Inspection on 19/01/06 for Archers Point

This inspection was carried out on 19th January 2006.

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 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

Archers Point 05/02/08

Archers Point 25/04/06

Archers Point 21/04/05

Archers Point 07/10/04

Archers Point 16/04/04

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 Archers Point 21 Bickley Road Bromley Kent BR1 2ND Lead Inspector Cheryl Carter Unannounced Inspection 19th January 2006 11:30 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 Archers Point DS0000006884.V278154.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. Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Archers Point Address 21 Bickley Road Bromley Kent BR1 2ND 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 8468 7440 020 8467 3478 Mr Om Parkash Grover Mrs Nirmal Kanta Grover Mrs Nirmal Kanta Grover Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: Archers Point is a large detached three-storey purpose built residential home for the care of the elderly. The home is set back from a busy main road, with some off street parking to the front of the building. The home is within each reach of Bickleys main line station, local shops and public transport. The resident’s accommodation is on the two lower floors accessed by a lift. The owners occupy the third floor. Residents have access to a large garden at the rear of the home. The accommodation offers two lounge areas one with a TV, a dining area and various sitting areas around the home. There are 17 single bedrooms, three double bedrooms and seven rooms that have en-suite facilities. There are grab and hand rails on stairs, in passageways, toilets, showers and bathrooms. Specialised bathing and toilet equipment and lifting aids are available. Central heating is provided to all areas of the home and residents can control the temperature of their own rooms. The radiators and hot pipes are guarded to lessen the risk of accidents. Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by the Lead Inspector and the Regulation Manager, following up on the previous inspection that was done on 28th May 2005 and the additional visit that was carried out 0n 19th July 2005. Time was spent looking at staff files, health and safety issues and meals. A tour of the premises also took place. During this inspection only a selection of the key National Minimum Standards were assessed. What the service does well: 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 contacting your local CSCI office. Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 6 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 Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 A pre-admission assessment is undertaken with potential residents so that they can be sure that the home will suit their needs. The home does not offer intermediate care. EVIDENCE: The home has a Statement of Purpose and a Service User’s Guide but these documents need to be updated. (Req. 1) The pre-admission assessment covers all the needs of the services users and this form the basis for subsequent care planning. The remainder of the standards were covered at the previous inspection and were met. Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Each service user has a care plan that sets out their care needs. There were some discrepancies in the drug administration records. EVIDENCE: The documentation on the service users file had not changed since the last inspection. All communal areas were clean and tidy. The home has recently employed a new cleaner. Service users rooms seen were well decorated and showed that they were personalised. The garden area was colourful and free from hazards. The inspectors were shown the laundry room by the provider. This room was neat and tidy and free from odours. There is now a new washing machine with sluicing facilities has been installed in the laundry room. The registered manager must ensure that where there arend written entries in the drug administration records these must be countersigned by the doctor. (Req. 2) Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 The home does not have a programme of activities for service users. The home serves a balanced diet to service users. EVIDENCE: The home provides activities for the service users, however there need to be a programme of activities tailored to the needs of the service users. The home would benefit from a designated activity organiser. (Recommendation 1) The menus seen showed that there are a varied and balanced meals for service users. The registered manager should publish the menu for the service users daily. (Recommendation 2) Standards 13 and 14 were assessed at the previous inspection and were met. Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The home has a complaints policy. Not all staff have received training in the protection of vulnerable adults. EVIDENCE: There is a complaints policy in place. The complaints book was seen and there were no recorded complaints. The manager said that some staff had received training in adult protection. The registered person shall make arrangements; by training all staff including ancillary staff in the Protection of Vulnerable adults. (Req.3) Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23, 24, 26 The home was free from odours and there have been some improvement in the environment. The home could benefit from some further improvements in the kitchen. EVIDENCE: The registered provider has embarked on a programme of refurbishment in the home, some bedrooms have been redecorated and new carpets fitted. The toilet seats have been replaced and there is now a new washing machine with sluicing facilities. The alarm bell cord need to be adjusted so that it is convenient for service users to use in the case of emergencies. Some attempts have been made to refurbish the kitchen. There is a new oven in place. There now need to be a programme of deep cleaning in the kitchen. The registered person must ensure that all parts of the home are kept clean. (Req.4) The home has plans to phase out the shared rooms, however the registered provider still need to submit the plans to the Commission as to how the work will be carried out with minimum disruption to the service users. Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 12 Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 13 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): 27, 28, 29, 30 The home provides opportunities for training and development, however the recruitment/vetting procedures failed to meet regulations and had the potential to place service users at risk. EVIDENCE: There was evidence of ongoing training and development, which is available to all staff. Four staff members are currently doing Level 2 NVQ and two staff members are doing level 3. Some files did not contain all the required documents. One staff file had only one reference; there was no proof of ID. Not all staff has received Prevention of Vulnerable adult training. Although staff records have improved since the previous inspections, there are still shortfalls and do not meet the requirements. The Registered Person must ensure that all information and documents are obtained in respect of persons working at the care home. (Req. 5) Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 37, 38 Improvements are required in the home’s record keeping so that the home can demonstrate that service users interests are protected. EVIDENCE: The registered provider/manager is currently doing the registered manager’s award training. There should also be a system in place to seek the views of the service users about the day to day running of the home.(Req. 6) The home needs to undertake an effective quality assurance audit that seeks the views of service users, staff, health professionals and relatives about the service provided by the home.(Req. 7)) This would give a better indication as to how satisfied the service users are with the service provided. Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 15 There is room for improvement in the record keeping so that the home can demonstrate that service users interests are protected. The registered person shall ensure that records referred in Schedule 4 are kept up to date.(Req. 8) The fire records indicated that no alarm tests were carried out since November and the records relating to evacuations were vague. The registered provider should take clear written advice from the fire officer regarding evacuation in the case of a fire. The registered provider must take adequate precautions against the risk of fire. (Req. 9) Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 16 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 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 x 3 3 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x x 2 2 Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 6 Requirement Timescale for action 15/03/06 2. OP9 13 3. OP18 13.6 The Registered Person must ensure that the Statement of Purpose and Service User Guide is updated to include all the areas specified in the Regulation The registered Person must 15/03/06 ensure that all handwritten entries on the medicine chat is countersigned by the GP The registered person shall make 15/03/06 arrangements; by training all staff including ancillary staff in the Protection of vulnerable adults. The registered person must ensure that all parts of the home are kept clean. The Registered Person must ensure that all information and documents are obtained in respect of persons working at the care home. The Registered person must ensure that the views of residents be sought with regards to the day to day running of the home. . The Registered person must DS0000006884.V278154.R01.S.doc 4. 5. OP26 OP29 23 (2d) Sch2 15/03/06 15/03/06 6. OP33 21 15/03/06 7. OP 33 24.1 a, b 15/03/06 Page 18 Archers Point Version 5.1 8. 9. OP37 OP38 17.3 23. 4 a,b,c,d ensure that a quality assurance programme is in place using a verifiable tool and produces an annual development plan which is open for inspection. The registered person shall ensure that records referred in Schedule 4 are kept up to date The registered provider must take adequate precautions against the risk of fire. 15/03/06 15/03/06 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. 2 Refer to Standard OP12 OP15 Good Practice Recommendations The Registered Provider should have a daily programme of activities for Service Users that is interesting and stimulating. The registered manager should publish the menu for the service users daily Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Archers Point DS0000006884.V278154.R01.S.doc Version 5.1 Page 20 - 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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