Inspection on 18/09/07 for Antokol

This inspection was carried out on 18th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Antokol 10/06/08

Antokol 14/01/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Antokol Antokol 45 Holbrook Lane Chislehurst Kent BR7 6PE Lead Inspector Key Unannounced Inspection 18th September 2007 10:10 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.V342676.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.V342676.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 Ms Alina Gaskin Care Home 34 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (32) of places Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 places registered for service user category DE(E) relate to named service users only. 10th August 2006 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, a sitting room with a library, and a separate lounge, which has Polish satellite TV.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.V342676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced over a one day period by one inspector. The inspection was facilitated by the Manager Alina Gaskin and her Deputy. The inspector toured the premises including communal areas and individual bedrooms. During the tour the inspector met with and spoke to residents with whom she could converse, many residents in this home do not speak English hence this was limited. At the time of the inspection there were only three staff that could speak English, the two Managers and a senior care worker all of whom the inspector had met with previously. To obtain information from staff who could not converse with the inspector, staff surveys were provided to them. These were handed out and staff asked to get assistance from friends or family in completing them. There were no relatives in visiting or health professionals although surveys were left for them to complete. The inspector sampled two care plans and the supporting documentation including that obtained prior to admission for assessment purposes. The medication systems including storage and record keeping were inspected. A selection of health and safety, service certificates as well as quality assurance audits were also inspected. Over all the level of care residents receive is good and this is enhanced by the staff and ethos of the home being fully reflective of their origins. This was confirmed by the feedback during the site visit and the surveys returned. However there are areas relating to recruitment and training of staff that compromise the safety for residents. In some areas there needs to be improvement which are further detailed in the body of this report. What the service does well: The service provides a good level of care for the residents who reside there. Equipment is provided and the home engages with specialist services to promote resident care. Feedback from health professionals related to improvement in resident’s physical health whilst living in Antokol and that they have a professional relationship with the staff. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 6 The residents are encouraged to participate in the home and do so. They are often involved in light domestic chores, which they enjoy. There is a large garden, which is used by several of the residents. The Polish ethos running throughout the home enables residents to settle well in the unfamiliar surrounding. It was evident that residents have choice in their day and exercise their preferences. The home enables residents to maintain a level of independence within a supportive environment without fostering dependency. The home although not purpose built is maintained in a clean tidy and hazard free manner. Bedrooms were personalised What has improved since the last inspection? What they could do better: The home recruits Polish speaking staff to maintain the ethos of the home and this is positive for residents, however this can present difficulties. The are limited numbers of staff who are able to comprehend and converse in English and this poses a problem when dealing with members of the multi-disciplinary team, documentation and attendance of courses. As not all of the policies and procedures are translated into Polish, staff who cannot read English would be unable to freely access them or understand them, without an interrupter, and this in turn limits their knowledge base. It was evident that in one file there was no evidence of POVA or CRB clearance prior to employment. Induction was limited and did not cover the basic information required to conduct the work. Fire training for some staff was overdue. The Registered Manager must ensure that staff are subject to robust recruitment procedures including CRB, POVA and fully completed application Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 7 forms with supporting references are in place prior to employment. This is now outstanding and enforcement action is being considered. All staff must be provided with sufficient training to undertake the work they do and all staff must be provided with mandatory training at appropriate intervals. This is now outstanding and enforcement action is being considered. The Registered Manager must ensure that all staff are aware of adult protection and whistle blowing procedures including reporting to external bodies. 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.V342676.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.V342676.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home seeks out information regarding the prospective residents prior to admission. Once admitted to the home a fuller assessment is conducted to ensure that the residents needs can be met. EVIDENCE: Since the last inspection the home has applied to vary their registration and this has been approved by the CSCI registration team .The home is now able to admit residents who suffer from dementia this was confirmed in a letter dated 22/6/07 from Central Registration Team at the CSCI. The Statement of Purpose has been amended to incorporate this change. Another proposed change will be the reduction in beds from 34 down to32 when double bedrooms become single occupancy. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 10 The inspector sampled admission procedures for two residents in the home. The two residents case tracked, included a new admission and a lady who was seen in her bedroom. She was quite dependent physically. In the first file inspected there was information received prior to admission including a pre assessment dated 3/7/07. The Manager advised the inspector that she did not go herself to see residents, as this was, in her opinion, a fruitless exercise. She preferred to have residents came to the home for assessment as it provided more information and gave a better indication of their needs and presentation. All residents are subject to a trail period of four weeks, which allows time for a fuller assessment and to see if, the resident settles. Prior to admission, and during the initial contact stage, residents are sent out a Statement of Purpose and Service Users Guide. The first resident case tracked was actually a friend of one of the Management Committee hence his referral. The inspector was advised that this resident had been made fully aware of Antokol and the care that it provided. This resident had been in another care home previously and there was comprehensive information obtained from them. The activities of daily living assessment provided information on medial problems including risk assessments specific to identified needs. The Social Services had provided their assessment and this included good information. The panel information in respect of the placement discussion and decision was available. The inspector was unable to locate the Terms and Conditions or the Contract issued to the resident although was advised that these were issued to every resident. Confirmation of placement is after the trail period of four weeks. In the second file inspected, this resident been admitted 2004 and there was limited information relating to the original assessments. There was an admission checklist, which indicated completion of relevant documentation on admission. Trial visits and overnights stays are offered should the resident wish to partake of this service. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health care in this home is well catered for both from the staff themselves and support from the multidisciplinary team. Medications are well managed although staff need to be extra vigilant to ensure that individual residents medications are safely stored. EVIDENCE: Two care plans were inspected including the latest admission. The first resident who was part of the case tracking met with the inspector although this gentleman was unable to speak English hence there was little to be gained from the conversation although signs of well being were noticeable. The care plans were well organised and contained a clear photograph of the resident. The care plans and supporting risk assessments were written in Polish and English although the daily events were in Polish only .The care plan indicated the resident suffered from short term memory loss. The resident’s areas of need, including the support and care that he required, were identified Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 12 within a standard care plan format dated 28/7/07. There was a specific care plan for Dementia although this could have been expanded upon especially in the interventions section. There were risk assessments in respect of those areas identified. There was a falls screening tool and his weight was recorded. In the second care plan there was again a standard care plan with areas of need outlined and interventions detailed. Risk assessments including those for manual handling were in place. The inspector recommended in those residents where there are nutrition issues or skin integrity problems identified, specific risk assessments are in place and kept under review. Within the AQAA- the home stated that nutrition risk assessment were in place although not with in the files sampled. In addition, those residents requiring cot side should be subject to a comprehensive review which sets out the need pro’s and con’s of applying cot sides. The home undertakes review of care plans although these are limited and they have identified that these need to be more comprehensive in content. Within the second file was sheet headed “ Significant Life Events “which provide a good background on the resident. The health professional sheet indicted attendance by the GP, District Nurse Chiropodist and Optician. The home has recently changed the chiropodist to a cheaper service. The home should have in place an aid memoir to ensure that residents have regular health care checks and that staff are made aware of these. As the inspector toured she entered a room where the residents was sleeping in her chair. The inspector noted that on top of the table there was a box of codrydomol, which had an expiry date of 06/06. Although this was located in the bedroom, and the resident was present, it was not securely stored and was out of date. There were other tablets in a bottle without a label and a bottle of Oraldene which had expired 08/05.This was related to the Manager who secured them immediately, adding that the family members brought medications in usually purchased in Poland hence it is the resident’s own property. Staff must be alerted to this and ensure that if medications are brought in then these are made safe. In the event that these are to be self administered, them a risk assessment including this decision must be in place and kept under review. The inspector went through medications with one of the English speaking staff on duty. This staff member was NVQ level 2 trained .The inspector had met with this staff member previously. The medications are now supplied through a new company. Prior to the change over to the new supplier all staff had received medication training from the new supplier. The medication system in operation is the Monitored Dose System and medication administration records Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 13 (MAR) sheets are supplied. A new medication trolley has been supplied. The medication trolley was clean and tidy with no over stocking noted. The MAR charts were well completed with no gaps evident. Allergies were recorded on the charts although on some, namely those residents who did not suffer allergies, the statement “ none known” was omitted. The inspector did however see the previous charts where this was recorded. Clear photographs of the residents were attached. Those eye drops in use had the date of opening entered .At the time of the inspection there were no residents on controlled drugs. There were two residents in the home who self administer their own mediations. These residents are issued with a cassette on a weekly basis. Confirmation of this was obtained by the GP, and secure storage is supplied in bedrooms. Staff monitor compliance by observation and checks. This is an area where risk assessments should be documented and kept under review Those medications to be administered “ when required “, need to have the reason indicated. There are seven staff that administer medications and a signature list was on site. In the last twelve months two staff have completed certified medication training .The fridge temperatures were recorded daily. Those medications, which are not required, are returned to the pharmacist with records and the receiving pharmacist signs this. It was evident throughout the home that specialist equipment was in place and used appropriately, this included four specialist beds. Those residents who were in bed had call bells and fluids to hand. Staff were observed to knock on doors before entering. Prior to the site visit the inspector had received good feedback regarding the care of one resident who was admitted to the home. The Care Manager was quoted as saying “ the care she is receiving is holistic and satisfactory “ and went on to say her condition had improved whilst in Antokol. Favourable comments were also received from the optician regarding the standard of care and staff working in the home. Antokol DS0000006883.V342676.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have choice in their day and independence is promoted. The home needs to ensure that there are enough varied activities available to provide stimulation and entertainment to all residents in the home. This is particularly important with Dementia residents who are less inclined to initiate activities. EVIDENCE: Residents in the lounge areas were noted to be sleepy during the morning tour. The TV was playing –however there were few watching it. The home provides Polish TV and newspapers for the residents. English newspapers and a library are also provided. In addition, a new quiet area has been developed which was very pleasant and offered residents choice in where they spend their time. The home has identified within their own AQAA assessment, that there is a need to provide more varied activities, this should be investigated. The home Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 15 should look into group and 1: 1 activities that are beneficial with Dementia residents. There are plans to replace the TV aerials, as the reception is sometimes poor. Those residents with whom the inspector was able to converse – as not all of them could do so, Polish being their only language, were satisfied with the care. In bedroom 34, the resident was bed bound, this room was particularly pleasant, light and airy, and this made her stay more comfortable. She was very satisfied with the standard of the accommodation provided. In addition there was a specialist bed and a hoist in use. Just before lunch an armchair exercise group took place in the lounge by one of the visitors who comes in regularly. Residents were observed to assist with table laying and clearing up after the meal, which is something that they enjoy. The home has a chapel service every Friday and Sunday and on request at 3pm daily. The home has two cats, which many of the residents have in their bedrooms for periods of time. This was something which they enjoyed as several had had pets prior to admission. The food served in the home is traditional Polish food. Great efforts are made to obtain the original ingredients required for specific dishes. The food is prepared on site all homemade. The food is something which residents enjoy and mealtimes serves as an opportunity for residents to engage with one another. Mealtimes can be flexible to meet the resident’s needs. Drinks and food are provided on demand. Fresh fruit, biscuits and drinks were all readily available on the day of the site visit .The home was awarded the Clean Food Award April 07. Please see recommendation 1. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information is provided to residents and relatives on how to make a complaint and external avenues to pursue this if they are dissatisfied with the outcome. One staff member was unfamiliar with the term whistle blowing or what do should the situation occur. In addition there was limited information which staff could use, namely available in Polish, to action or refer adult protection matters. EVIDENCE: The complaints procedure was on display and available within the Statement of Purpose. The policy on display was in both the English and Polish language. There is a complaints policy, which specifies response times for complaints. In the complaints file there was the information in relation to one complaint received July 2006, nil since. There was information about the complaint the action taken and a statement on the outcome, although this did not specifically state whether the complainant was satisfied with the outcome. This should be clearly stated. The CSCI have received one letter of compliant that has been passed to the responsible individual for a response. The response was received after the site visit hence not discussed. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 17 The only staff member, other than the Managers, to meet with the inspector had a working knowledge in relation to dealing with complaints and suspected abuse. She had a very limited knowledge of whistle blowing and was unable to provide the inspector with any information. Not all staff are aware of adult protection and whistle blowing procedures and as this has been ongoing since September 2006, enforcement action is being considered. The information in respect of Interagency Working for adult protection issues had not yet been translated in to Polish, hence those staff that could not speak English, would be unable to follow the guidance. All information, which staff need to use, including the policies and procures must be accessible and useable for staff. The home has purchased a training video in relation to adult protection and training on this subject has improved, however the inspector was unable to test this due to language barriers. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is an adapted building maintained in a domestic manner although there are parts which require updating and upgrading .All areas were clean, tidy and hazard free which is beneficial for residents to live in. EVIDENCE: The home has benefited from new carpets in some areas and redecoration. The are currently awaiting quotes from companies to replace or repair the windows as these are in need of attention. Additional lighting has been provided on the ground floor. Wheelchair ramps have been provided to the front and the garden exit to the home. The garden has had additional fencing to replace the old one. The garden is a large pleasant area, which many of the residents enjoy in the warmer weather. This had been the venue for a garden party earlier this year. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 19 The home was clean and tidy throughout. The home was hazard free and equipment safely stored. Bedrooms were personalised and several of the residents stated they preferred to spend time in them. Bedroom 38 has been enlarged to provide a better standard of accommodation. This reconfiguration is proposed for bedroom 32 as well. In the three outlets tested the hot water was running cool. The dining area and the kitchen have undergone extensive refurbishment on the last two years and are very pleasant. The dining area is particularly spacious and allows resident to move freely between tables even with mobility aids. Bathrooms are in need of refurbishing and this underway. The home has just had a quote for a new bath to be installed on the top floor. Within the next twelve months the plans are to provide two new refurbished bathrooms and install an assisted bath. In relation to the new registration category, by which the home can admit residents who suffer Dementia, it is essential that the environment is geared to these people ensuring safety and orientation are addressed within a domestic setting. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet resident needs. Staff are subject to recruitment procedure although the inspector was unable to test these as the information was in Polish. Induction was not fully completed which introduces an element of risk to residents. Staff must be provided with terms and conditions, job descriptions and contracts available in a manner that they can understand. EVIDENCE: On the day of the inspection there were three staff that were English speaking including the Manager and her Deputy. The inspector sent time with all three, although it was difficult to obtain information from those staff who did not speak English and therefore difficult to establish their level of knowledge on topics. In the absence of staff interview the inspector gave out staff questionnaires asking them to complete when they could using other people to translate if required. The senior care assistant was interviewed .She confirmed that she had completed NVQ level 2 and had been in post thirteen years on day duty. The training, which she had received in the last year, included a two day first aid course, fire and manual handling. She also stated that she had attended Basic food hygiene, infection control and abuse although was unclear of the dates. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 21 On speaking with this staff she had a working knowledge of MRSA and the precautions to take although she was unclear about the term Clostridium Dificile. After the site visit, the inspector provided information to the home relating to this subject. This staff member was unable to provide any information in relation to Dementia. As the home is now able to admit residents with Dementia it is essential that all staff are familiar with the presentation of the disease and the specific care that these residents require. Staff need to be fully aware of the implications and problems around Dementia including memory loss, communication difficulties and disorientation Two newly appointed staff files were selected for inspection. Both were Polish staff and both worked in the kitchen. The information in the personnel files was in the main written in Polish therefore the inspector required the assistance of the Manager to translate. In the first file there was an application form, which detailed the applicant’s work history and education. Should there be gaps in the information provided, then these are explored at interview by the Manager. The references again were in Polish hand written. The Manager via a telephone call or e- mail communication confirms references. There was confirmation of the employee’s identity including her Polish ID card. The inspector could not locate the POVA check or CRB although there was said to be a Polish CRB clearance. The Manager stated that as this staff was a kitchen assistant, and she would always be working under supervision and never be alone with residents. There was a “ Statement of Particulars” included in the file which outlined terms and conditions. The job description was issued, although this was in English, this staff member could not understand or read English. This needs to be addressed. This staff member had been employed since 13 August 2007. There was a record of the in house induction that the employee had undertaken, although only two areas were covered, an introduction to Antokol, and fire safety. The other statutory topics had not been addressed including basic food hygiene, which is essential when working in the kitchen. The second personnel file was that of an employee who had started 22/7/07.There was the staff member’ s photograph, application form and the Statement of Particulars in place. Two references were available including one with an official stamp; the other was as in the previous file, hand written. There was evidence of CRB and POVA clearance. Her induction included statutory topics and those relating to working in the kitchen. Supervision was poorly addressed and this needs to be improved upon, again this is something which the home themselves had identified as a short fall. The inspector was advised that only new staff have been issued with terms and conditions whilst existing staff are still without these. This was said to include Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 22 the two Managers. This has been the subject of much dialogue between staff, the CSCI and the Polish Citizens Committee and must be addressed. The home has signed up to become a member of The Bromley Care Homes Training Consortium. This is a forum which provides regular and relevant training to care home staff .The lack of English speaking staff can be a barrier and prevent them participating in external training courses. Internal training courses are provided for the non English speaking staff however this cannot address all training issues and is time consuming. Of the care staff team, 50 have completed or are working towards completing NVQ level 2. Failure to obtain up to date CRB checks on new staff and to ensure that staff have undergone mandatory training in respect of fire training are ongoing issues so enforcement action is being considered. Please see requirement 1. Antokol DS0000006883.V342676.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced and trained individual who understands the day-to-day operation of the home. Health and safety measure are in place to maintain the environment safely for residents. Quality assurance measures are in place although these need to incorporate the view of the residents staff and all stakeholders involved with the home. EVIDENCE: The Manager of the home has successfully completed the RMA and NVQ level 4 training. The CSCI have conducted the fit person procedures and confirmed her ability to manage the home. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 24 The home is a member of The National Care Homes Association, which is a body that works with care homes producing relevant information, guidance and advise. The inspector sampled a number of health and safety records. There were a number of manuals relating to health and safety in care homes, several were the National Care Homes Association publications. The home has a general risk assessment, which covers the building itself, and other services such as the water and lighting. Hazard risk assessments were in place for the kitchen. This had been conducted June 07. In addition, the home had commissioned an occupational therapist to assess the building, this was conducted January 06. The inspector saw certificates for the lifting equipment six monthly checks under the LOLER regulations. The lift service and five year electrical inspection were deemed satisfactory November 06. The fire procedure training and servicing of equipment documentation were all inspected. There was information on the location of fire equipment. There were records on fire safety training for all new staff as well as a list of employee’s issued with fire instructions. From the information provided eight staff had needed annual fire training due August 07,this had not been addressed. Staff must be trained and regularly updated on all mandatory topics including fire training. Fire equipment had been inspected January 07 and June 07. Fire drills had been conducted twice in 2007. There records were without the staff signatures of those who attended nor residents or visitors. The nurse call is checked regularly by staff. The annual gas service had been conducted May 07 although no certificate received. The employers liability insurance was on display and valid. The day of the inspection an AGM of the committee was due to take place although neither of the Managers are invited to attend this. It is questionable how much information the committee would have on the day to day operation of the home without either of the Manager present. On raising this with Mr Lish he advised the inspector that input was obtained from a very involved committee member who frequently visits the home. Regulation 26 visits are undertaken infrequently and these must be conducted unannounced monthly and a report on the findings left. There were said to be few of these visits undertaken and therefore few reports. Other quality assurance measures included a resident’s questionnaire conducted August 07, of the twenty sent out, fifteen responses were received. Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 25 A table of responses had been devised and overall the responses were positive. Other audits, which have been conducted, include care plans July 07, bedroom inspection February 07,and food August 07. All of these audits had an allocated section for corrective action to be recorded. The two residents who were included in the case tracking were sampled for financial checks to be undertaken. The resident’s monies were checked and found to be correct although they were without two staff signatures to confirm the transaction or that of the resident .One initial only was in place as the only indication of the transaction. This needs to be addressed especially where the home has residents who are not able to comprehend this type of information. Please see requirements 2 and 3. Antokol DS0000006883.V342676.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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 x X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 30 X 2 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 2 2 2 X 2 Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 27 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 OP30 Regulation 18 Requirement The Registered Manager must ensure that staff are provided with induction suitable to the work they undertake. The Registered Manager must ensure that all records and transactions relating to residents monies are properly accounted for and signed to that effect. The Registered Manager must ensure that all health and safety issues are addressed including staff training. Timescale for action 30/12/07 2 OP35 17 30/12/07 3 OP38 23 30/12/07 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. OP12 Antokol Refer to Standard Good Practice Recommendations The Registered Manager should review the activities provision within the home. DS0000006883.V342676.R01.S.doc Version 5.2 Page 28 Antokol DS0000006883.V342676.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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.V342676.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. 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