Inspection on 29/07/04 for Conifers The

Care Home For Older PeopleConifers, The473-475 Green Lanes Palmers Green London N13 4BSUnannounced Inspection29th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Conifers, The Address 473-475 Green Lanes, Palmers Green, London, N13 4BS Email address Name of registered provider(s)/company (if applicable) Mrs Bridget Murray Name of registered person (if applicable) Ms Olivia Moyo [awaiting registration] Type of registration Care Home No. of places registered (if applicable) 30 Tel No: 020 8882 3249 Fax No: 020 8882 6160Category(ies) of registration, with (number of places) Old age, not falling within any other category (30) Registration number G080000398 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 19th March 2004 YES YES 29/10/04 If Yes refer to Part CConifers, ThePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 329 July 2004 14:15 pm Georgia Chimbani Caroline MitchellID Code141671Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionN/A Ms Olivia Moyo [Matron]Conifers, ThePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementConifers, ThePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Conifers, The. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Conifers, ThePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Conifers is registered for 30 older people and provides nursing care. The home is a privately owned family-run home and the proprietors own one other care home in Totteridge, North London. The home, which is situated in Palmers Green, is a detached, two-storey building in the busy Green Lanes road. It is close to all local amenities; shops, restaurants, pubs, churches etc. The upstairs can be accessed by a lift. There are 26 single rooms and two shared rooms. Fourteen rooms have en-suite WC and shower facilities which have been adapted to provide sit-down access. The stated aims of the home are to provide long-term nursing care for older people.Conifers, ThePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Conifers, ThePage 6 Present at this unannounced inspection was Ms Olivia Moyo the matron of the home and two inspectors. Ms Moyo is in the process of registering with the CSCI as the registered manager. Presently management duties are shared between her and Ms Lorna Bailey. Mrs Murray the registered person arrived after the inspection had commenced and she left before the inspection was completed, however, during the time she was in the home she made herself available to the inspectors. All staff present participated fully in the inspection process. The inspection took place in the afternoon after lunch when most service users were resting in their rooms therefore to minimise disruption only three service users who were observed sitting in the communal areas or their bedrooms were interviewed. Feedback from service users regarding the quality of care was generally positive. One service user had issues with some members of staff however the matron was aware of these and efforts had been made to resolve these. Thirteen requirements were issued at the last inspection five are met and eight are restated. A further eight requirements are issued bringing the total number of requirements following this inspection to sixteen. The registered person is encouraged to comply with these within the timescales set to avoid further action by the CSCI. Failure to comply with restated requirements concerning health and safety for example fire doors being wedged open will result in enforcement action. Choice of home (Standards 1-6) Three standards were assessed. One was met. Full assessments are undertaken on service users prior to admission. The home is able to meet service users needs, however more evidence is required in support of a variation application for a service user who has developed dementia. The statement of purpose must be reviewed. Health and Personal Care (Standards 7-11) Five standards were assessed. Four were met. Care plans were in place and the wishes of service users in relation to their death were recorded. Service users are treated with dignity and respect. Some medication issues need to be addressed. Daily Life and Social Activities (Standards 12-15) Two standards were assessed. One was met. Evidence was available that service users have a full choice about their meals however service users activities need to be recorded. Complaints and Protection (Standards 16-18) One standard was assessed and not met. Records of complaints received by the home were viewed however the home needs to ensure that any action taken and the date are clearly recorded. Environment (Standards 19-26) Three standards were assessed. One was met. The requirement to ensure that clinical waste is disposed of properly was met and no unpleasant odours were detected. There are some maintenance issues to be addressed and an assessment by an Occupational Therapist must be arranged. Staffing (Standards 27-30) One standard was assessed and met. There were sufficient staff on duty at the time of the inspection. Conifers, The Page 7 Management and Administration (Standards 31-38) Six standards were assessed. Two were met. The home has attempted to seek the views of service users and their families about the quality of the service but the response had been very low. The registered person needs to carry out monitoring visits and send copies of her report to the CSCI. A finance and development plan for the home was still not available. No access was available to supervision records therefore these will be examined at the next inspection. The registered person is required to ensure that fire doors are self-closing and not wedged open and that a Fire Officer visits the home.Conifers, ThePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 4 OP1 The registered person must include in the Statement of Purpose that the home will accommodate service users who develop dementia as long as the home can meet their needs. The temperature of the area where medication is stored must be kept below 25oC. The registered person must ensure that service users activities are recorded in daily records. The registered person must ensure that the deficits identified in the commentary are rectified. The registered person must carry out monthly unannounced visits to the home and send a copy of the report to the CSCI.31/12/032 313OP931/12/0317(1) OP12 Schedule 331/12/034 23(2) 5 26(1) 6 7 8 13 OP38 25 OP33 OP34 OP1931/1/0431/12/03The registered person must produce a financial 31/1/04 business plan for inspection. The registered person must ensure that staff receive formal supervision sessions. The registered person must ensure that the issues addressed in the commentary are addressed and rectified. 31/12/0318OP3631/1/04Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements.Conifers, ThePage 9 RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard It is recommended that the registered person obtain service users or relatives signatures for all financial transactions, and countersigned by the manager.1OP35CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). 30 adults of either gender over the age of 65 needing nursing care. 1 specified service user who is under 65 years of age may remain accommodated in the home. The home must advise the regulating authority at such times as the specified service user attains 65 years of age.Met (Yes / No) YES YES YESConifers, ThePage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The registered person must include in the Statement of Purpose that the home will continue to accommodate service users who develop dementia only for as long as the home can meet their needs and subject to an agreed variation to the conditions of registration. A copy of the revised statement of purpose must be sent to the CSCI on completion. This requirement is amended and restated. 2 OP4 The registered person is required to ensure that the current certificate of registration is displayed. 15/8/0414, 6OP130/8/04314OP4The registered person must provide the CSCI with a letter from the service users placing authority in support of the proposal that the home is still able to meet the specified service 30/8/04 users needs. This information will be used by the CSCI in reaching a decision regarding the application for a variation.Conifers, ThePage 11 413(2)OP9The registered person is required to provide a cooling system in the area where medication is kept to ensure that temperatures are maintained below 25 degrees Celsius. This requirement is amended and restated. The registered person must ensure that service users activities are recorded in daily records. This requirement is restated.30/10/04517(1) OP12 Schedule 330/8/04622OP16The registered person is required to ensure that clear records are maintained of all complaints received by the home, any action taken and the time taken to respond to them. The registered person is required to ensure that the wall above the kitchen door is repaired and a cover is placed over the florescent light. This requirement is restated. The registered person is required to ensure that the floor covering in room four, the ground floor shower room and the sluice room is replaced. Redecoration of the corridors and the annex to the laundry room is required. The registered person is required to ensure that the shower head is fixed to the wall and the lock on the bathroom door in room 21 is repaired. The registered person must ensure that the premises and facilities are assessed by an Occupational Therapist to ensure that where appropriate, service users are provided with the recommended equipment and adaptations. The registered person must carry out monthly unannounced visits to the home. Reports of her visits must be maintained in the home and copies sent to the CSCI. This requirement is amended and restated.30/9/04723(2)(b)OP1930/9/04823(2)(b)(d)OP1930/12/04923(2)(b)(d)OP1930/8/041023(2)(n)OP2230/11/041126(1)OP3330/8/04Conifers, ThePage 12 25 12OP34The registered person must produce a financial business plan for inspection. This requirement is restated. The registered person must ensure that staff receive formal supervision sessions. This requirement is restated.30/9/041318OP3630/9/041413(4)(c), 23(4) 23(4) 16(2)(g)OP38The registered person is required to ensure that fire doors are not wedged open and are self-closing at all times. This requirement is restated. The registered person is required to arrange a visit by a fire officer to the home. The registered person must replace the microwave oven in the kitchen15/8/0415 16OP38 OP3830/10/04 30/10/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * It is recommended that the registered person obtain service users or relatives signatures for all financial transactions, and countersigned by the manager. This recommendation is restated.1OP35* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Conifers, ThePage 13 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NA YES NO YES NO NO YES NO NO NO YES NO YES 3 0 0 NO NO YES NO X X 29/7/04 14.15 3.0Conifers, ThePage 14 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Conifers, ThePage 15 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are:YESHAIRDRESSING AND TOILETRIES 2 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that the statement of purpose states that the home will continue to accommodate service users who develop dementia only for as long as the home can meet their needs and subject to an agreed variation to their conditions of registration. The registered person advised the inspectors that a copy of the revised statement of purpose had been sent to the CSCI together with other documentation following the requirements at the last inspection. Following this inspection this documentation was not available on file therefore in the absence of this documentary evidence this requirement is restated.Conifers, ThePage 16 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The case files contained assessments by care managers and the homes own assessment tools. Continued compliance with this standard was confirmed.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? The inspectors observed that service users appeared well looked after and they were regularly provided with refreshments. Two service users confirmed that they were well looked after. The home currently has a variation allowing it to accommodate a service user under the age of sixty-five however the certificate of registration displayed did not reflect this. The registered person is required to ensure that the most recent certificate of registration is displayed. The home is in the process of applying for a variation for a service user who has developed dementia. The inspector was given a copy of a recent assessment by the placing authority however while this stated the service users needs there was no indication of whether these were being appropriately met by the home. The registered person must provide the CSCI with a letter from the service users placing authority in support of the proposal that the home is still able to meet the specified service users needs. This information will be used by the CSCI in reaching a decision regarding the application for a variation.Conifers, ThePage 17 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard is not applicable.Conifers, ThePage 18 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? A sample of service user care plans was examined. They were found to be sufficiently detailed and there was evidence of monthly reviews. This was seen as evidence of compliance.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X X3 Key findings/Evidence Standard met? Records examined indicated that service user had regular access to a variety of healthcare professionals. Discussions with the matron and examination of care plans revealed that despite most service users in the home being bed bound, there were no service users with pressure ulcers except for three service users with leg ulcers. This standard is assessed as met.Conifers, ThePage 19 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 1 Key findings/Evidence Standard Met? At the previous inspection the registered person was required to ensure that all medication received into the home in the nomad boxes is checked against any accompanying documentation. The registered person was also required to ensure that the temperature of the area where medication is stored is kept below 25 degrees Celsius and that hazard notices are displayed when oxygen is used in service users rooms. The inspectors were able to confirm that appropriate checks and records were completed for any medication received into the home. The matron advised that there were no service users requiring oxygen however hazard notices were displayed when it was in use. Medication is kept in two locked trolleys near the nurses station however records of temperatures of this area were in the region of 32 degrees Celsius which exceeds the recommended levels. The registered person is required to provide a cooling system in the area where medication is kept to ensure that temperatures are maintained below 25 degrees Celsius. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Discussions with service users confirmed that they were treated with respect and their privacy respected by staff.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that the wishes of service users in relation to their death are recorded. Documentation on file confirmed that this information had been recorded. This was seen as evidence of compliance.Conifers, ThePage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 1 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that service users activities are recorded in daily records. The inspectors noted that there was no documentary evidence to confirm compliance with this requirement therefore, This requirement is restated.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Conifers, ThePage 21 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that service users are enabled to express choice about the menus and their choice is recorded. Discussions with the cook revealed that service users were consulted regarding their choice of food before every meal. This was confirmed in discussions with service users. An inspection of the kitchen showed that it was well stocked with fresh fruit and vegetables and fridge and freezer temperatures were being maintained. The inspectors observed a board in the kitchen that gave details of service users dietary needs for example if they had no sugar in their tea or had their food pureed.Conifers, ThePage 22 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 11 X X X X X X 2 Key findings/Evidence Standard met? The homes record of complaints was examined. Some complaints received had been recorded however some complaint details were not given and reference was made to a letter in a separate file. It was also difficult to determine the action taken and the date in relation to some complaints made therefore the inspectors were unable to clearly determine which complaints had been substantiated or not and time taken to respond to them. The registered person is required to ensure that clear records are maintained of all complaints received by the home, the action taken and the time taken to respond to them.Conifers, ThePage 23 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence This standard was not assessed on this occasion. Standard met? YES 0 0Conifers, ThePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 1 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that the ramp leading to the garden at the rear of the building was not used and that the wall over the door in the kitchen is repaired and the florescent light repaired and a cover obtained. The inspectors were able to confirm that the ramp at the rear of the building was not being used as a no entry sign was in place. The matron advised that no risk assessments had been carried out to see if the gradient meets building regulations and a decision had been taken to restrict access to the ramp. The inspectors were able to confirm that the ramp at the rear of the building was not being used as a no entry sign was in place. The inspectors observed that attempts had been made to repair the wall above the door in the kitchen but the plastering was falling away. The florescent light was working but it still had no cover. The registered person is required to ensure that the wall above the kitchen door is repaired and a cover is placed over the florescent light. During a tour of the building the inspector noted that the home was clean and brightly decorated however the following areas were identified as needing repair or maintenance: The floor covering in room four needs to be replaced and a window restrictor is required on one of the windows. The floor covering in the shower room on the ground floor needs to be replaced. The shower head needs to be attached to the wall. The floor covering in the sluice room needs to be replaced. The lock on the bathroom door in room 21 needs repair. Redecoration is required in the corridors and the annex to the laundry room.Conifers, ThePage 25 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? The home has three electric and one manual hoists that have been recorded as regularly serviced. The inspectors saw evidence of pressure mattresses used to reduce the risk of service users developing pressure sores. A service user interviewed stated that she found her commode uncomfortable as it was too small for her. The registered person must ensure that the premises and facilities are assessed by an Occupational Therapist to ensure that where appropriate, service users are provided with the recommended equipment and adaptations.Conifers, ThePage 26 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was not assessed on this occasion. YES NO NO X X X X Standard met? 0 X XX X X XConifers, ThePage 27 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? At the time of the inspection the home was found to maintain high levels of hygiene and no offensive odours were detected. At the previous inspection the registered person was required to ensure that the yellow bags are regularly disposed of and that the skip is fitted with a cover. The matron informed the inspectors that yellow bags are collected once a week and it was observed that the skip had been fitted with a cover. This was seen as evidence of compliance.Conifers, ThePage 28 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X3 Key findings/Evidence Standard met? The home was adequately staffed on the day of the inspection. The matron explained that on a typical day the home would have six carers and two RGNs in the morning, four carers and one RGN in the afternoon and two carers and an RGN at night. On the day of the inspection an RGN was sick therefore the Matron had stepped in to cover their duties. This standard is assessed as met.Conifers, ThePage 29 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered person and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard was not assessed on this occasion. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Conifers, ThePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered person is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 32 (32.1 ­ 32.7) The registered person ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Conifers, ThePage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 1 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure a better uptake of service user satisfaction questionnaires and produce the results for inspection. The registered person was also required to carry out monthly unannounced visits to the home and send a copy of the report to the CSCI. The registered person advised that despite sending out questionnaires with invoices only three responses has been received. These were examined and found to contain positive feedback. The inspectors reminded the registered person that she was required to carry out monthly visits to the home, compile a report a copy of which would be maintained in the home and another sent to the CSCI. The last report received from the registered person was dated March 2004. This requirement is restated. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? At the previous inspection the registered person was required to produce a financial business plan for inspection. The registered person advised that this requirement had not been met therefore it is restated. The insurance certificate displayed in the home was no longer valid however the registered person produced documentation confirming that this had been renewed but a new certificate had not yet been received. This was seen as evidence of compliance.Conifers, ThePage 32 Standard 35 (35.1 ­ 35.6) The registered person ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X2 Key findings/Evidence Standard met? At the previous inspection it was recommended that the registered person obtain service users or relatives signatures for all financial transactions, and countersigned by the manager. The manger who deals with service user fiancés was not present at the time of the inspection therefore compliance with this recommendation will be assessed at the next inspection. This recommendation is restated.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that staff receive formal supervision sessions. The matron advised that she had no access to staff supervision records as they were locked in a cabinet and the key was with the manager who was not present at the time of the inspection. Compliance with this requirement will be checked at the next announced inspection. This requirement is restated. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that service users records are stored in a lockable facility. The matron showed the inspectors a lockable storage space at the nurses station where service users files are now stored. This was seen as evidence of compliance.Conifers, ThePage 33 Standard 38 (38.1 ­ 38.9) The registered person ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 1 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that portable appliance testing is carried out and automatic closing devices are fitted to fire doors. The inspectors noted that fire doors were still wedged open in various ways. Some fire doors in the ground floor corridor did not appear to be self-closing. The registered person is required to ensure that fire doors are not wedged open and are self-closing at all times and that a visit by a fire officer to the home is arranged. Failure to respond to the repeated requirement regarding wedged fire doors will result in enforcement action. The following health and safety checks were confirmed as having been carried out by the home; Portable appliance testing 17/10/03 Fire alarm servicing 22/4/04 Fire equipment 8/12/03 Emergency lighting 14/5/04 Nurse call system 17/10/03 Lift 28/5/03 Safe water analysis 27/11/03 Environmental health visit 19/2/03 Gas 19/10/03 Electrical installation 3/10/02 [valid for 3 years] Hoists 23/1/04 and 23/7/04 The accident book was examined and it revealed that there were no major injuries recorded except four falls since February 2004. The registered person is required to replace the microwave oven in the kitchen as the one seen at the time of the inspection had developed rust inside.Conifers, ThePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance 30 adults of either gender over the age of 65 needing nursing care. CommentsYESYES Condition Compliance 1 specified service user who is under 65 years of age may remain accommodated in the home. CommentsYES Condition Compliance The home must advise the regulating authority at such times as the specified service user attains 65 years of age. Comments Service user will be reaching the age of 65 in October 2004.Lead Inspector Second Inspector DateGeorgia Chimbani Caroline Mitchell 3 August 2004Signature Signature SignatureRegulation Manager Frank ClarkePublic reports It should be noted that all CSCI inspection reports are public documents.Conifers, ThePage 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Unannounced Inspection of The Conifers N13 conducted on 29 July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible AN ACTION PLAN HAS BEEN RECEIVED FROM THE PROVIDER.Conifers, ThePage 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 31 August 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Conifers, ThePage 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mrs Bridget Murray of The Conifers N13 confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 29 July 2004 and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Mrs Bridget Murray of The Conifers N13 am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 29 July 2004 for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Conifers, ThePage 38 - 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. 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