Inspection on 18/05/09 for Arden Lodge

This inspection was carried out on 18th May 2009.

CQC found this care home to be providing an Adequate service.

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

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Arden Lodge 946 Warwick Road Acocks Green Birmingham West Midlands B27 6QG Lead Inspector Jill Brown Key Unannounced Inspection 18th May 2009 08:30 DS0000072992.V375827.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. DS0000072992.V375827.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address DS0000072992.V375827.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Arden Lodge Address 946 Warwick Road Acocks Green Birmingham West Midlands B27 6QG 0121 706 7958 0121 706 7958 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) Lindale Homes Ltd Manager post vacant Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places DS0000072992.V375827.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category 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 with in any other category (OP) 33 The maximum number of service users to be accommodated is 33 2. Date of last inspection New service Brief Description of the Service: Arden lodge is a 33-bedded care home for older people. At the time of the inspection Arden lodge was limited to taking only 25 residents. The residents’ accommodation on the 2nd floor is currently not in use as it is amidst refurbishment and there is no acceptable fire escape route. Arden Lodge is situated on the Warwick Road, a short distance from the centre of Acocks Green, where there are a range of facilities including shops and recreational facilities. The home is on a main bus route and is well served by public transport. The home has single and shared bedrooms with en suites over the two floors in use. The home has a passenger lift. There are two assisted bathrooms (one with an assisted shower in as well as an assisted bath) and an assisted shower facility on the first two floors. There is a lounge with dining space to the rear. The home has a garden that is accessible to residents. The home is currently being refurbished and newly refurbished bedrooms have new furniture, good en suites, televisions and call alarm services. The fees for home were about to change but for last year up until 31 March 2009 the home charged between £326-69 and £359-98. People placed by Birmingham City Council did not have to find a top up. There were extra charges for hairdressing and chiropody services where these are wanted. DS0000072992.V375827.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We visited the home without notice on a day in May 2009 and undertook a key inspection where we looked at the majority of the National Minimum Standards. This our first visit to this home Arden Lodge. Prior to November 2008 this building housed a home, Hillcrest, which had been assessed as a poor service. The home gave us information in an Annual Quality Assurance Assessment (AQAA) before the key inspection. The AQAA shows how the home rates their performance in the areas set out in this report and how they intend to make improvements. During the inspection 2 peoples care was case tracked, this involves looking at all the records about this people and how the home manages their care. We looked at another 2 peoples care records. We spoke to all of these people and 5 others. We spoke to 2 relatives and a health professional during the inspection. We looked at the homes medication records. We looked around parts of the building and viewed the health and safety checks that had been undertaken. We spoke to the acting manager, the responsible person on behalf of the company and the owner. We sent out comment cards and received 6 completed by people that live in the home and 3 from relatives. We have received no complaints about the home since it became Arden Lodge. Information about all of the above is contained in this report. What the service does well: People living at the home have an increasing number of activities and entertainments and more are planned. Currently there are visits from Motivation and Co once a week and Progressive Mobility monthly, newspapers are delivered, there is sky sports available and a member of staff has been trained in sports massage. People are able to stay in their rooms or join other people in the lounge. DS0000072992.V375827.R01.S.doc Version 5.2 Page 6 People said that the food was good. We found that people had breakfast as soon as they were ready in a morning so some people had breakfasts early others much later. People had a choice of hot food at every meal and snacks were available as wanted. People said:Food its very nice. Food is better than it was. The foods lovely. There are good contacts with health and new people have access to health services. A health professional said:The staff are more responsive, overall staff report if they have concerns and do what is asked of them. Relatives were happy with their contacts with staff, management and owners and said: the staff are very friendly and caring. The new owner has done a lot of work to make it brighter, He (the new owner) is clear about the standard of service he expects to be given. He (the new owner) is very friendly. What has improved since the last inspection? This a newly owned service and usually we would not at the first inspection be looking at improvements. However the owner and management have had to work very hard having taken over a poor service to set up new systems and improve the environment. The home has now standardised forms to record assessments and care planning and this assists staff to find information quickly. People living in the home and relatives spoken to on the day of the inspection said that the service was improving. The home has made and is making substantial improvements to the environment. The most notable are:The home has a new central heating boiler. A person said The building is warm all the time now I used to get cold. There is a new call alarm which records when the call was answered and this helps the management ensure that people get a good service. A number of bedroom and en suites have been stripped to the brick, replastered and had new equipment and furniture. A relative said The home is being systematically refurbished. This is being achieved without major upheaval or inconvenience to residents, the new management has brought a breath of fresh air to a dated establishment which is already looking brighter and more up to date. DS0000072992.V375827.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. DS0000072992.V375827.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 DS0000072992.V375827.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3, People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is information available to people about the intention of what the service will be but this is not quite in place in all areas and this could lead to some people being disappointed in the short term. Information collected about people in some cases was enough to ensure that good plans of care could be put into place for others more information was needed. This could lead to peoples needs not being met. EVIDENCE: We looked at the admission process for two people and found the amount of information given to and collected about people before they were admitted varied. The home had a place to record whether the homes complaint DS0000072992.V375827.R01.S.doc Version 5.2 Page 10 procedure, contract and service user guide had been given but this was left blank. The home has a Statement of Service that is in draft form and some amendments were needed to ensure that it contains all the information required and reflects the service for all people in the home at the moment. It would be useful to consider how this can be organised so as the facilities change it can be updated easily. Both people were given the homes contract however this contract was for supported living that the organisation also runs and this gave wrong information such as people living in the home have to sign the timesheets for staff. However people case tracked had the protection of a three-way agreement between the home, social services and the person. Information collected about people contained details about peoples health conditions and personal care needs. There were places to record information about peoples life history, lifestyle and daily living preferences. This was completed well on one assessment and not so well on another. This information helps the service write plans of care that tell staff how to meet peoples needs in a way that they would wish. For example information collected on one persons files stated a preference for certain type of soap, drinks they do not like and favourite meals. These small adjustments to care can make living in a home more acceptable for a person. One person stated that they were at the home for a few weeks deciding if this home would suit them. People having a trial stay at the home helps them decide if the home would suit them. DS0000072992.V375827.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst care planning is improving there are some gaps which can mean that people will not get their needs met. People in this home have the benefit of good referrals to health professionals and this means health care needs are met. Medication was no consistently administered and this means that peoples health could be affected. EVIDENCE: Since the new owners have taken over the home they have tried to standardise the paperwork available and put systems in place so information can be found more easily. This has meant that all the people in the home have new care plans. Care plans have been written using existing information and this means that they are not detailed enough to give person centred care. Care DS0000072992.V375827.R01.S.doc Version 5.2 Page 12 plans have not been signed and dated and have some gaps. For example not all of peoples health conditions, such as gout result in a care plan and information about activities are not always transferred from the assessment to the care plan. This could lead to peoples needs not being met. However in some areas plans have good information such as the plans covering challenging behaviour. These plans include information about how to talk to the person, how to respond to behaviour and what to report and record and this helps to determine whether peoples behaviours are increasing and whether specialist help is required. The management gave assurances that new people coming into the home will have more detailed plans and that existing peoples plans will be renewed at the point of review. We spoke to a health professional about their contact with the service and how the home has worked with them in the care of a number of people. They said The home has improved. It has started to look much better. The staff are more responsive, overall staff report if they have concerns and do what is asked of them. We found on the day of the inspection the manager requesting advice about a persons condition from the district nurse. Records seen suggested that for skin care the home was doing as requested by the health professionals and recording their actions, resulting in an improvement in a persons skin condition. People have risk assessments in place for ensuring peoples skin remains healthy, nutrition, falls and moving and handling. This ensures risks identified can be lessened. We found for one person that has a large number of falls that they had been referred to the falls clinic, an assessment of the time of falls had been undertaken and plans were being put into place to try and minimise the effects of these falls. People had been referred to the speech and language therapist to ensure good nutrition. People were weighed on a monthly basis however the day and time of the being weighed is not always recorded and this means an assessment can not always be made of the severity of a weight loss or gain. The manager stated that sit on scales had been ordered and this will make the weighing of people easier. People had access to GPs, dentists, opticians and chiropodists routinely and when needed. This helps to maintain peoples health. New people admitted to the home are asked about their contacts with these services and where they had not seen them for some time referrals were made. Care plans record what medications people are on but not what these are for, and whether any foods or drinks react with them. This information is useful for care staff assisting people with their medication. The manager had a good DS0000072992.V375827.R01.S.doc Version 5.2 Page 13 knowledge of medications and what they were for. A signature sheet for staff was not in place so that initials used on the Medication Administration Record (MAR) can be identified. Not all medications were signed as being correct when they were brought into the home this means that the home cannot be assured that they have received the right amount of medication in all cases. For one person a medication was not given as prescribed and as confirmed by a health professional and this could lead to the person being unwell. One medication was signed for and not given. One person did not receive their morning medications as prescribed, no effort was made to determine if some of the medications could be given later, no consultation was made with the manager about whether this could be resolved. The home has a controlled drug cabinet this has yet to be fixed to the wall to ensure that medication is kept safe. Controlled drugs were all accounted for against the controlled drug register and the MAR. People appeared to be treated with respect and talked to in a kind and friendly manner. The new owners have not had keys available to give to individuals for bedrooms. As the home is being refurbished this matter is being addressed. We spoke to some people that share a room and they assured us that this was their choice. Screening needs to be available in all shared rooms to ensure that peoples privacy and dignity can be maintained. DS0000072992.V375827.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in this home have a range of activities and there are plans to improve on these including outings. Activities assist people in maintaining an interest in the world around them. Peoples visitors are made welcome and this helps to maintain peoples relationships. People had access to good, nutritious food at all reasonable times and this helps to ensure that people are kept well. EVIDENCE: People living in the home have varying ability to initiate activities for themselves. Some people go out during the day visiting with friends or going shopping, the majority however stay in the home. Some people enjoy knitting or reading and the owner has arranged for newspapers to be delivered to the home on a daily basis. A number of people enjoy watching sport and the owner has arranged for sky sports to be available to them. People spoken to had DS0000072992.V375827.R01.S.doc Version 5.2 Page 15 been asked about activities and were waiting for arrangements for some trips out; these hadnt yet been organised. The gardens had been cleared of discarded items and now were safer for people to spend some time out of doors. The home organises a person who has training in massage to attend the home and people are offered massages of hands or painful areas. One person said I had my knee massaged and it felt better. Some people had activities mentioned in their assessments that were not in their care plans and this could lead to these interests being lost. A motivation entertainer attends the home weekly and Progressive Mobility comes in monthly. Plans were being made for other entertainers to come in the home. Where people had recorded that they wanted to maintain their religious beliefs efforts were made to assist people with this. There were no undue restrictions on visitors. We spoke to 2 relatives during the inspection and they could see improvements in the home. They said the staff are very friendly and caring. The new owner has done a lot of work to make it brighter, he is clear about the standard of service he expects to be given. He is very friendly. People can move around the home as they want, spend time in their rooms or in the lounge if they wish. Peoples movements are not unduly restricted. People spoken to thought they could get up and go to bed when they wanted. The dining area was set up with tablecloths, napkins and menus. A person living in the home said There are now beautiful table cloths. The menus suggested that people had a wide choice of breakfast of cereals, toast, bread and butter and preserves, pancakes, bacon, sausage, egg beans and tomatoes with a selection of fruit juices. We saw people availing themselves of these choices. People were given their breakfast shortly after they arrived in the dining room allowing people to have an early or later breakfast. There was a bowl of fruit on the table. Menus on the table and people spoken to confirmed there was a choice of lunch meal and a hot option of food was available at teatime as well as sandwiches. The menus stated that snacks were available throughout the day these included yoghurts, biscuits, cheese and crackers, fresh fruit and cakes. People said about the food provided I always have cornflakes with cold milk and toast, I dont like a cooked breakfast. The foods lovely. Had bacon and sausage sandwich for breakfast. My relative became very thin but has put on weight. You cant say anything wrong about the food its very nice. Food is better than it was. The staff look after my relative well she enjoys the menu options and the food standard. Food is not always to (my relatives) liking but may be due to (their) general poor appetite. DS0000072992.V375827.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are protected by management that ensure that issues of concern are referred to the appropriate agencies. People using the service have good relationships with the staff and management and this means they feel able to raise any concerns. EVIDENCE: We have received no complaints about this service and the home has not had any complaints. The people we talked to were happy about the service and knew who to talk to about their concerns. We are aware that a number of issues were raised by the new owner about the management of the home prior to and immediately after it being taken over. This resulted in the then registered manager being dismissed. Some of these issues are resulting in independent legal action. The home has advised us of any issues where people have required safeguarding due to actions of other people in the home or where the person has put themselves at risk. We have confirmed with other agencies that they have been informed and this meets the expected standard. DS0000072992.V375827.R01.S.doc Version 5.2 Page 17 People are recruited appropriately having checks to ensure they are safe to work with vulnerable people. DS0000072992.V375827.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service have the benefit of an improving environment. Although all areas are not yet up to standard substantial progress has been made. EVIDENCE: Before the home was taken over we were very concerned about the standard of the accommodation offered to people in this home. The new service has been in operation for 5 months and has made great strides in improving the environment. The home has a new central heating boiler a person said The building is warm all the time now I used to get cold. There is a new wireless call alarm system, which is more reliable and allows the furniture in the bedroom to be moved to suit the person. This alarm also has a facility to record when a call has been made and when it was answered. DS0000072992.V375827.R01.S.doc Version 5.2 Page 19 Areas of the home have been decorated such as the front hall on temporary basis until the full restyling of the home is completed. Other areas such as a number of individual bedrooms and the assisted bathroom on the first floor have been completely stripped to the brick, re-plastered, and restyled to a high specification. We spoke to two people who have these finished bedrooms and they are very happy with this makeover. The new bedrooms have new en suites including new tiling, toilets, wash hand basins and ventilation. There is new furniture and bedding in these bedrooms and a flat screen television is being provided as standard. However due to the amount of work needing to be done all registered rooms are not ready for occupation, some bedrooms in use have not yet been refurbished and are not at the standard the owner is aiming for. We were made aware that the laundry is to be rebuilt and the kitchen areas are to be refurbished which were issues under the previous owners. A relative commented about the home The home is being systematically refurbished. This is being achieved without major upheaval or inconvenience to residents, the new management has brought a breath of fresh air to a dated establishment which is already looking brighter and more up to date. We looked at the needs of one highly dependent person and found that appropriate equipment has been secured to ensure that they get the care they need. A new hoist has been bought to move people that need transferring from place to place. When we walked around the building we found that access to unsafe areas were locked to prevent people accessing them whilst work was being done. The home had little evidence of being disrupted by the work being done and was generally clean and fresh. The manager had put in place in some measures to improve infection control. A number of broken washing machines and been removed from the premises and equipment is intended to be bought following the upgrading of this area. People said: There have been improvements it is better. The rooms are clean and nice. They need to make sure (my relative) doesnt hang up dirty washing. DS0000072992.V375827.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in this home have the benefit of appropriate levels of staff to meet their needs. The new owners have demonstrated that they intend to ensure that all staff have the training needed to ensure that their practice remains current and this safeguards people living in the home. EVIDENCE: We were given 6 weeks rotas of staffs working hours and we took these away to analyse them. We found that the home has 2 waking night available to assist people throughout the night. The home has a senior member of staff available for all day shifts and the number of care staff varied between 2 and 4 care staff with less being available at weekends. The managers hours were additional to this. The home plans to have a cook and a housekeeper available everyday. Duty rotas show that there is a planned handover between shifts of half an hour and this helps to ensure that staff are given information about any incident or emerging care needs for that day. From comment cards and talking to people, people thought they received help when they needed it. The homes Annual Quality Assurance Assessment showed that 9 staff from 15 have achieved a National Vocational Qualification level 2 in Care (NVQ2). This DS0000072992.V375827.R01.S.doc Version 5.2 Page 21 means that staff have been trained how to care for people and this meets the standard. One person who had just started at the home has started training and induction that leads on to an NVQ 2. We looked at three staff files one staff member had been employed recently. We found that this person had been recruited following completion of an application form, interview, and appropriate checks being undertaken. Copies of the interview questions and responses were available and references and checks of the Protection of Vulnerable Adult lists were undertaken before the staff member started work. A person living in the home was part of the recruitment process and this is good practice as empowers people to be able to ask questions of potential new staff. Staff receive an employee handbook which sets out the behaviour the company expects We looked at the training records for 2 members of staff and found that courses on health and safety, infection control, moving and handling and safe administration of medication had been undertaken since the new owners have taken over. This is planned to be a part of updating of training for the whole staff group and part of this is a refresher course on safeguarding of people. One person said I am happy with all the staff. DS0000072992.V375827.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home can be assured that the home is moving to being run in their best interests. There needs to more development of systems to ensure that there is consistently good information for staff and people living in the home and to ensure that all parts of the service are monitored. EVIDENCE: There is no registered manager for the home. The acting manager is applying to be registered but this has been delayed by the changeover from the DS0000072992.V375827.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection and the new commission (the Care Quality Commission). The acting manager has worked at the home in a senior position for a number of years and is currently working on a National Vocational Qualification level 4 in care and will be undertaking the Registered Managers Award when this is completed. The owner and the management team have had to look at improvements in all areas of the homes working practice. This is no small task. Although the home has some way to go in some areas their intention to improve the service to people living in the home is already having an effect. The homes annual quality assurance assessment form needs some work to ensure that it provides us with a clear picture of the service offered to people, shortfalls and plans for improvement. The Annual Quality Assurance Assessment can be used as a basis for the homes quality assurance for continued improvement. The owner is daily in contact with the home at present. People who are able know who the owner is and have talked to him. There have been clear practical demonstrations of the management trying to respond to peoples wishes as well as needs for example the provision of sky sports and the delivery of newspapers. However it is acknowledge that it will take more time to ensure a consistently good service across all areas. A number of people have small amounts of money kept at the home to pay for services such as hair care and chiropody. The management have started new systems of recording and securing peoples money so people have access to it when they want. We looked at the records and the money held for three people. We found that the money was correct to the records. We found that receipts were kept for any spending that the home did on behalf of people living in the home. As a new service some health and safety checks are required before the home was registered with us. At this inspection we noted that the home as the appropriate level of insurance, lifting equipment has been maintained and the water tanks and supply have been cleared as free of Legionella. We looked at the fire safety records and risk assessment. A new fire panel is in place as well as smoke and heat detectors and these meet the requirements of the West Midlands Fire Service. The home has yet to set up personal evacuation plans for each of the residents. DS0000072992.V375827.R01.S.doc Version 5.2 Page 24 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 3 2 X X 3 X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 DS0000072992.V375827.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2), 12(1)(a) Requirement All medications must be given as prescribed by the clinician. Timescale for action 30/06/09 2 OP9 13(2), 12(1)(a) This is to ensure that people remain as well as possible. Where medication is not given as 30/06/09 prescribed the home must seek advice about the best course of action. This is to ensure that medications that can be safely are given later if necessary. The controlled drugs cabinet must be securely fixed to the wall. This is to ensure that the drugs are kept securely. The refurbishment of the home must continue until it is of a consistent standard. The home should provide a time plan for the works. This is to assure us of continued refurbishment of the home, peoples living conditions improve in a timely way and for us to DS0000072992.V375827.R01.S.doc Version 5.2 Page 26 3 OP9 13(2), 12(1)(a) 30/06/09 4 OP19 23(b)(d) 30/06/09 assess progress. 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 3 4 5 6 7 8 9 Refer to Standard OP1 OP2 OP3 OP7 OP9 OP10 OP10 OP31 OP33 Good Practice Recommendations The homes statement of purpose needs to be an accurate reflection of the service now and what the service hopes to have in place. The contract needs to be adjusted so it reflects the service and all terms and conditions are relevant to the people in the home. Information collected about people should be to a consistent quality and reflect the standard. Where a need is identified a plan should be put in place to met this need. A list of staff signatures and initials should be kept for those staff signing the Medication Administration record. As the home is refurbished people should be offered keys to their rooms and records should be kept of whether these have been issued. All shared rooms should have screening to ensure that peoples dignity is maintained whilst personal care is given. The manager must go through the registration process with the Care Quality Commission. The home should develop a Quality Assurance system that looks at all areas of the service, involves people living in the home and stakeholders views and results in an annual plan. DS0000072992.V375827.R01.S.doc Version 5.2 Page 27 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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