Inspection on 29/08/07 for Chrissian Residential Home Limited

This inspection was carried out on 29th August 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

Chrissian Residential Home... 24/02/09

Chrissian Residential Home... 03/11/08

Chrissian Residential Home... 29/08/06

Chrissian Residential Home... 17/12/05

Chrissian Residential Home... 10/06/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Chrissian Residential Home Limited 526-528 Woodbridge Road Ipswich Suffolk IP4 4PN Lead Inspector Mary Jeffries Key Unannounced Inspection 29th August 2007 15:30 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 Chrissian Residential Home Limited DS0000058102.V349641.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. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chrissian Residential Home Limited Address 526-528 Woodbridge Road Ipswich Suffolk IP4 4PN 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) 01473 718652 feizal.molabaccus@ntlworld.com Chrissian Residential Home Limited Mrs Bibi Rookian Molabaccus Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th August 2006 Brief Description of the Service: Chrissian House is situated on a main road into Ipswich town centre. The home comprises two buildings joined together at ground and first floor level. One is known as the annex. There is a medium sized garden to the rear of the building, with patio area and a small amount of outdoor furniture and seating. The accommodation was developed in early 2002 to meet the standards at that time. The number of double rooms was reduced, and new rooms were created when the development was completed. The garden has had landscaping, and is attractively maintained. The home caters for those with low and medium needs only. The home has stair lifts to aid those with poor mobility. The home would not accept a resident who was a wheelchair user at the time of admission. Chrissian Residential Home Limited DS0000058102.V349641.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 key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. An Annual Quality Assurance Assessment (AQAA) was provided by the home prior to the inspection. The inspection occurred on an afternoon and early evening in August 2007 and took four and a half hours. The process included a tour of the building, observations of staff and resident interaction, and the examination of a number of documents including residents’ care plans, medication records, the staff rota, recruitment, training records and records relating to health and safety. The inspection was facilitated by the manager (who is currently seeking Registration). The existing Registered Manager also participated. There were three vacancies in the home at the time of the inspection. Eleven residents responded to the pre inspection Have your Say survey, and three were spoken with at the inspection. Nine members of staff responded to the pre inspection Have your Say survey, and three were spoken with at the inspection. Three relatives responded to the pre inspection Have your Say survey, and two were spoken with at the inspection. Three residents were tracked. What the service does well: Residents are fully assessed before moving into the home, they have the opportunity to visit before admission and the home will facilitate this if needed by assisting with transport. A homely atmosphere is provided. Residents can expect to have choice regarding their daily routine, and for relatives to be free to visit and made welcome. Residents’ health needs are well met. Adequate staffing levels are maintained and staff are regularly supervised. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 6 The home is clean and homely, and maintained to an adequate standard. 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. Chrissian Residential Home Limited DS0000058102.V349641.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 Chrissian Residential Home Limited DS0000058102.V349641.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): 1,3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have the opportunity to visit the home before deciding whether to live there, but they may not have all the information they need to make a fully informed choice. They can expect to be fully assessed to ensure that the home can meet their needs. EVIDENCE: All eleven residents who responded to the Have your Say survey stated that they had received enough information about the home to decide whether to live there and also that they had received a contract. The manager has confirmed that they do not receive the contract prior to admission. The manager advised that individual residents do not all have a copy of the Service User Guide in their rooms, however, copies were available in a holder set on the wall in the entrance hall. Despite residents’ views, this document does not meet the current regulations; it did not include a copy of terms and Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 9 conditions, the fee payable, the arrangements for paying for any additional items, nor reference to the latest inspection report’s availability. The AQAA stated that the report is available for everyone to view. The document did contain residents’ views. A new survey was being undertaken. Two of the residents tracked had been admitted since the last inspection. Both had preadmission assessments undertaken by the home on file and Social Care single assessments. One had notes in their file to show that they had been collected by the home to visit for a day prior to admission, the other had been assessed at the Bartlett hospital. The home does not provide intermediate care. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 10 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a care plan that is regularly reviewed, and to be referred to all relevant health care services. They cannot be assured that all risk will be fully assessed. EVIDENCE: All nine members of staff who responded to the Have your Say survey stated that they were given up to date information about the needs of the people they care for. All three relatives who responded to the pre inspection survey indicated that the home gives the support and care to their relative that they expected or agreed. Two thought the home always meets the needs of their relative; one indicated that it usually does. Ten of the eleven residents who responded to the Have your Say survey stated that they always receive the care and support they need, one stated that they usually did. All residents were clean and tidy, and appropriately dressed; no odours were detected. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 11 The three residents tracked all had care plans that had been completed in a timely way. Staff spoken with had a good knowledge of individual residents’ needs and preferences. Care plans had been developed since the last inspection and contained good detailed information on the whole. One resident who had fallen out of bed twice, and on one occasion injured them self, had bedsides in place. The resident said that they did not like these, as they sometimes got up in the night and wanted something to eat. They said that they now had to climb over the bed rails, if they wanted some cereal to eat in the night. The file showed that the bed-side rails had been in place for less than a week, the resident had signed to state that these were acceptable, and there were notes on file to show that consultation with the District Nurse had taken place, however, there was no evidence to show that the home had looked at other alternatives to meet the need of minimising the risk of the resident falling out of bed. Paper work had been prepared for the District Nurse and the relative to sign to evidence their consent when they next attended. The resident advised that some night staff were good, and that one night they had come down and had a couple of slices of bread and butter and were able to sleep after that, whereas, they advised, other carers say that they can’t have anything to eat at night. The manager confirmed that the resident did sometimes like to have something to eat later in the evening, as they were able to eat lots of small meals rather than large meals, and was aware that the resident was restless at night. The night care plan stated that the resident might get in the early hours of the morning to eat. One of the residents tracked had not had any recent accidents, but their relative advised they had a fear of falling; they had a falls risk assessment on file which indicated that this was a low risk. One resident had been using a wheel chair. Their relative advised that they had seen two carers transfer the resident into the wheelchair and had thought that they had done it very well, as although the resident is not heavy they do not help themselves in any way with this process. The resident had a moving and handling risk assessment on file. One relative who answered the survey noted; “…... falls a lot, and cannot walk well, the care home supports (them) well, (they) have not had a serious fall here, it’s a wonderful home.” Care notes were good, with an entry for each resident made by each shift. The file of one of the recently admitted residents showed that they had been referred to a number of health professionals following admission, including the dietician, the incontinence advisor and the chiropodist. An occupational therapist had visited and a wheel chair for outside use had been ordered. The resident had a pressure sore. The district nurse was visiting twice a week to attend to this, and an electric air mattress was in place. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 12 One resident who had been living at the home for a number of years had seen an optician within the last twelve months. They and their relative confirmed that they had been in good health and not required any other medical intervention. The relative said that the home looked after the residents’ health well, and advised that they had had a short stay in hospital a couple of years before which the home had, quite correctly, achieved the residents admission. Their records showed they had been reviewed regularly at monthly intervals. All eleven residents who answered the questionnaire stated that they always receive the medical support they need. The home had new medicine cabinets, one for the main building and one for the annex. These were fixed to the wall when not in use. The administration of the teatime medication was observed in the annex and Mars sheets were inspected. Where PRN (as required) medications were given, the number of tablets given was recorded. A Boots monitored dosage system is in place. No errors were found. The manager advised that they check medication records once a fortnight and do a stock take once or twice a month. The member of staff administering medication advised that they had received Boots training. Eight members of staff who responded to the Have your Say survey confirmed that they had been given training to administer medication. One said they had not. The manager advised that staff would not do medication unless they were trained. The AQAA indicated that Boots training was provided. Ten of the eleven residents who responded to the Have your Say survey answered the enquiry, “Do staff listen to what you have to say and act on it”; they all answered positively. The home noted on their AQAA that the television now in the veranda was as a result of resident’s requests. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 13 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. Residents can expect to enjoy life in the general ambience of life in the home, and to be treated and responded to as individuals but they will not have access to very many activities in the home on a regular basis. EVIDENCE: Seven of the eleven residents who responded to the Have your Say survey indicated that there were always activities arranged by the home that that they could take part in, one indicated there usually were, two indicated that there sometimes were. Two residents survey responses showed that they went out to join in activities or clubs in the community. One relative who answered the survey stated that it would be nice to have bingo, like they sometimes used to have. A relative who was spoken with advised that they thought that the home was good, but that the only thing they felt it should do better was to have more activities. The manager advised that there is an activity programme, but on Thursday afternoons only. This included board games, word games, gentle exercises and sometimes one resident spoke about their life story. A record of activities for the previous three Thursdays showed that 3 had participated on one occasion, 5 on another and 7 on another. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 14 The AQAA states that a church service, the Salvation Army and the library service visit the home. One of the residents tracked had it noted on their daily living plan that they attended a weekly church service; the manager advised that they take some residents to church on Mondays. The owners are often in the home and they take time to speak with individual residents. All residents appeared contented. None were seen sleeping for long periods. Two out of three relatives who responded to the pre inspection Have your Say survey indicated that they thought the home always kept them up to date with important issues affecting the resident, one thought that it usually did. The home has installed pigeonholes where correspondence to relatives and residents could be left routinely. Two relatives spoken with advised they could visit when they wanted to, and were made to feel welcome in the home, one confirmed that they were always offered a cup of tea when they arrived. Nine of the eleven residents who responded to the Have your Say survey indicated that they always like the meals at the home, one that they usually did and one that they sometimes did. Breakfast each day is fruit juice, porridge or cereals, and toast. Cooked breakfast was not available. Lunches included quiche, shepherds pie, turkey casserole, baked or fried fish, mince and dumplings and were served with fresh vegetables. A choice was available each day. The home catered for three diabetics and one resident who sometimes preferred vegetarian food. The manager advised that if a resident did not want either of the choices they were asked what they did want and the home tried to accommodate this. The fresh fruit available in the home for between meal times had been brought in for residents by their relatives. One resident said, “The food is too good, its’ well prepared alright but they give me too much. I have a friend who will bring me in a banana; they will put it in the fridge and mash it up for when I want it. I don’t always seem to get the service in that, but these are just odd things.” The Service User Guide states that breakfast is at 7am or on request. One resident spoken with said that they always get up at 8.30 for breakfast; they advised that they could have a cup of tea in their room if they wished, but that they didn’t want this. Their relative advised that the resident had become more independent since being at the home, as their spouse used to “wrap them up in cotton wool.” They commented: “You wouldn’t believe the difference in them”, and said that being at the home had given the resident a “new lease of life.” There are a variety of places for residents to spend their day in the home, the dining room, the sitting room, the veranda and the annex. There was a positive atmosphere in the room, with some residents speaking in groups, some sitting doing puzzles. One relative advised that the resident visited them Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 15 some weekends, but that towards the end of the day the resident is keen to return, and concerned that their friends in the home would be missing them. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to know who to speak to if they have a concern and to have access to a proper complaints policy. They can be assured that staff have a good understanding of adult safeguarding and know what to do if they are concerned for a resident. EVIDENCE: The Service User Guide contains a summary of the complaints policy, and copies of the guide were available in the hallway. Ten of the eleven residents who responded to the Have your say survey indicated that they always knew who to speak to if they were not happy, one noted that they usually did. Recently a neighbour had sent an email to the home, and copied it to customer first who in turn copied it to CSCI, advising of their concerns about a resident who had been seen wandering outside of the home in such a manner and stated that they had reported it to the police. It was established at the inspection that the home had not received this email as it was incorrectly addressed. The home had independently reported this matter to CSCI, the circumstances in which the resident had left the home, which is not a secure dwelling, and the appropriate actions taken to seek help from mental health services in Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 17 responding to the resident’s needs. At the time of the inspection the resident was no longer abiding at the home. A copy of the complainants email has subsequently been given to the home so that they may respond to the neighbour whose concerns were expressed in good faith and with genuine concern. No other complaints had been received. All nine members of staff who responded to the Have your Say survey stated that they know what to do if a resident /relative/advocate or friend has concerns about the home. They gave answers which included referring to the management, Social Care Services and CSCI. All three relatives who responded to the pre inspection Have your Say survey indicated that they knew how to make a complaint of necessary, two indicated that when they had raised a concern the home had always responded appropriately, one stated that it usually had. Eight members of staff responded to the Have your Say survey question about adult safeguarding, confirming they were aware of PoVA procedures. A carer spoken with was able to speak about the signs that might indicate abuse, and different types of abuse, and advised that they would report any such concerns to management immediately. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26. Quality in this outcome area is good. Residents can expect to live in a homely and clean environment that is well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had been redecorated in the communal areas and new carpets laid since the last inspection, and other improvements made to the fabric of the building. The two chair lifts had been replaced with new ones and new garden furniture purchased. Further upgrading had been planned including new paving in the garden so that full access to the entire length of the garden which is maintained to a very good standard was available for all residents. The small step outside of the veranda was only just large enough to accommodate a walking frame, and the owners confirmed that this is to be changed with the new paving. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 19 On the day of this announced inspection, the home was clean throughout, with no unpleasant odours. The main sitting room appeared cheerful and homely. The size of individual rooms and communal space meets the National Minimum Standards. A number of bedrooms were seen; they had been personalised by residents as they chose with personal possessions and individualised decoration. The manager advised that bedrooms were being redecorated as they became vacant. Rather than a locked drawer, residents have a locked box in their room, but this is not secured to any furniture and so is vulnerable. Paper towels and liquid soap were seen to be in place in all shared bathrooms. The home had a clinical waste disposal contract with Ipswich Borough Council. A resident spoken with said that the carers used gloves and aprons when they were attending to their personal care. Following the last inspection the home advised that a new procedure had been introduced for laundry. The manager was asked to describe the process for washing, which was appropriate; two types of laundry bags for soiled and nonsoiled laundry were available. The laundry had not been redecorated, and the grouting between the tiles on the floor had worn away in parts. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by an experienced well-trained staff group. EVIDENCE: Minimum staffing levels are 3 members of staff by day, and 2 by night. Staffing levels are being maintained at satisfactory levels, and staff turnover is low. In addition to the carers there was a cook and manager on duty and the owners’ son, who remains a manager was attending to maintenance. There had been a domestic cleaner on duty during the morning. Some staff indicated that they felt they were under pressure at times; the staff ratios are good and the roster showed that staffing levels are maintained. A member of staff advised that they were most pushed just before and after lunch. They advised that just one resident needed help feeding, and one needed encouragement. The AQAA states that no agency staff had been used in the last three months. All of the carers are female. The AQAA and the home’s training analysis showed that over 50 of staff held NVQ 2 or above. Two files of recently recruited staff were inspected, and were found to be in good order. Both had two written references and Criminal Records Bureau Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 21 checks which had been received prior to the worker commencing at the home. There was proof of identity on both files. Following the last inspection the home had responded by advising that moving and handling assessments had been completed for all residents at risk of falls, and that they had provided moving and handling training by a person trained to instruct in this, enhanced it with a video training pack. They advised that this had been given to 75 of staff, and 100 would be completed by January 2007. A copy of the trainers’ current training certificate was provided at the inspection. The AQAA stated that fifteen members of staff had received training on infection control. The manager advised all staff had now had this training, provided by Otley College. The file of a longstanding member of staff inspected had evidence of this training and training in moving and handling, health and safety, risk assessments, food hygiene, fire, first aid and adult safeguarding in the last twelve months. A file of a member of staff recruited in January had evidence of induction training, moving and handling, infection control, food hygiene, first aid, adult safeguarding and medication training. All three relatives who responded to the pre inspection Have your Say survey indicated that they thought that the care staff had the right skills and experience to care for the people in the home properly. One resident spoken with said that some of the night care staff were not as considerate as they could have been when they came to change the bed at night if they had had an accident. They explained that they pulled the bedclothes right off, and that because they were wet this made them very cold. The other resident spoken with in depth said that staff were “lovely”. All nine members of staff who responded to the Have your Say survey gave positive responses to the three questions about training they receive, confirming that it was relevant to their roles, helped them understand the needs of residents and kept them up to date with new ways of working. Chrissian Residential Home Limited DS0000058102.V349641.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. 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. Residents can expect to live in a well-managed service. EVIDENCE: Mrs Bibi Molabaccus remains Registered Manager, however, another member of staff been appointed as manager, and had submitted a complete application to become the Registered Manager. They had previously been an owner/manager and advised that they held an NVQ 4. A member of the owner’s family who had been considering applying for the role advised that they had decided to focus on some other administrative matters, which would enable them to continued to have time to speak with residents, and aspect of the work they enjoyed. They were still identified as a manager. A staffing structure document was available that showed this person Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 23 to be responsible for wages, financial matters, induction and recruitment, training and statutory requirements. The document showed staff to be accountable to both the manager and owners’ son, and both of these to be accountable to the Registered Manager. The diagram did not show the formal working relationship between them. If the manager is registered they will have legal responsibilities contained within the role of the other manager and the structure of the formal relationship between them will need to be clarified. Also the other manager’s relationship with residents and the reporting responsibilities they have to the manager will need to be defined. There was no new job description for the other manager, who had effectively moved into a new role. No problems had arisen, and the manager advised that they appreciated the support and interest of the owners and the other manager (who is their son), however roles will need clarifying before the manager is registered. Eight members of staff who responded to the Have your Say survey confirmed that their manager gives them enough support and discusses their ways of working; one commented that the manager sometimes did. Records of regular quarterly supervision were on file, this is slightly less frequent than the standard recommends. The manager who deals with finance, recruitment and training advised that that the home does not get involved in residents’ finances. They advised that Social Care Services had been in discussion with them and had asked whether they could hold an account for one resident, but that the home had advised they could not do this. The home was awaiting the social worker’s advice on how the resident could access their personal finances. Relatives’ quality assurance questionnaires were in the pigeonholes on the day of the inspection. A recent quality assurance document had yet to be produced. Regulation 26 monitoring is not required at present as the owner is also the Registered Manager. The manager advised that all food preparation takes place on the premises. A critical control point hazard analysis (HACCP) was in place for food production. The freezer that had previously been stored under the stairs had been moved in accordance with fire the officer’s advice. The maintenance file recorded weekly checks of the fire alarm, and supervision records indicated that fire procedures had been discussed on a quarterly basis with staff in supervision. Fire extinguishers had been serviced in September 2006. Weekly water temps of hot water outlets, which do have regulators, were recorded. The bath hoist and three hoists had been serviced in May 2007. Chrissian Residential Home Limited DS0000058102.V349641.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 X 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 3 X 3 X 3 3 X 3 Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 25 NO 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 5 Requirement The Service User Guide must comply fully with the regulations so that prospective residents have access to the information they require to make an informed choice about the home. The bed sides risk assessment for the resident who has climbed over these, must be reviewed. The night care plan should be updated for the resident who likes to get up in the night, and should include details of how their needs and wishes should be met if the resident does get up. The recreational and activities programme must be developed so that residents have sufficient opportunities to take part in meaningful activities within the home. Residents’ lockable storage must be secured, so that it is not portable. The laundry floor must be repaired so that it is impermeable and readily cleanable to reduce unnecessary risks of infection. DS0000058102.V349641.R01.S.doc Timescale for action 31/10/07 2 3 OP7 OP7 13(4) 15(1) 01/09/07 12/09/07 4 OP12 16(2)(n) 31/10/07 5 6 OP24 OP26 23(2)(m) 13(3) 31/10/07 31/10/07 Chrissian Residential Home Limited Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP31 Good Practice Recommendations The job description for the manager should enable them to take responsibility for fulfilling his duties and the working relationship of the manager to the other manager defined. Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Chrissian Residential Home Limited DS0000058102.V349641.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!