Inspection on 24/09/07 for Atfield House

This inspection was carried out on 24th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Ashlong House

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

The Royal Star and Garter Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Atfield House St John`s Road Isleworth Middlesex TW7 6UH Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 24th September 2007 10:15 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 Atfield House DS0000069410.V351128.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. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Atfield House Address St John`s Road Isleworth Middlesex TW7 6UH 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 8560 3994 020 8758 0502 venita.couzens@barchester.com Barchester Healthcare Homes Ltd Venita Roselie Couzens Care Home 64 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0), Terminally ill (0) Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 36 beds for Elderly Frail Service Users over 60 years of age of whom 12 may be for palliative care 28 beds for Elderly Mentally Infirm Service Users over 60 years of age Palliative care is to be provided in the ground floor Church Ferry Unit. The staffing hours are increased by the Registered Manager. Date of last inspection 28/12/06 Brief Description of the Service: Atfield House is a purpose built care home with nursing, first opened in 1997. It is owned by Barchester Healthcare. The home is in Isleworth, approximately two miles from Hounslow town centre. There are shops nearby, buses into Hounslow, and Isleworth train station is close by. The home has attractive grounds and a secure garden. Although registered for 64 people, one room has been converted into a hairdressing/therapy room. All bedrooms are single rooms, with 62 of them being en-suite. The home is on two floors, with a lift, and is split into 2 separate units for a total of 36 beds for general nursing care and 28 beds for residents living with the experience of dementia. Residents are also accepted for respite care and includes recovery from postoperative periods. A three month time limit applies. Physiotherapy is available two days a week within the home. The GP visits Tuesdays and as required. Chiropody and optical services are available as required. Three activity organisers provide a programme of activities, one of whom is also qualified as a massage therapist. There is an attractive secure garden area plus other gardens available. Fees are in the range £580 to £1000 per week. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 24 hours was spent on the inspection process, and was carried out by 3 Inspectors, one of which was a CSCI Pharmacist Inspector. The Inspectors carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 16 residents, 10 staff and 3 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, representatives/visitors and health & social care professionals have also been used to inform this report. What the service does well: Prospective residents are fully assessed prior to admission to ensure the home is able to meet their needs. Service user plans are comprehensive and provide clear information about each resident’s needs and how these are to be met. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. Information regarding end of life care wishes is recorded and respected. The activity provision in the home, to include the obtaining of comprehensive life history information for each resident so that activities can be tailored to individual interests, is of a high standard. The home has an open visiting policy and visiting is encouraged. Contact information regarding advocacy services is available in the home. The food provision at the home is good, offering variety and choice. The home has clear procedures for the management of complaints and safeguarding adults issues, and these are adhered to. The home provides a good standard of accommodation and is clean and fresh. Procedures are in place and being followed for infection control. The home is being appropriately staffed to meet the needs of the residents and this is kept under review. There is a comprehensive induction and training programme for all staff. The Registered Manager is approachable and listens to people, and works with the staff to maintain standards throughout. There are robust employment procedures in place, which are being adhered to. There is a good system in place for quality assurance to maintain the quality of the service. All staff receive regular supervision to discuss practice and development matters. Overall there are good procedures and practices in place for the management of health & safety in the home. Overall the comments received via the CSCI comment cards were positive. Examples of these are: ‘The whole atmosphere at Atfield House is calm and considerate’. ‘Atfield House staff give a complete and very professional service in every way possible’. ‘Friendly and efficient’. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 6 ‘Its always clean and fresh. Relatives can eat with their relatives in the home dining room at an affordable cost’. 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. The summary of this inspection report can be made available in other formats on request. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 7 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 Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed on each floor and had been well completed. The home also obtains a copy of the needs led assessment undertaken by social services. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 9 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): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plans were comprehensive and complete, thus providing staff with the information required to care effectively for each resident. Shortfalls were identified in the management of medications and this could place residents at risk. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides good end of life care, thus ensuring that residents and their families have their wishes and needs fully discussed, recorded and met. EVIDENCE: Service user plans were sampled on each unit. The documentation is comprehensive and had been clearly completed to identify resident’s needs and how these are to be met. New care plans had been formulated for any newly identified needs. The service user plans had been reviewed monthly and when there had been any relevant changes in a resident’s condition. Risk assessments for falls had been completed and with one exception the falls risk management documentation had been updated following any falls. The Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 10 shortfall was addressed at the time of inspection. There was evidence of input from residents and/or their representatives in the Care Profile Review. This is carried out 6 monthly and whenever there is a significant change in a residents’ condition. Following discussion with the Registered Manager it was agreed that a review should be offered in the near future to 2 residents and their representatives so that the service user plan documentation is understood and agreed by all parties. Daily records were clear and detailed the care being provided. Care staff records are also in place and care staff are encouraged to write about the care given to each resident as part of the multidisciplinary records. There was evidence that the service user plans are audited and action plans are in place to address any shortfalls identified. Overall the documentation is comprehensive and completed to a good standard. The Registered Manager reported that there were 4 residents with pressure sores, two of which had been acquired in hospital. Wound care documentation was viewed for two residents. This was comprehensive and included pressure sore risk assessments, individual care plans, skin plans plus wound assessment charts for each wound, photographs and evidence from the tissue viability nurse specialist. Special sheets to minimise skin friction were available to assist with pressure area care. Nutritional assessments had been carried out and staff had received recent training updates in the completion of the nutritional assessment documentation. Residents are weighed monthly and more often if a problem is identified. Where a resident refuses to be weighed this is clearly recorded. Moving & handling assessments and documentation is comprehensive and provides a clear picture of each residents moving & handling needs and the equipment to be used for each manoeuvre. Continence assessments had been completed for each resident. For the use of bedrails there is a ‘safe use of bed rails pre-use checklist’ plus a monthly inspection list and a daily checklist for bedrail safety. The actual reason and appropriateness of use of bedrails for each individual had not been recorded and there was no evidence of written consent for their use. Ways of addressing this were discussed with the Registered Manager and the Deputy Manager. There was evidence of input from healthcare professionals to include GP, physiotherapist, community psychiatric nurse, tissue viability nurse, podiatrist and optician. Healthcare professionals are encouraged to complete their own entries in the service user plan documentation. An audit of medication was undertaken in all three units in the home. It was noted that generally the recording of receipts of medication, administration and disposal was good. Nurses need to ensure that they date the receipt of medication in all units so that they can provide evidence that medicines are being given and recorded accurately. No omissions were noted in recording administration on the Medication Administration Records (MAR). However when auditing medication several discrepancies in the expected totals were identified e.g. nicorandil, risperidone, Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 11 aspirin and diazepam. Too many tablets were left which means perhaps that some medicines are possibly not being given but recorded as given. For one resident prescribed two antibiotics one too many tablets had been administered. There was evidence of review of medication by the prescribers and good practices of keeping the original prescription and discharge letters and dosage changes with the MAR for evidence. Risk assessments were in place for residents having swallowing difficulties when taking their medicines. Nurses checked resident’s blood pressure and pulse and recorded accurately when results were not at the expected target level. The home needs to ensure that to prevent the risk of infection from blood borne diseases that they follow national guidance and use lancets for professional use when testing blood glucose. Records of checking blood glucose were inspected and all were completed according to individual protocols. The recording of Controlled Drugs needs to be tightened up on. Balances were correct but each page should be clearly labelled with the form of the medication in addition to the name and strength. Any controlled drugs, which are discarded because a part dose is prescribed, must also be recorded and signed and witnessed. Midazolam must be kept securely whilst awaiting destruction. The air conditioning had been broken in one of the units for over 6 weeks and room temperatures were reading 32 degrees. Medicines must usually be stored below 25 degrees to maintain their potency. Fridges needed defrosting to ensure that temperatures are maintained between 2 and 8 degrees again to ensure appropriate storage of medication. Staff were seen caring for residents in a friendly, gentle and professional manner, respecting their privacy and dignity. Some comments received reflected that not all staff were familiar with traditional greetings and the Deputy Manager said that further customer care training would be provided. Residents did comment that the staff are caring. Residents were well groomed and dressed to reflect individuality. Personal clothing was well cared for and labelled, and laundry and dry cleaning facilities are available. Residents are referred to by their preferred term of address and gender preferences for personal care provision are recorded and respected. Information regarding the wishes of residents and relatives regarding end of life care discussed and recorded. Where the resident and/or their families do not wish to discuss such matters this is also recorded. The Deputy Manager said that wherever possible this topic is discussed as part of the admission process. The home uses the Barchester Healthcare ‘End of Life Care Pathway’ to care for residents during their final days. Some staff had received training in end of life care. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home is good, providing a variety of activities, outings and entertainments to meet the residents needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: The home has 3 activities co-ordinators and there is a weekly programme of activities on display and a copy is given to each resident. The programme is also on display and the Deputy Manager explained that, as a result of discussion with relatives, this is displayed a week in advance so that relatives know what is going on and can choose to attend the home to join activity sessions. Information in each service user plan in respect of residents’ life history and hobbies and interests is comprehensive. This is often completed by a member of the residents’ family and provides a good picture of the individuals life and significant events. Where a resident does not wish to share their life history information this is recorded and respected. A daily diary of Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 13 activities plus a monthly summary is completed in each service user plan. Events are arranged to celebrate significant days, for example Patron Saints Days, Ascot Ladies Day and Wimbledon, and the activity arranged is in keeping with the actual day. Residents are encouraged to join in activities and outings, however if they do not wish to do so then this is respected. On Courtyard unit each corridor has a theme: film, seaside and countryside, with relevant pictures and touch-friendly tapestries. Rummage chests and user-friendly chests of drawers with various items in each were seen for the residents to look through, plus soft toys for them to cuddle are available, and these have been provided in accordance with current dementia care research. The home has sensory equipment that is portable and can be used in individual residents rooms. Overall the activity provision at the home is very good and is tailored to meet the needs of the residents. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and refreshments are offered. One visitor commented that staff offer support to the relatives as well as the residents. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information regarding advocacy services was on display in the reception area, to include ‘Alzheimer’s Concern’ and ‘Care Aware’. One inspector viewed the kitchen. It was clean and tidy. Some shortfalls in records are commented on under Standard 38. The home has a 4 week seasonal menu with choices available at each meal. Additional alternatives are available and a good choice of meals is provided. The chef has attended residents’ meetings and is open to suggestions for additional meals to be included on the menu. Residents spoken with commented that the food provision is good and choices are offered. Meals were well presented and staff were available to assist residents with their meals as needed. Fresh fruit is available throughout the day. Snacks and drinks are available throughout the 24 hour period. If residents are not hungry at a particular meal then this is noted and food offered again later. There were no residents with cultural dietary needs and the Registered Manager said that should the need arise they are able to buy in meals to meet cultural needs. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a robust system in place for the safeguarding of residents from abuse. EVIDENCE: Details of the complaints procedure are available in the Statement of Purpose and Service User Guide, and are also displayed in the home. There had been 11 complaints since the last inspection and all concerns are recorded. These had all been fully investigated and responded to. The Registered Manager has an ‘open door’ policy for visitors, and does deal promptly with any concerns raised. Representatives spoken with said that the Registered Manager is approachable and deals promptly with any issues. The home has adult protection policies and procedures in place that dovetail with the Hounslow Safeguarding Adults documentation. Staff spoken with said that they had received POVA training and were clear to report any concerns. The Registered Manager reports to CSCI and the Hounslow Safeguarding Adults Team any incidents that she feels might require investigation under safeguarding adults procedures, and appropriate procedures are followed. A discussion took place regarding any incidents where a resident is aggressive towards another resident or a visitor and the Registered Manager said that significant events of this nature would be reported in future. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained and is furnished to a high standard, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: A tour of each unit was carried out. There was evidence of ongoing redecoration and refurbishment and the home looked smart and well maintained throughout. New armchairs and sofas had been purchased and the Deputy Manager said that the sofas allow for residents and their loved ones to sit together, providing a very positive addition to the furnishings in the home. Bedrooms were in the process of being decorated. The Registered Manager said that the rolling programme of bed replacement is almost complete and any new beds purchased are height adjustable to ground level, thus residents at risk of falling out of bed can have their bed near the ground with a safety Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 16 mat beside it, to maintain their safety. The bath and shower facilities are in the process of planned redecoration and refurbishment. The gardens are well maintained and provide pleasant areas to sit out in. The dementia care unit is so designed as to allow residents to wander along the corridors freely and the area is secure. There is a courtyard garden in the middle of the dementia care unit, providing a safe area for residents to walk in if they so wish. Corridors have handrails and there are grab rails in the toilet facilities. Moving & handling equipment was available on each unit. One Inspector viewed the laundry facilities. The room was clean and the laundry was being well managed, to include personal clothing items. The washing machines have a sluice programme for infection control. Protective clothing to include gloves and aprons was available throughout the home. Infection control procedures are in place and were being followed. The home was clean, fresh and bright throughout. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents can be met, and prompt action is being taken to address identified shortfalls. Systems for vetting and recruitment practices are in place and protect residents. There is a comprehensive ongoing training programme, providing staff with the skills to meet the needs of residents, to include specialist care needs. EVIDENCE: Staffing rosters are available for each unit and the kitchen and ancillary staff. At the time of inspection the home was being appropriately staffed to meet the needs of the residents. One Inspector discussed the need to ensure that the Registered Manager reviews residents dependencies on an ongoing basis in order to ensure staffing is maintained at levels to meet residents needs at all times. The home has accessed NVQ in care training with several staff now registered to undertake level 2, and 17 members of staff having completed the training, with a further 6 in progress. Barchester Healthcare are corporately aware of the need for 50 of all care staff to be qualified to NVQ level 2 or above, and this is being progressed. Some staff are undertaking NVQ training in dementia. The Registered Manager reported that one of the kitchen assistants and one of Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 18 the hostesses are doing NVQ level 2 in catering and hospitality. Four staff are working to attain the NVQ assessors qualification. Two sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001. There is a comprehensive pre-employment checklist to ensure all checks plus documentation is completed in full. The home has an induction programme that meets the Skills for Care common induction standards. The training matrix viewed indicated that staff had received periodic training in topics relevant to the needs of the residents. There is an annual training and development plan that is formulated by the Registered Manager and a training budget is available. The Registered Manager said that they are working towards employing a full-time trainer for the home. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the skills and experience to manage the home, with further training booked to provide up to date knowledge for effectively managing the home. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Staff receive regular supervision thus providing a forum for individual discussion and reflection on practice. Overall the systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. Shortfalls should be easy to address. EVIDENCE: The Registered Manager is a first level registered nurse with 4 years experience of managing care homes. She has undertaken periodic training relevant to her role and the needs of the residents. The Registered Manager is Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 20 still to undertake the Registered Managers Award NVQ level 4 and has provided CSCI with a confirmed start date for this training. Staff spoken with said that the Registered Manager and Deputy Manager are approachable. The Registered Manager said that she has an ‘open door’ policy for staff, residents and visitors and that any issues are listened to. There are clear lines of accountability within the home. Some comment was received that residents would like to see the managers more frequently and this was fed back to the Registered Manager and the Deputy Manager. There is a quality assurance system in place. Regular audits are carried out to include full home audits, health & safety, catering, infection control, activities, nutrition & dining, dementia care provision, medication and service user plan audits. Satisfaction questionnaires to residents, representatives and stakeholders are sent out annually and the information collated and results published. Separate meetings are held each for representatives, residents and staff, and minutes of each meeting are taken. The home has attained the Investors in People Award. Regulation 26 unannounced visits on behalf of the Responsible Individual take place and copies of the reports are forwarded to CSCI. The home does not hold money for any of the residents. There was evidence that staff are receiving regular supervision and this is recorded. The Registered Manager supervises the senior staff and this is then cascaded down for all staff. The servicing and maintenance records were sampled. Those viewed were up to date. The hot water temperatures are checked monthly and these were within safe range. The maintenance man has a book in which any repairs are recorded and these are promptly addressed. All staff undertake health and safety training prior to carrying out any related procedures and updates are carried out at the required intervals. The home has a health & safety committee that meets every 3 months to discuss any issues plus new legislation and guidance. A quarterly health & safety bulletin is published. At the time of inspection the records for fire drills were not available. There was evidence that whenever the fire alarm activates staff do carry out correct procedures, however this does not include all staff and this must be addressed. Some of the kitchen records to include cleaning records and delivery temperatures of refrigerated and frozen products had not been completed for the previous 10 days and this needs to be addressed. Generic risk assessments for equipment and safe working practices were in place and the need to personalise these specifically for Atfield House had already been identified during an external health & safety audit. Information for safe working practices is available in areas of the home. Regulation 37 notifications are sent to CSCI in line with the current guidance. Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 X 3 3 X 2 Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 13(4)&(7) Requirement Bedrail assessment documentation must clearly identify the need for and appropriateness of the use of bedrails for the individual. Written consents for the use of bedrails must be obtained. Thus the needs and wishes of the resident will be ascertained and met. When medicines are received into the home, receipts must be signed and dated after checking. The home must expand its audit tool to randomly check quantities to provide evidence that medication is being administered as prescribed. The accurate recording of Controlled drugs must be improved. The disposal of unused part doses must also be recorded in the Controlled Drug Register. To prevent the risk of infection the home must use lancets for professional use when testing for blood glucose. The clinical rooms must be DS0000069410.V351128.R01.S.doc Timescale for action 01/11/07 2. 3. OP9 OP9 13(2) 13(2) 14/10/07 01/11/07 4. OP9 13(2) 01/10/07 5. OP9 13(2) 01/11/07 6. OP9 13(2) 01/11/07 Page 23 Atfield House Version 5.2 7. OP38 23(4)(e) 8. OP38 13(3) maintained at a temperature of not more than 25 degrees and fridges maintained between 2 and 8 degrees. There must be evidence that fire drills for all day and night staff are being carried out at the required intervals to ensure staff are fully aware of fire drill procedures. All kitchen records to include cleaning and food delivery temperature records must be kept up to date in order to ensure resident’s safety is maintained. 01/11/07 05/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Atfield House DS0000069410.V351128.R01.S.doc Version 5.2 Page 25 - 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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