Inspection on 10/06/08 for Antokol

This inspection was carried out on 10th June 2008.

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

Antokol 14/01/08

Antokol 18/09/07

Antokol 10/08/06

Antokol 18/10/05

Antokol 27/06/05

Antokol 15/03/05

Antokol 26/10/04

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Antokol Antokol 45 Holbrook Lane Chislehurst Kent BR7 6PE Lead Inspector Miss Rosemary Blenkinsopp Key Unannounced Inspection 27 May and10th June 2008 09:05 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 Antokol DS0000006883.V365915.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. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Antokol Address Antokol 45 Holbrook Lane Chislehurst Kent BR7 6PE 020 8467 8102 020 8468 7190 antokolhome@btconnect.com 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) Polish Citizens` Committee Housing Association Limited Vacant. Care Home 34 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 34 14th January 2008 Date of last inspection Brief Description of the Service: Antokol is a large detached house built in 1905. It was extended in 1986 and can now provide care to thirty-four elderly Polish people living in this country. The home maintains the Polish traditions, which the residents were accustomed to in their younger days. Stairs and a lift access all areas in the home. All the rooms have wash-hand basins. The bathrooms, shower room and toilets are located on both the ground floor and first floor. Some of these facilities have special adaptations and equipment to meet the needs of the residents. On the ground floor there is a large dining room, two sitting rooms, and a library. The home has Polish satellite TV installed which allows residents to keep updated with vents occurring in Poland. A newly designated quiet room is now operational. Residents may have telephones in their own rooms at their own expense. A pay phone is provided for both incoming and outgoing calls. There is parking to the front of the building and some off street parking available. Staff are provided throughout the day including waking night staff. The fees in this home range between £ 500.00 to £570.00 Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 1 star. This means the people who use this service experience adequate. The inspection site visit was conducted over a one and a half day period. The Manager facilitated the two inspection visits. Periods of observation were undertaken in the sitting areas and over the lunch time period. Prior to the inspection the Manager had completed the AQAA and forwarded this to the CSCI. Comment cards were provided to relatives, staff and residents during the inspection. During the visit the inspector met with a visitor and residents together, several residents and observed staff interaction and engagement with residents. Two residents and one relative returned comment cards. Staff were interviewed as part of the site visit. All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans staff personnel files as well as health and safety records. Feedback was provided to the Manager at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. Within the comments received from one resident and her son was the following “The staff provide unconditional care “. Their overall feedback to the inspector was very positive. What the service does well: The home provides a good level of service to residents in a home which is retained in line with the Polish traditions. The home has close links with the Krakoff religious home and it is through them that religious sisters are provided who work in the home. The religious home also refers a number of staff who are people who are known to them having been involved with the Krakoff religious order in some way. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 6 The presence of the nuns in the home, the chapel and the regular services, provide comfort and support to many of the residents whom are practising Catholics. The home ensures that Polish festivities and celebrations are remembered including celebration of Polish birthdays. Staff were observed to provide care in a kind and compassionate manner .They allowed residents to be as independent as possible without posing any risk to them. Privacy and dignity issues were well addressed. What has improved since the last inspection? What they could do better: The home needs to further develop the current care plans so that it incorporates comprehensive information about the residents on which the staff can base their care. Staff personnel files were without job descriptions, terms and conditions, heath questionnaires or notes taken during the interview process. Staff had some knowledge on those topics selected for questioning although this needs to be further enhanced and training on topics such as MRSA and Clostridium Dificile needs to be undertaken. Terms such as whistle blowing need to be revisited with further input. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Antokol DS0000006883.V365915.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 Antokol DS0000006883.V365915.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): 3. People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service The pre-admissions procedures provide residents with limited information which they require in order to make any decision regarding placement at Antokol, and to establish whether the service is right for them. Staff have little information on which they can confidently assess the needs of the resident, to ensure that they can meet those individuals’ needs, and on which to base an initial care plan. EVIDENCE: At the time of the first site visit there were twenty seven residents in the home which included one resident who was on two weeks respite. The home had no residents who had pressure sores, Clostridium Dificile or MRSA. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 10 The home will need to amend the Statement of Purpose and Service User Guide to reflect the changes in management and the staff personnel so that the information is accurate. It also needs to include the new category for registration which is Dementia to ensure that the information provided truly reflects the service offered. Assessment information of those residents selected for case tracking was inspected. Residents are subject to assessment by senior staff in the home. Of the two files selected one had been admitted April 2008 and the other January 2008 which was around the time of the change in management. In the first file selected the Antokol admission sheet was completed in English. It contained information on previous hobbies, food and drink preferences, medications and presenting problems. On the sheet headed “pre admission assessment”, only the next of kin was indicated and other information was not completed. There was a hospital discharge notification in the file. The Community Care Assessment was not available. These documents only provided basic information about the resident, and it would not give staff enough on which to confidently assess the resident’s suitability for admission to Antokol. In the second file there was some assessment information completed although not comprehensive in content. The placing authority had completed the Community Care Assessment and this contained good information on which staff could form an initial care plan. The placing authority had also confirmed the placement of that resident in the home. In a third file there was a good assessment from the placing authority and a care plan from a pervious nursing home. A hospital letter was also on file. There was an absence of records relating to trial visits, information provided to the resident and/or their family prior to admission and detailed assessment documents including all available information from the multi disciplinary team. Without sufficient pre assessment information it would be difficult to judge whether the resident’s needs could be met by the home and the staff team employed. Residents must be issued with a contract which indicates costs, the room to be occupied and outlines the trial periods and any reason for termination of the placement. Confirmation that the home is able to meet the resident’s needs must be provided by the home, to the resident in writing. Antokol DS0000006883.V365915.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): People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service Residents can be confident that their needs will be met by staff in the home supported by members of the multi disciplinary team in a caring manner. The information in care plans provided limited information to ennable the staff to deliver the care. Without comprehensive information inconsistencies in care and approach does not ensure residents health care needs are meet. Medications were safely managed which provides protection to residents. EVIDENCE: We observed staff delivering care through the first site visit. All care was provided in a friendly, although respectful manner, where privacy was maintained. Staff knocked on residents doors and waited for a response. It was apparent that choice was promoted and independence facilitated with staff support. Staff were seen to meet resident’s needs without hurry, allowing Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 12 resident’s time to engage in the activity. Staff demonstrated a confident manner when delivering care. These observations were supported by resident’s comments and that of a relative interviewed and the GP. There was equipment in use including manual handling aids. The three care plans selected for inspection were those included in the assessment section of this report. Care plans are written in Polish and English. There is a standard format used which provided an outline of needs indicted by way of a tick list and additional comments where appropriate. The care plan documentation covers activities of daily living and includes finances and mental health problems. There was some good information about the resident’s preferences i.e. rising and retiring times, although some sections could be more comprehensive to provide staff with better information on addressing needs. Care plans need to be kept under review to accurately reflect resident’s current needs. The reviews need to detail the progress made or otherwise, in respect of that individual problem, and not simply as current, a review date. Without good records of reviews it would be difficult to establish if the plan of care was actually being effective. One care plan referred to the resident suffering memory loss, however there was a lack of comprehensive interventions for staff to adhere to ensure consistent and appropriate care was provided for this resident. The supporting daily events records were written in English and in this care plan it referred to issues such as wandering, pacing up and down and confusion. The inspector met this resident and all of the above were evident as well as a level of distress which emanated from her level of confusion and whereabouts of her family. More detailed interventions to address these very obvious problems should have been available to staff to enable them to deliver the appropriate care to reduce her distress. In the care plans supporting risk assessments were in place for manual handling and a weight record. The home has good support from members of the multidisciplinary team. There is a medical sheet which lists the visit made by health professionals indicating the date although little else. This should be expanded to include a short summary of the action taken during the visits and any follow up required. The accident book indicated that one resident had had accidents on two subsequent days. In the event that residents are falling or sustaining accidents a risk assessment should be in place to address the issue. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 13 A comment card from the home’s visiting GP indicated that in his opinion the service was excellent. The medication systems were inspected. The medications and drug trolley were safely stored in a clinical room which is kept locked. The medication trolley was well organised, tidy and no over stocking evident. The medication charts were completed with a photograph of the resident and their known allergies recorded. This ensures that the identity of the resident can be confirmed prior to any medication being administered and that staff are alerted to the allergies which they suffer and take appropriate action. Those medications received in to the home were recorded as such. There were some written instructions on the drug charts to alert staff to possible side effects of the drugs in use. Thos medications to be administered “as required“had some instructions although one medication Loperamide needed the instructions to be reviewed. The GP had signed the homely remedies list. Eye drops were dated on opening. Those medications which are controlled drugs were correctly stored with the supporting register. Other documentation included the staff signature list for those who were administering medications and records of the fridge temperature. Within the home there are three residents who self medicate. This was confirmed in writing by the GP and in support the home had conducted a risk assessment to ensure resident were safe and competent to do so. This was also include in the care plans and kept under review. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 and 15. . People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service There are a varied selection of activities provided including those residents who prefer or need individual activities. Choices are provided which means residents are enabled to input into their day. This promotes resident’s independence and enhances individuals’ well being. EVIDENCE: The home has a mix of clients with physical impairment and those suffering from Dementia. It is important with such a cross section of abilities that activities are at an appropriate level to maximise participation and enjoyment. With those residents’ who suffer from Dementia the home should explore activities relating to reminiscence, reality orientation and validation therapy to establish if any of these are suitable to those residents living in Antokol. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 15 Residents were spending time in the garden which is well maintained. Others were in the two lounge areas watching Polish TV whilst others were in their bedrooms. In the lounge there were no jugs of fluids available and although staff were giving out drinks regularly, fluids should be freely available. It is particularly important with elderly residents to ensure that they are hydrated. Visual prompts may help to them to ask for a drink. A selection of daily newspapers in English and Polish are provided, and residents were seen to access these from the library. The home has appointed an activities coordinator to engage residents in more social and leisure interests. We met this gentleman who spoke some English. He confirmed that he was doing daily activities such as exercise, gardening and 1: 1 sessions. On the second site visit the activities co ordinator was observed to be in the garden with several residents. Residents did say that activities were available, although not all of them wished to partake of them. We met with one resident and their son. They had been in the home for almost 25 years. He was positive about the service received and enthusiastic about the staff. Their son who visits regularly, made the following observations and comments. Ha said that he was always made welcome, provided with tea and a meal offered, he was having lunch when the inspector met with him. He acknowledged that the home had changed considerably over the time his mother had been admitted, and previously his father had also been in the home. The home had been originally for retired Polish people former military personnel and such like. He could see that dependency had increased and more confused people were now in the home than previous. However he still felt the “place was unique” and that staff provided “unconditional care “. He had nothing but praise for the staff and the home. This was echoed by his mother. Another comment card indicated good care although included the following “ my father would occasionally enjoy an outing possibly and more procative stimulation would be better ”. The lunch was observed. It was a pleasant affair where residents engaged with one another and assisted with clearing up and generally looking after others. There were good signs of independence choice and well being over this period. The kitchen was immaculately clean. Good quality food supplies were evident. Fresh fruit was available in the dining areas. There were good comments received regarding the food, which is mainly Polish, although other dishes can be requested. The home had been issued with the clean food award up to June 08. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 16 Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 17 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): 16 and 18. . People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service Complaints information is available for residents in a format they can understand. Staff had a basic working knowledge and understanding of adult protection and whistle blowing, more input is required in these areas, to ensure that they take the appropriate course of action should it occur. EVIDENCE: The home has on display the complaints information in both English and Polish. This provides residents, visitors and staff with information that they need to raise any areas of concern. There is a separate complaints form which is used to record complaints, action taken and outcomes. It should be slightly amended to include a statement as to whether the complainant is satisfied with the outcome of the investigation. The complaints file was inspected. It contained 1 complaint for the last twelve months. This had been investigated by the Polish Citizens Committee. The file itself needs to be reviewed and organised. A complaints log should be developed so that a summary of all complaints received is available at a quick glance, and this may highlight any emerging themes. It is important that all complaints, regardless of how trivial or how raised, are recorded so that Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 18 accurate information is available. This would further demonstrate an open approach to such matters. Currently there is one issue which is the subject of Adult Protection procedures. This had been referred by the home after information came to light during a Regulation 26 visit. This is to be commended and provide evidence of transparency in the system. Many of the staff in the home have had adult protection training which had been addressed through external trainers and in their NVQ training. Staff with whom we spoke had a basic knowledge of adult abuse and all knew that cases of suspected or actual abuse should be reported. They were aware of the internal mechanisms although the contact details of external bodies were not known by two of the staff. The term whistle bowing was still not fully understood by the staff who were interviewed. This needs to be addressed. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 19 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): 19 and 26. . People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service The environment is maintained clean and hazard free. Sufficient equipment and facilities are provided to meet resident’s needs. The various communal areas, lift access and specialised equipment all add to benefit resident’s daily lives. EVIDENCE: The home is an adapted building located in a residential part of Chislehurst. Although the home is not purpose built there was evidence of investment in equipment, redecoration, flooring and soft furnishings all of which benefit resident’s lives. The home was clean tidy and odour free on both days of the inspection. There have been improvements made to communal areas with development of Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 20 another quiet lounge area. There are three communal areas in the home including the library and two sitting areas. In addition there is a large dining area. Bedrooms are located over the two floors and there is a lift facility. Bedrooms were personalised and many had items of furniture ornaments and pictures from their previous homes. Some residents have their own telephone lines which enable them to easily contact family and friends. A specialised bath for those residents with mobility problems has been installed and additional equipment was observed to be used. There is a large garden which is well used in the warm weather and seating is provided. Parking is by way of road side and off street parking. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29 and 30. . People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service Staff are provided in sufficient numbers with an appropriate skill mix to meet the resident’s needs. Ancillary and administration staff work to support the care staff. Staff are subject to some recruitment procedures although these are not sufficiently robust to ensure the staff employed are suitable fit and healthy to undertake the job. Staff are provided with training and induction to enable them to undertake the work they perform and provide residents with the support and assistance they need. EVIDENCE: At the time of the first site visit there were five care staff on duty and Mr Nowak. In addition there was an administrator, domestic and ancillary staff also on duty. Staff with whom we meet had an adequate command of English both in terms of understanding and communicating the answers. This is an improvement from previous inspections where there have been no staff except for the Managers and one senior care staff, who could talk to us. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 22 The staff demonstrated an adequate knowledge on all topics they were questioned about, which included adult protection, infection control and dementia. Staff stated that they had received quite a lot of training including the mandatory topics and those specific to the resident population. Training certificates in staff personnel files confirmed this. Staff personnel files were selected for inspection including that of the recently employed handyman. The files themselves were lacking in some of the items required to evidence safe staff recruitment. However all files did contain CRB and POVA first clearance. Passport photographs and checks on the individual’s identity including their national insurance number were retained. References obtained from Poland and in Polish were on file. The Manager confirmed that these were obtained from, where applicable, their last employment. Items which were missing included health clearance, job descriptions, terms and conditions, interview notes and offer letters. The full induction provided should be evidenced to reflect what is included and the period of time it took. More rigorous and robust recruitment procedures need to be in place to afford protection to the residents and the staff member themselves. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 23 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): 31, 33, 35 and38. . People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service The home is managed by an experienced person, who is responsive to residents, relatives and staff. Health and safety servicing and maintenance is addressed to ensure the home is safe for residents. Quality assurance measures are limited therefore give little information on how the service can be improved upon to benefit residents. EVIDENCE: Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 24 The Manager has recently taken up post from another care related facility. He has management experience although not specifically the experience of managing a regulated service such as a care home. In light of this, he has sought to spend time in a neighbouring care service, shadowing the Manager. He has applied through the CSCI to become the registered manager and this application is currently being dealt with through the Central Registration Team. A selection of health and safety service certificates were inspected during the second site visit. There was evidence of regular servicing on gas, portable electrical appliances and the five year electrical wiring as well as the passenger lift. Stickers to hoists indicated that these had been serviced April 2008 confirming that they were safe to use. The records relating to fire procedures were inspected. The fire risk assessment was in place. Weekly fire alarm testing of various points was recorded. Additional information including the location of fire call points and the fire procedure were in the file. All staff cover fire training during induction and fire training is provided thereafter. There were two fire drills recorded January 08 which had no staff signatures and June 08, after the first site visit, which had four staff signatures. All staff need to sign for training provided as confirmation of their attendance. Staff should receive regular updates with the recommendation of four a year for night staff and two a year for day staff. All staff including ancillary, administration and others must be updated annually on fire procedures which must be evidenced. The home has a number of training DVD’s including one for fire. These can be useful but staff also need practical experience of situations. Fire equipment had been serviced and subject to inspection May 08 and the fire panel April 08. The home has automatic door release in the event that the fire alarm sounds. The Deputy Manager had completed a four day first aid course and five other staff a one day course. The Manager should ensure that there is always a staff member with a first aid certificate on each shift including night duty, so that in the event of an accident competent staff are available on duty. Manual handling training had been held two weeks previous for all staff. The home should look to appoint specific staff to act as fire warden’s and health and safety officers to ensure that these issues are addressed thoroughly and competently by staff who are appropriately trained to do so. The employer’s liability insurance certificate was current. Resident’s money was checked and correct. Staff signatures are in place for transactions when residents are not be able to sign this for themselves. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 25 Invoices were seen for items such as chiropody. Individual receipts were retained for other expenditure. There was evidence of large amounts of money that had been retained for individual residents, which was safely retained in the safe. Where possible the home should look to have only small amounts of cash on site as this reduces the risk of theft. The last Regulations 26 report was dated February 2008. These need to be conducted monthly and a report on the findings left. Regulation 26 visits have taken place although reports were not available to evidence such. It was through information obtained from residents during a Regulation 26 visit the shortfalls in practice came to light which is now underway with Adult Protection procedures. This is to be commended. Minutes relating to a residents meeting were in Polish. Staff meetings had been held twice in April and another was planned. More work needs to be done to developed quality assurance mechanisms to ensue that the opinions of residents, staff and relatives are obtained and input into the service provided. An annual review of the service should be undertaken, which includes the views of all stakeholders and whereby they can input into the development of the service. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 26 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 2 X X X 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 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x X 3 Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 27 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. 1 Standard OP3 Regulation 14 Requirement The Manager must ensure that all prospective residents are subject to fully comprehensive assessments, supported by Community Care Assessments and any other information available through the multi disciplinary team. Once assessed as suitable for admission, residents must have this decision confirmed in writing with contracts outlining the terms and conditions of placement. The care plans must be comprehensive in content and fully reflective of needs including physical, psychological and social problems. Staff must be fully conversant with adult protection procedures including external referral agencies and have a working knowledge of whistle blowing. Staff must be issued with terms and conditions, job descriptions and prior to employment satisfy the employer of their health status and capability to fulfil the DS0000006883.V365915.R01.S.doc Timescale for action 30/08/08 2 OP3 14 30/08/08 3 OP7 15 30/08/08 4 OP18 13 30/09/08 5 OP29 19 30/09/08 Antokol Version 5.2 Page 28 6 OP33 24 role that they are employed for Quality assurance measures must be improved upon to incorporate the views of all stakeholders 30/09/08 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 OP12 Good Practice Recommendations The Registered Manager should review the activities provision within the home in light of the varying abilities of the resident population. Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Antokol DS0000006883.V365915.R01.S.doc Version 5.2 Page 30 - 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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