Inspection on 12/10/07 for Conifers The

This inspection was carried out on 12th October 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

Conifers The 06/12/05

Conifers The 09/12/04

Conifers The 29/07/04

Conifers The 01/11/02

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Conifers The 473-475 Green Lanes Palmers Green London N13 4BS Lead Inspector Caroline Mitchell Key Unannounced Inspection 10:30 12th October 2007 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 DS0000027805.V338585.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. DS0000027805.V338585.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conifers The Address 473-475 Green Lanes Palmers Green London N13 4BS 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 8882 3249 020 8882 6160 conifersnursing@btconnect.com Mrs Bridget Murray Ms Olivia Moyo Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places DS0000027805.V338585.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2006 Brief Description of the Service: The Conifers is registered as a care home with nursing care for up to thirty older people. The home is a privately owned, family- run home and the proprietors own 1 other care home in Totteridge, North London. The home, which is situated in Palmers Green, is a detached, 2 storey building in the busy Green Lanes area. It is close to all local amenities including shops, restaurants, pubs, churches etc. The upstairs can be accessed by use of the lift. There are 26 single rooms and 2 shared rooms. 14 rooms have en-suite WC and shower facilities, which have been adapted to provide wheelchair access. The stated aims of the home are to provide long-term nursing care for older people. Placements at the home costs between £540 and £640 for each person per week. Toiletries are provided, but residents are expected to pay separately for some personal items of choice. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to residents and other stakeholders. DS0000027805.V338585.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an unannounced basis and took 6 hours to complete. The Matron, aided the inspector in the process. During the inspection the inspector met and spoke to several residents and was able to speak to 2 people in some depth. The inspector toured the building and reviewed a number of written records kept in the home including the written records for 3 residents, the personnel records for 2 staff, and the training records for all staff, along with records regarding health and safety, complaints, medication, and the food served in the home. Throughout the inspection the inspector was able to spend time in observing staff practice. Some information provided to the Commission by the registered person via the annual quality assurance assessment is also included as part of this report. What the service does well: What has improved since the last inspection? What they could do better: There is a need generally, to re-emphasise the importance of falls prevention A 2 recommendations are made in respect of this. Additionally, it is recommended that alternative methods of ensuring the safety of those residents who choose to keep their bedroom door propped or wedged open be sought. It is also recommended that alternative choice of main meal be provided as a standard part of the lunchtime menu. The registered person has a good history of compliance with requirements and recommendations made by the Commission and the inspector is confident that they will address these issues in an appropriate and timely fashion. DS0000027805.V338585.R01.S.doc Version 5.2 Page 6 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. DS0000027805.V338585.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 DS0000027805.V338585.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): 2, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. Where the assessment has been undertaken through care management the service receives a summary of the assessment and a copy of the care plan. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The management team consider the application before agreement is give for the admission. Prospective residents are given the opportunity to spend time in the home and their relatives encouraged to be involved. New residents are provided with a Statement of Terms and Conditions/Contract; this sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. This gives a clear understanding of what residents can expect. EVIDENCE: DS0000027805.V338585.R01.S.doc Version 5.2 Page 9 The inspector examined the written records for 3 residents. Each file contained all of the necessary pre-admission assessment information so that the home was clear about people’s needs before they moved in. All 3 residents had been admitted to the home from hospital and a number of assessments had been provided to the home from health care professionals such as occupational therapists, physiotherapist and nursing staff. There was evidence that senior staff from the home visited the prospective residents prior to admission and good quality assessments had been undertaken. These assessments were comprehensive and covered all care needs, including day-to-day care, specialist nursing needs, their social compatibility and any specialist communication needs they might have. It was clear from the admission notes for 1 person that at the time of their admission, their relatives were made welcome and remained with them throughout the day. It is noted clearly in the home’s brochure that Chiropody and Physiotherapy services are included as part of the service. The home provides a contract to each person at the time of admission and it is made clear, who is responsible for providing any specialist equipment required by individual residents. DS0000027805.V338585.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. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each resident’s plan; they give an overview of their health needs and act as an indicator of change in health requirements. Staff respect privacy and dignity and are sensitive to changing needs. They listen to people and take account of what is important to them. People have access to healthcare and remedial services. The health care needs of residents unable to leave the home are managed by visits from local health care services. People have the aids and equipment they need. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. There are adequately safe facilities for keeping medication. Medication is administered by qualified nursing staff. There is a need generally, to reemphasise the importance of falls prevention. Staff work to clear and robust practices when caring for people who have degenerative conditions and terminal illnesses. Care staff work to a high consistent standard in monitoring pain, distress and other symptoms to ensure people receive the care they need. DS0000027805.V338585.R01.S.doc Version 5.2 Page 11 EVIDENCE: The inspector reviewed the written records for 3 residents with regard to their health care needs. The inspector noted that each person had a good quality care plan and risk assessments in place. Each person’s written records reflected that they were reviewed by a GP on a regular basis especially when unwell. Residents had also had access to support and treatment from a range of health care professionals such as dentists and opticians, speech therapists and physiotherapists. Where bed rails were used, the inspector noted that buffers were fitted and that, in written records the risks were described that had led to their use. Permission had been sought from the resident, their representative and the GP. At the previous inspection the registered persons was required to ensure that where bed rails are used, a risk assessment is in place regarding the risks involved in their use, and include interventions to minimise these risks. At this inspection the inspector was able to confirm that these issues had been addressed. The inspector reviewed the records of 1 person who had a peg feed at the point of admission. The inspector noted that the hospital had provided all of the necessary information regarding this, and a referral had been made to the community dietician for ongoing support. A clear record was kept by the home of the use and care of the peg feed, including all medication administered via this route. The inspector observed that signs displayed to indicate that barrier nursing was in place for 1 person. The inspector noted that several staff have recently had training in infection control. The inspector reviewed the records of accidents, reviewed the written records for 2 residents who had fallen recently, and met the residents concerned. The inspector noted that each person had risk assessments in relation to the risk of falls in their written records and that these were updated to reflect the risks as people’s needs changed. However, there was room for improving these by including more guidance for staff regarding interventions to reduce the risks, specific to each person. Recommendations are made in relation to this, and in relation to providing training for staff regarding falls prevention. The inspector noted that 2 people were being treated for pressure sores at the time of the inspection. The inspector reviewed the nursing records of their care and noted that clear instruction was provided regarding the types and frequencies of treatments. At the previous inspection a recommendation was made for the registered persons to ensure that descriptions of the progress of the wound be included in the nursing records and the inspector found that this recommendation had been acted upon. Records reflected that people, who DS0000027805.V338585.R01.S.doc Version 5.2 Page 12 had recently been treated for pressure sores, had them when they were transferred from hospital, and that of the 4 people recently treated, 2 people’s sores had now healed. The inspector noted, that where the risk of pressure sores was identified pressure-relieving equipment was being used. 1 person’s records also indicated that their diet and liquid intake was being closely monitored. The feedback from residents was positive about staff. 1 person said that they were “very good”. People indicated that staff were sensitive to their needs and ensured that their privacy was respected. The inspector observed that staff were careful to ensure that people’s doors were closed when they were being provided with personal care. Medication is administered by qualified nursing staff and their competence is assessed as part of their induction and personal development plan. The inspector observed medication being administered by 1 staff member. This was done competently and with sensitivity. The medication procedure and records provide a clear audit trail for the receipt, administration and disposal of medication. Medication is kept in 2 locked trolleys near the nurses’ station, and although this is not ideal, it is acceptable. DS0000027805.V338585.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. People have the opportunity to develop and maintain important personal and family relationships. The staff team gives help with communication skills, to enable residents to fully participate in daily living activities. People are offered meaningful activities. The menu is varied but could offer further choice at lunchtimes. The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. Care staff is sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. They are aware of the importance of feeding at the pace of the person, making them feel comfortable and unhurried. EVIDENCE: There are activities arranged by the home that the residents can take part in, although some people said that they preferred to stay in their rooms. It was clear from resident’s records seen by the inspector that their relatives visited on almost a daily basis. The inspector observed several relatives spending time with residents and that those who were visiting at lunchtime were offered lunch, and that there was a relaxed and friendly atmosphere. DS0000027805.V338585.R01.S.doc Version 5.2 Page 14 Nutritional assessments were included in residents’ records. In addition, the inspector noted that 2 staff have undertaken a 10 week course in nutrition and peg feeds. The records of 1 person, reviewed by the inspector reflected that there was a concern about them loosing weight prior to admission and that they had re-gained weight since admission. Feedback from residents is that is that the standard of food provided in the home is good. The inspector observed that drinks and snacks were being taken around to residents throughout the day. At lunchtime some people were being helped to eat by staff, the inspector observed that where their food was pureed, it was done seperately and the staff were gentle and discreet in the way in which they were helping people. Where they are well enough, residents have a choice of where they sit to have their lunch. People are consulted regarding their choice of food before each meal. However, 1 resident told the inspector that there were no choice of main meal provided on the menu at lunchtime, although there was a choice at teatime. The inspector observed another resident saying that they did not like their meal at lunchtime, but they were not offered an alternative. A recommendation is made in relation to this. At the previous inspection it was recommended that the registered persons continue to target recruitment to Greek and Turkish speaking staff to help in communicating with Greek and Turkish residents. As a result of this and of feedback from relatives, the registered person has ensured that there are more staff members in the team who can speak to residents in their first language. DS0000027805.V338585.R01.S.doc Version 5.2 Page 15 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. The home has a complaints procedure that is clearly written and easy to understand to help anyone living at, or involved with, the service to complain or make suggestions for improvement. The complaints procedure is supplied to everyone living at the home and is displayed within the home. Residents and others involved with the home understand how to make a complaint and are clear about what will happen if a complaint is made. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. The home understands the procedures for Safeguarding Adults and has previously attended meetings or provided information to external agencies when requested. Staff training in the area of protection is regularly arranged by the home. Some staff have also had training around dealing with physical and verbal aggression. EVIDENCE: The home has a complaints procedure, provided to all residents and their relatives, and the inspector noted that it is displayed in the home. There is a post box for comments in the home, so that people can use this to give feedback and remain anonymous if they wish to. The inspector reviewed the record of concerns and complaints that is kept in the home. 2 complaints had been recorded since the last inspection. Records indicated that they had been dealt with fairly and satisfactory solutions had been found to the issues raised. DS0000027805.V338585.R01.S.doc Version 5.2 Page 16 Detailed records had been kept of the complaints, the investigations, the outcomes and action taken as a result. The inspector spoke to 2 residents in private and both were clear who they would talk to if they had any concerns or complaints. Neither wished to raise any concerns with the inspector at the time of the inspection. The inspector noted that a number of staff have recently received training regarding safeguarding people and that some staff have been trained in dealing with challenging behaviour. No issues had arisen regarding safeguarding people since the previous inspection. DS0000027805.V338585.R01.S.doc Version 5.2 Page 17 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, 21, 22, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there and provides specialist aids and equipment to meet their needs. The home is generally a pleasant, safe place to live, although there is a need to revisit the issue of people’s bedroom doors being propped open, in terms of fire safety. Bedrooms are shared in limited situations and when it does happen it is only by agreement with the people using the service, and they are given the choice to move into a single room when 1 becomes vacant. Screens are provided for privacy and the rooms reflect the chosen décor and personal belongings of both people. People who use services are encouraged to personalise their bedrooms. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet residents’ needs, and are in sufficient numbers and of good quality. The home is well lit, clean and tidy and smells fresh. The home has an infection control policy, and staff are encouraged to work to the policy to reduce the risk of infection. DS0000027805.V338585.R01.S.doc Version 5.2 Page 18 EVIDENCE: During the tour of the building the inspector noted that the overall standard of the fabric and decoration in the building was good. The people who have a higher care and nursing needs are provided with rooms near to the nurses’ station on the ground floor. Despite people being nursed, the home is not clinical in appearance, and manages to keep a homely feel. There are sufficient toilets, showers and bathroom facilities. The bathrooms have are fitted with thermostatic mixer valves. The home has a separate laundry with a sluice facility. There are a number of hoists, and there was clear evidence that they have been regularly serviced. There is a lift available to provide access to the upstairs floor. There is a nurse call system installed. The manager explained that new floor covering is to be provided in the corridors in the The inspector was pleased to note that many rooms had people’s photos on the bedroom doors to help them to identify their rooms. There are 2 shared bedrooms and the rest are single. The shared rooms are provided with screens in order to protect people’s privacy. The rooms seen by the inspector were comfortably furnished, with evidence of peoples’ own personal effects being used to brighten, and make them more homely. These included pictures, and small items of furniture. 2 of the residents who spoke to the inspector said that they had been in the home for quite a long time were settled there, and happy with their rooms. Many rooms had laminate flooring provided. The home was comfortably warm at the time of inspection and covers have been provided for the radiators. The inspector noted that the home felt comfortable, fresh and clean throughout. 1 person was being barrier nursed and there were notices in appropriate places warning of this. The home has a control of infection procedure and staff were observed to be adhering to the procedure. The inspector noted that some staff had recently been provided with training regarding infection control. The inspector noted that there are written requests for bedroom doors to be kept open during the daytime on 3 of the residents’ files seen by the inspector, and several people had their bedroom doors propped open during the inspection. The inspector discussed alternative methods of ensuring the safety of those people who keep their doors open in the event of fire, such as individual automatic door closures. A recommendation is made in respect of this. DS0000027805.V338585.R01.S.doc Version 5.2 Page 19 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. There are consistently enough staff available to meet the needs of the people living in the home. The way in which the rota is managed ensures that there are qualified nurses on duty at all times. The home ensures that staff receive relevant training. The home puts a high level of importance on training and staff are supported through training to meet the individual needs of residents. The home has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for people’s protection. There are clear contingency plans for cover for vacancies and sickness and there is little use of any agency or temporary staff. Supervision sessions are regular and notes are taken of each session. EVIDENCE: The inspector noted that there were good levels of staffing at the time of the inspection. This included the matron, 6 carers, 1 qualified nurse, the cook, the housekeeper and the administrative officer. The inspector was provided with a copy of the planned staffing rota for the week of the inspection, and this indicated that there are usually at least 6 care staff, and quite often 2 qualified nurses on duty, including the manager. DS0000027805.V338585.R01.S.doc Version 5.2 Page 20 Staff personnel files were examined for 2 staff who had been recruited recently. All files were found to contain the relevant information specified under the Care Homes Regulations. There was evidence to indicate that all staff had been subject to appropriate CRB checks. The home has a stable core team of nursing and care staff who have worked there for some years. In addition, they regularly recruit adaptation nurses. The inspector saw evidence of the system that is in place to provide induction, ongoing supervision and appraisal of nurses’ and care staff members’ competence. The inspector remains impressed with the comprehensive nature of this system and with the clear and well-organised way in which it was presented. Each staff member has a personal development plan that outlines the training that they have undertaken and highlights their training needs. Evidence that each person’s competence has been assessed in a broad range of nursing and care procedures is also recorded as part of supervision. This takes place weekly in the case of the adaptation nurses, and monthly for other staff members. DS0000027805.V338585.R01.S.doc Version 5.2 Page 21 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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required qualification/s and experience and is competent to run the home. The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. The management team promote equal opportunities, has good people skills and understand the importance of person centred care and effective outcomes for people who use the service. The service has sound policies and procedures, which the management team effectively review and update. The management team ensure staff follow the policies and procedures of the home. The management process ensure that staff receive feedback on their work. The home works to a clear health and safety policy, all staff are fully aware of the policy and are trained to put theory into practice. Regular random checks take place to ensure they are working to it. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. The home has a consistent record of meeting relevant health and safety requirements and legislation, and of monitoring its own practice. Records are DS0000027805.V338585.R01.S.doc Version 5.2 Page 22 of a good standard and are routinely completed. The manager ensures risk assessments are completed and taken into account in planning the care and routines of the home. The home has the necessary insurance cover in place to enable it to fulfil any loss or legal liabilities. EVIDENCE: The matron is the registered manager of the home. She is a qualified RGN and has considerable nursing experience. She has recently completed the registered managers award. In addition there is a floor manager, who helps to maintain the day-to-day running of the home and takes responsibility for the quality assurance systems in the home. The floor manager is the daughter of the registered person and as been part of the management team for a number of years. The managers come cross as committed, professional and efficient. The inspector saw the records kept in the home of any incidents and accidents. This was noted to be well organised and staff had provided full and comprehensive information of any accidents and incidents that had taken place. There are processes in place for the home to ensure that people’s views are incorporated in they way the home is run. Feedback cards are used twice a year in addition to the post box mentioned under Standard 16 of this report. Information from the registered person provided via the annual quality assurance assessment indicates that changes and improvements have been made to the menu, the languages spoken by staff, and activities as a result of feedback received by the home. The home does not help residents to manage their finances. Records reflect that where people need help to manage their finances this tends to be done by their families. The home provides all toiletries and where other items, such as hairdressing, are needed the floor manager also approaches peoples’ relatives about this. Information from the registered person provided via the annual quality assurance assessment indicates that the relevant checks and maintenance is undertaken promptly. During the tour of the building the inspector noted that the health ands safety awareness in the home is of good standard. Records reflect that induction training includes reference to all necessary areas of health and safety in the home. There are several fire doors that are fitted with automatic closures. The inspector noted that a fire risk assessment is in place, and in the light of the fact that resident’s bedroom doors are propped open; there is reference to the importance of ensuring that fire doors are closed in the event of a fire. DS0000027805.V338585.R01.S.doc Version 5.2 Page 23 DS0000027805.V338585.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 X 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 3 X 3 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 X X 3 DS0000027805.V338585.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. Standard Regulation Requirement Timescale for action 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 OP8 Good Practice Recommendations It is recommended that residents’ risk assessments regarding falls are developed further to include interventions to reduce the risks, specific to each person. It is recommended that staff be provided with training regarding falls prevention. It is recommended that alternative choice of main meal be provided as a standard part of the lunchtime menu. It is recommended that the registered person seek alternative methods of ensuring the safety of those residents who choose to keep their bedroom door propped or wedged open. 2. 3. 4. OP8 OP15 OP19 DS0000027805.V338585.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 DS0000027805.V338585.R01.S.doc Version 5.2 Page 27 - 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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