Inspection on 09/12/04 for Conifers The

Care Home For Older PeopleConifers The473-475 Green Lanes Palmers Green London N13 4BSAnnounced Inspection9 December 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 manager (if applicable) 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 29/7/04 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 39th December 2004 09:30 am Georgia Chimbani Tola Akinde-Hummel Marilyn MackenzieID Code141671Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNA Mrs Lorna Barry [Floor Manager] and Mrs 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.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 5 Present at this announced inspection was Mrs Olivia Moyo, the matron and registered manager and Mrs Lorna Barry the floor manager. Both managers and staff involved in the inspection cooperated full with the inspection process. Interviews were carried out with service users, relatives and staff. Feedback from service users and relatives regarding the quality of care was generally positive. Staff were also very positive about the quality of care offered to service users and the management style at the home. Sixteen requirements were issued at the last inspection, thirteen are met and three are restated. A further eight requirements are issued bringing the total number of requirements following this inspection to eleven. The inspectors were concerned to note that the requirement relating to fire doors is restated from the previous two inspections. The registered person is urged to give priority to this requirement to avoid enforcement action by the CSCI. Choice of home (Standards 1-6) All six standards were assessed and met. The statement of purpose has been reviewed to include the required information. Files examined contained signed statements of terms and conditions and preadmission assessment information. There was evidence to confirm that the home is able to meet service users needs. Health and Personal Care (Standards 7-11) All five standards were assessed. Three were met. Medication practises within the home meet the national minimum standards. Interviews with service users confirmed that staff treated them with dignity and respect. Service users wishes in the event of their death were recorded. Care plans were in place however information must be presented in a way that ensures service users needs are clear. Clarity is required on how scores for risk assessments are determined. Daily Life and Social Activities (Standards 12-15) All four standards were assessed and met. There were detailed records of service user activities and discussions with management confirmed that there were no restrictions on visitors in the home. Service user are encouraged to make decisions regarding all aspects of their life in the home. The inspectors received positive feedback regarding the quality of food and alternatives offered at the home. Complaints and Protection (Standards 16-18) All three standards were assessed. One was met. The inspectors received confirmation that service users living at the home are registered to vote. 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. Staff must receive training in adult protection. Environment (Standards 19-26) All eight standards were assessed. Seven were met. Standards relating to communal space, toilet and bathing facilities, heating and lighting and individual accommodation are met. No offensive odours were detected in the home on the day of the inspection. A restated requirement is made relating to some maintenance issues that need to be addressed. Staffing (Standards 27-30) All four standards were assessed. Two were met. Conifers The Page 6 There were sufficient staff on duty at the time of the inspection. Staff files contained the required information and all but one staff had the required level of CRB disclosure. Some staff are working towards the attainment of an NVQ qualification. Staff require training in core areas of practise. Management and Administration (Standards 31-38) All eight standards were assessed. Five were met. The registered manager has the necessary qualifications and competencies to run the home. Discussions with staff and observations by the inspectors revealed that the home has a positive style of management. Records indicated that staff receive regular supervision. Records of money received on behalf of service users must be maintained. A review of the reporting format of regulation 26 visits is required. Fire doors were still wedged open and checks are required of water storage tanks.Conifers ThePage 7 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 actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Conifers ThePage 8 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 ensure that care plans are presented in a way that ensures 1 15 OP7 30/4/05 that all aspects of service users needs and wishes are taken into account. The registered person is required to ensure that service user risk assessments are signed, dated and maintained up to date. Risk 30/4/05 assessments must also clearly indicate how the decision on the level of risk is arrived at. The 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. [timescale of 30/9/04 not met] This requirement is restated.213(4)(c)OP8322OP1631/3/05413(6)OP18The registered person must ensure that all staff receive adult protection training and that 30/4/05 local authority adult protection procedures are available in the home. The registered person is required to address the areas detailed under standard nineteen in the body of this report. This requirement remains in the timescale stated at the previous inspection.523(2)(b)(d)OP1930/4/05Conifers ThePage 9 619 OP29 Schedule 2The registered person must ensure that an enhanced CRB disclosure is applied for, for a member of staff who currently has a standard disclosure. Confirmation must be sent to the CSCI upon receipt of the enhanced CRB disclosure. The registered person is required to ensure that all staff working in the home have received training in the following core areas; moving and handling, infection control, fire safety, food hygiene and first aid. Training in some of these areas must have started by 30/4/05. The registered person is required to review the report format for regulation 26 visits by the provider to ensure that it includes more detailed information. The registered person must ensure that accurate records are kept of all money received by the home on behalf of service users. The registered person is required, in consultation with the fire authority to ensure that all fire doors in the home are self-closing at all times and that fire risk assessments are updated. [timescale of 15/8/04 not met] This requirement is amended and restated form the previous two inspections. The registered person is also required to ensure that checks of water storage tanks are carried out and that that tests are carried out on the risk of Legionella.28/2/05713(6), 18(1)(a)(c) (i)OP3030/04/05826(1)OP3328/2/05917, Schedule 4 OP35 para 930/4/051013(4)(c), 23(4)OP3828/2/051113(4)(c)OP3830/4/05Conifers ThePage 10 RECOMMENDATIONS 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 * 1 OP4 It is recommended that the registered person in consultation with service users and or relatives where appropriate, arrange for physiotherapy visits to meet the needs of service users. It is recommended in the guidelines from the Royal Pharmaceutical Society `The Administration and Control of Medicines in Care Homes that medicines should be stored in a dedicated clinical room that contains a wash-hand basin and suitable locked medicine cupboards.2OP9* 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 11 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 YES YES YES NO NO NA YES NO YES NO YES YES YES YES YES YES NO YES 5 3 11 NO NO YES YES 18 9 7/12/04 10.00 7.0Conifers ThePage 12 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 13 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 (£) 488.00 To (£) 525.00Any charges for extras If yes, please state what the extras are:YESHAIRDRESSING AND TOILETRIES 3 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that the homes statement of purpose is revised. At this inspection it was noted that the homes statement of purpose has been revised. It now states that any service user who develops dementia while living in the home will, following an application to and agreement by the commission, continue to be accommodated there for as long as the home can continue to meet their needs. This was seen as evidence of compliance.Conifers ThePage 14 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). 3 Key findings/Evidence Standard met? The inspector examined a random sample of service user files. These contained signed contracts/statements of terms and conditions including information detailed under standard two of the national minimum standards for older people. This standard is assessed as met.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? A random selection of six service user files was examined and these were found to contain the pre and post admission assessment information.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. 3 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that the current registration certificate is displayed. On arrival in the home the inspectors saw the current registration certificate prominently displayed in the foyer. Through observation and interviews with service users, the inspectors were able to confirm that they were happy with the care offered at the home and their needs were being met. Feedback forms completed by relatives on behalf of service users also confirmed this however a few relatives did feel that physiotherapy sessions were a need that needed to be fulfilled. It is recommended that the registered person in consultation with service users and or relatives where appropriate, arrange for physiotherapy visits to meet the needs of service users. At the previous inspection the registered person was also required to 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. Following the last inspection the required information had been sent to the CSCI and the home now had a variation allowing it to look after two service users with a diagnosis of dementia.Conifers ThePage 15 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. 3 Key findings/Evidence Standard met? The home provided evidence that prospective service users were able to visit the home before admission however where service users had no relatives and they were admitted straight from hospital it was not always possible for them to visit the home. During discussion with a service user and her relative it was confirmed that the family members had visited the home on separate occasions prior to approving their relative to be placed there.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 16 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. bService 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. 2 Key findings/Evidence Standard met? A sample of six service user care plans was examined. Generally the level of information contained in their service users files was good. It did however need to be ordered in a way that captured all aspects of the individuals care such as, health, social, religious and cultural needs and wishes and in a format that assists care staff to be clear about all the needs of the service user. The registered person must ensure that care plans are presented in a way that ensures that that all aspects of service users needs and wishes are taken into account.Conifers ThePage 17 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) 18 02 Key findings/Evidence Standard met? At the time of the inspection there were no service users with pressure ulcers. There was documentary evidence on file to indicate that service users had access to a range of health care professionals. Information held at the nurses station gave details of visits by health care professionals and the service users seen at each visit. The inspectors were able to view risk assessments held on file for a number of service users however there was evidence that some risk assessments were not being signed and dated on completion and there was no clarity on how risk assessments scores were arrived at. For example the Norton risk assessment tool was used and a total risk assessment score was noted but there was no evidence to show the grading of the different aspects of the risk assessment to indicate areas of particular concern or risk. The registered person is required to ensure that service user risk assessments are signed, dated and maintained up to date. Risk assessments must also clearly indicate how the decision on the level of risk is arrived at. 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. 3 Key findings/Evidence Standard Met? The pharmacy inspector assessed this standard and the following is a summary of her assessment. This minimum standard is being met. A clear audit trail for the receipt, administration and disposal of medication could be established. The area where the medication is stored is not ideal, but the temperature is being monitored and recorded and maintained below 25oC. It is recommended in the guidelines from the Royal Pharmaceutical Society `The Administration and Control of Medicines in Care Homes that medicines should be stored in a dedicated clinical room that contains a wash-hand basin and suitable locked medicine cupboards.Conifers ThePage 18 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? The inspector interviewed four service users and two relatives during the course of the inspection and they confirmed that service users were treated with respect and their privacy was respected. Staff were observed as being courteous to service users and knocking on bedroom doors before entering.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? Service user files inspected confirmed that their wishes in the event of their death are recorded.Conifers ThePage 19 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. 3 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 were shown very detailed records indicating the dates, type and level of activity that service users participated in. This standard is assessed as met.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. 3 Key findings/Evidence Standard met? At the time of the inspection two residents were celebrating their birthdays. One resident had at least four members of his family in his room and they were clearly relaxed and having a party. The other resident had already had visitors and was waiting for more relatives to arrive in the evening. A relatives interviewed stated that there were restrictions on visiting after 8pm. A member of staff confirmed this however another member of staff stated there were no restrictions on visiting. A discussion was held with the floor manager and matron to clarify the conflicting information. The inspectors were informed that there were no restrictions on visiting however most relatives tended to visit early in the evening and as a result there may be some who assumed that there were restrictions on visiting later in the evening. The manager added that visits were not encouraged before 10.30am to prevent disruption to the service users personal care and breakfast routine however where an early morning visit was deemed necessary it could take place.Conifers ThePage 20 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. 3 Key findings/Evidence Standard met? The inspectors saw evidence to indicate that service users were consulted regarding various aspects of their life in the home such food they wanted to eat and waking and sleeping times.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? The inspectors received very positive feedback from service users regarding the quality of the food offered at the home. The inspectors observed that lunch served on the day of the inspection was well presented and appeared appetising and nutritionally balanced. The cook advised that service users were given alternatives to the meal offered. This was confirmed as the inspector saw a service user eating chicken that had been prepared for her as an alternative option. Continued compliance with this standard was confirmed.Conifers ThePage 21 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? At the previous inspection the registered person was 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 home has received no complaints since the last inspection in July 2004 however the record of complaints has not been revised to enable accurate and sufficient recording of complaints information therefore as stated at the previous inspection it was difficult to determine which complaints had been substantiated or not and time taken to respond to them. The complaints procedure was examined and found to be satisfactory. 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. This requirement is restated.Conifers ThePage 22 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. 3 Key findings/Evidence Standard met? The inspectors confirmed that service users in the home are on the electoral register and are registered to vote by post.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 YES 02 Key findings/Evidence Standard met? There were no outstanding adult protection issues in the home at the time of the inspection. The home has the necessary adult protection policies and procedures however a copy of the local authority procedures are required to be maintained in the home. All staff are required to receive adult protection training.Conifers ThePage 23 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 wall above the kitchen door is repaired, a cover is placed over the florescent light and that the shower head is fixed to the wall and the lock on the bathroom door in room twenty-one is repaired. The registered person was also required to ensure that the floor covering in room four, the ground floor shower room and the sluice room is replaced as well as redecoration of the corridors and the annex to the laundry room. At this inspection it was observed that plastering and painting of the area above the kitchen door had been completed and a cover had been installed on the florescent light. The floor covering in the ground floor shower room had been replaced and the shower head attached securely to the wall. The following areas are still outstanding however they remain within the timescales stated at the previous inspection; A window restrictor is required on one of the windows in room four. 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 annex to the laundry room.Conifers ThePage 24 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. 3 Key findings/Evidence Standard met? The home has sufficient communal space. There are two lounges [one large and the other small] and a dining area. All rooms are airy brightly decorated and comfortably furnished. This standard is assessed as met.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? The home has sufficient toilet and bathing facilities to adequately meet the needs of service users.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. 3 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that the premises and facilities are assessed by an Occupational Therapist. At this inspection the manager advised that a larger commode had been provided for a service user therefore an Occupational Therapist assessment was not considered necessary. The inspector considered this to be evidence of compliance.Conifers ThePage 25 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 NO YES NO 26 14 2 0 3 26 00 0 2 0Key findings/Evidence Standard met? The home meets the national minimum standards relating to room sizes.Conifers ThePage 26 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. 3 Key findings/Evidence Standard met? The home is comfortably furnished and bedrooms inspected contained furnishings in line with the national minimum standards for older people. There was evidence that rooms contained lockable storage spaces and both double rooms have a screen to ensure the privacy and dignity of service users. 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. 3 Key findings/Evidence Standard met? Random checks of water temperature were made and these were found to be within the recommended level. Radiator covers are in place throughout the home.Conifers ThePage 27 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? No offensive odours were detected on the day of the inspection. The sluice room floor requires attention however this has been addressed under standard nineteen in the body of this report.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 5 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 Key findings/Evidence Conifers The 24 1 738.49 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 756.00 X X X9 18 1 Standard met? 3 Page 28 A copy of the current rota was viewed and the inspectors were able to confirm that it accurately reflected the staff on duty. On a typical day the home has an RGN and five carers on duty in the morning, and RGN and four carers in the afternoon and an RGN and two carers on waking nights. The inspectors were satisfied that staffing levels at the home were sufficient to meet service users needs. This was also confirmed through interviews with three members of staff. The inspectors noted that a member of the nursing staff listed on the rota as an RGN was an enrolled nurse. The manager advised that this member of staff was always on duty together with an RGN. The registered person is reminded that nursing staff in charge of any shift in a 24-hour period must be first level registered nurses. 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 manager 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 0 0 3 Key findings/Evidence Standard met? The manager advised that a number of care staff are working towards the attainment of an NVQ however no staff currently hold this qualification. The manager is aware of the requirement to have 50 of staff with an NVQ level two or more by 2005.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? A random sample of six staff file was examined. All files were found to contain the relevant information specified under schedule two of the Care Homes Regulations. There was evidence to indicate that all staff had been subject to CRB checks including POVA where applicable however one member of staff was noted as having a standard CRB disclosure instead of the required enhanced. The registered person must ensure that an enhanced CRB disclosure is applied for, for a member of staff who currently has a standard disclosure.Conifers ThePage 29 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. 1 Key findings/Evidence Standard met? Staff files examined indicated that some staff had received a variety of training courses while others still required training in core areas. For example one member of staff who had been working in the home for a year and a half had received training in adult protection but there was no documentary evidence of training in core areas. Discussion with the manager revealed that this member of staff was enrolled on an NVQ foundation training course and they had covered training in core areas as part of this course. Another member of staff who had worked at the home for a few months, admitted that she had not done this kind of work before but there was no evidence of training in core areas such as moving and handling, food hygiene, adult protection, fire safety, infection control etc. This is required. The registered is required to ensure that all staff working in the home have received training in the following core areas; moving and handling, infection control, fire safety, food hygiene and first aid.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 manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The matron is the registered manager of the home. She is a qualified RGN and has considerable nursing experience.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Management duties at the home are shared between the matron and the floor manager. Interviews with staff revealed that they thought highly of both managers and they had no concerns about the management of the home. The inspectors observed that management and staff appeared to have a comfortable and relaxed relationship. The inspectors were also encouraged to walk freely about the home without the presence of the manager. This was seen as a very positive and open style of management. This was seen as evidence of compliance.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. 2 Key findings/Evidence Standard met? At the previous inspection the registered person was required to carry out monthly unannounced visits to the home and reports of these visits must be maintained in the home and copies sent to the CSCI. At this inspection the inspector confirmed that regulation 26 monthly visits by the registered person were being sent to the CSCI however the report format must be reviewed to include more detail information instead of the current tick box format. The inspector advised that a letter had been sent to the registered person explaining this is greater detail. While the home carries out an annual quality assurance exercise, regular feedback is encouraged as evidenced by feedback forms prominently displayed at the entrance of the home. The registered person is required to review the report format for regulation 26 visits by the provider to ensure that it includes more detailed information.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 two inspections the registered person was required to produce a financial business plan for inspection. Following discussion with the Floor Manager it was agreed that a business plan was no longer required as most of the redecoration and other work required in the home had been satisfactorily carried out. This standard is assessed as met.Conifers ThePage 32 Standard 35 (35.1 ­ 35.6) The registered manager 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 Key findings/Evidence Standard met? 2 X X XAt 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 manager advised that all service users at the home administered their finances on their own or with support from their relatives if appropriate. However occasionally some relatives would give the manager small amounts of money for service users hairdressing requirements. The manager explained that if she was away this was sometimes left with care staff who were on duty. Following discussion it was agreed that a receipt book would be purchased and this would be used to record all money left by relatives for the use of service users. One receipt would be given to the relative and the other copy would remain on file. The registered person must ensure that accurate records are kept of all money received by the home on behalf of service users.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. 3 Key findings/Evidence Standard met? At the previous inspection the registered person was required to ensure that staff receive formal supervision sessions. Documentary evidence viewed at this inspection indicated that staff were receiving regular supervision. This was seen as evidence of compliance.Conifers ThePage 33 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? All service user records were appropriately stored and it was confirmed that service users could have access to their records.Standard 38 (38.1 ­ 38.9) The registered manager 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 fire doors are not wedged open and are self-closing at all times and to arrange for a fire officer to visit the home. The registered person was also required to replace the microwave oven in the kitchen. A tour of the kitchen indicated that a new microwave oven had been purchased. It was observed that fire doors were still wedged open. The manager informed the inspectors that previous guidance from the fire officer had been that it was acceptable to wedge open fire doors on condition that wedges were easy to remove fore example waste paper bins and if a fire risk assessment was available. Fire risk assessments were examined but there was no mention of the level of risk as a result of wedging open fire doors and the strategies to be taken in the event of a fire breaking out. The inspectors informed the manager that it was important that she get written confirmation of this as this was a considerable health and safety risk. The inspectors suggested that she explore the safer option of having automatic door closure devices fitted and to consult with the fire authority regarding the appropriate types of devices to be fitted. Documentation confirming that the following health and safety checks had been carried out was seen; Fire equipment checks 17/12/04 Fire alarm 15/10/04 Records of weekly fire alarm tests and quarterly fire drills were seen Emergency lighting 15/10/04 Portable appliance testing 8/11/04 Nurse call system 15/10/04 Lift servicing 22/9/04 Environmental health inspection 30/7/04 Gas safety checks 14/9/04 Electrical installations 3/10/02 [valid for three years] Hoist servicing 23/7/04 The registered person is required, in consultation with the fire authority to ensure that all fire doors in the home are self-closing at all times and that fire risk assessments are updated. The registered person is also required to ensure that checks of water storage tanks are carried out and that that tests are carried out on the risk of Legionella. Conifers The Page 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 Two specified service users who have a diagnosis of dementia may remain accommodated in the home. CommentsYES Condition Compliance The home must advise the regulating authority following the death of the specified service users. CommentsLead Inspector DateGeorgia Chimbani 31 January 2005Signature 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 Inspection of The Conifers N13 conducted on 9 December 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible NO COMMENTS HAVE BEEN RECEIVED FROM THE PROVIDER. WE ARE WORKING ON THE BEST WAY TO INCLUDE PROVIDER RESPONSES IN THE PUBLISHED REPORT. IN THE MEANTIME RESPONES RECEIVED ARE AVAILABLE ON REQUEST.Conifers ThePage 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments 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 28 February 2005, 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 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 9 December 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 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 9 December 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 Conifers The / 9 December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000027805.V180080.R02© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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!