Standard 35: 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. Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 18 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 x x x x x x 2 x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 2 x 3 Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 19 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. Standard OP18 Regulation 13 Requirement Timescale for action 01/11/05 2. 3. 4. OP25 OP25 OP36 13[3][4] 12 18 (1) a 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 01/11/05 analysis testing results are to be sent in to the Commission The need for window restrictors 01/11/05 must be risk assessed. Notes of supervision sessions 01/11/05 should be recorded and held on individual staff files. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Anne Residential Home (1) DS0000013405.V281353.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 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
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