CARE HOMES FOR OLDER PEOPLE
Daken House 240 Romford Road Forest Gate London E7 9HZ Lead Inspector
Sharon Lewis Unannounced Inspection 13th December 2005 07:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Daken House Address 240 Romford Road Forest Gate London E7 9HZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8221 2444 020 8221 2555 LM Kendon Settlement ****Post Vacant**** Care Home 43 Category(ies) of Dementia (24), Old age, not falling within any registration, with number other category (19) of places Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 43 BEDS ELDERLY MENTALLY ILL PERSONS - NURSING MINIMUM STAFFING NOTICE Date of last inspection 22nd August 2005 Brief Description of the Service: Daken House is a 43 bedded, purpose built nursing home. Daken House is owned by a charitable organisation, LM Kendon Settlement. Daken House primarily provides nursing care for people with dementia, living in the Borough of Newham. Permanent and respite (short term) accommodation is available. The home is divided into three separate units located on three floors. Strevens Unit on the ground floor has 9 bedrooms, The Reeves Suite situated on the first floor has 19 beds and The Glyde Suite on the second floor has 15 beds. Each unit has its own lounge, kitchen and dining area. Additional quiet lounges are available and there is a large activities/meeting room on the ground floor. Service users have access to their own hairdressing room within the building. A conservatory and range of patio areas with outdoor seating is also available. Daken House is situated on the Romford Road, in Forest Gate. Buses 25 and 86 run along this road to provide links to Stratford and Ilford. The nearest station is Forest Gate, British Rail Station. A small car park is available for visitors. A range of shops, services and amenities are situated on Romford Road and Woodgrange Road. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Unannounced Inspection was undertaken on a Tuesday starting from early morning and finishing in the late afternoon. The Inspection lasted approximately eight hours. The overall objective of this Inspection is to ensure service users are receiving the best possible care and their welfare is safeguarded and promoted at the care home. This Inspection specifically related to the recent adult protection allegation where additional requirements were made. The Inspector spoke to eight service users currently living at the home and a relative. Individual discussions were also held with the Acting Manager, a Registered Nurse on night duty, a Registered Nurse on day duty, four Health Care Assistants and the Laundry worker. Service users and staff files, medication and medication administration records, all health and safety records and other relevant documentation were also examined. A tour of the premises was also undertaken. A Commission for Social Care Inspection, Business Services Administrator shadowed this Inspection. The Inspector would like to thank all service users, relatives and staff members for their assistance with this Inspection. What the service does well:
Service users were consistent in their praise for the home and had no complaints. Service users related that they were “quite happy” “Is a nice clean place, generally get on well with everyone” “Food alright and I feel alright” “They look after me alright, do not worry myself”. Choices are offered at each mealtime. African/Caribbean and Asian options are available, alongside a traditional British meal. Specific dietary needs are catered for. Daken House have service users from diverse cultural groups, reflective of the local community. The staff team are also racially diverse. Collectively the staff team are able to speak a variety of languages that includes Hindi, Gujerati, Malayama, Swahili and Twi.
Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 6 The home is commended for their open sharing of information. All next of kin relatives were sent a letter informing them of the recent adult protection incident. It was observed and further evidenced by feedback from service users, relatives and staff that service users are able to exercise choice and control over their lives. Service users were observed making choices in their daily living in regards to getting up, choosing to remain in the communal lounge or retire to their rooms. Service users are allocated a key worker. A staff member who is responsible for co-ordinating the service user’s care plan, for monitoring its progress and for staying in regular contact with the service user and everyone involved. Guidance on signs effecting wellbeing have been given to all units and were found on the majority of service users files. Service users benefit from the consistent monitoring of their physical, psychological and emotional needs. This included guidance on malignant social psychology and promoting service users dignity. The home has a commitment to extending the range of clinical services offered, which are not provided through the district nurse service. The Deputy Manager is trained to take blood samples and further training is available to meet service users clinical needs. The home works in partnership with nursing home liaison nurse. Nurses have received training in male catherisation. The liaison nurse assists with phlebotomy, urine checks and wound care. Regular meetings are held with the Primary Care Trust and Daken House are part of the Intermediate Nursing Homes Project. The aim of this Project is to support nursing homes through training, to reduce hospital referrals. Daken House has additional links with the local specialist Incontinence Nurse. Service users benefit from home visits from a dentist, chiropodist and relevant health professionals. Service users files evidenced that their weight is recorded regularly. Service users routinely receive an influenza vaccine. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 7 What has improved since the last inspection? What they could do better:
During this Inspection thirteen legal requirements were highlighted and four recommendations. The Statement of Purpose and Service User Guide must be updated to include the details of the new Manager including their experience and qualifications. Prospective service users and their relatives must have current information to enable them to make an informed choice about where they live. Service user risk assessments must be dated. Service users must be protected by the home’s risk management system. The home must ensure all staff members including domestic staff receive adult protection training. All staff must have a full understanding of the adult protection procedure. The adult protection and whistle blowing procedures must be further developed. The whistle blowing procedure must explain that staff may contact the Commission for Social Care Inspection anonymously at anytime. The home’s practices must further promote service users well being and protect them from abuse.
Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 8 Weekly fire alarm tests must be undertaken and regular fire drills must be recorded. This requirement is repeated from the last Inspection. Service users must be protected by the home’s fire safety practices. Service users must be protected by more robust recruitment and employment practices. Staff files must be maintained in accordance with Schedule 2, The Care Homes Regulations 2001. Service users must be protected by the home’s recruitment practices. The home must ensure annual performance appraisals are introduced for staff. Service users must benefit from a well-supported staff team. The home must ensure service users meetings are re-instated. Previously monthly service user committee meetings were held. Service users must have the opportunity to discuss their views and inform the quality of care. The home must ensure service users are able to regularly engage in a range of meaningful activities. The home must meet service users social and recreational needs. Staff should inform service users of their meals and not just place food in front of them. Service users must be empowered with this necessary information. This recommendation is repeated from the last Inspection. The home requires extensive redecoration in the identified areas. The 2nd floor kitchen worktop must be replaced. Stained carpets must be steam cleaned or replaced. Toilets seats must be secured in the identified toilets. The home must ensure items are not stored at on top of the wardrobe in service users bedrooms. Service users must reside in a safe, homely well-maintained environment. The Home Manager should be aware of the home’s financial budget. A copy of the current business and financial plan must be forwarded to the Commission for Social Care Inspection. Service users must be protected and assured by the home’s financial viability. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Contracts and assessments ensure Daken House can meet service users needs. Service information must be updated to inform prospective service users choice. EVIDENCE: The Statement of Purpose and Service User Guide must be updated to include the details of the new Manager including their experience and qualifications. Prospective service users and their relatives must have current information to enable them to make an informed choice about where they live. Each service user is given a contract with terms and conditions. Contracts contain the necessary information as detailed in Standard 2.2 National Minimum Standards for Older People. This includes rooms to be occupied, overall care and services covered by fee, fees payable and by whom, additional services, rights and obligations and period of notice. Assessment of a service users needs ensure the home can effectively meet the
Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 12 needs of each prospective service user. Service users files evidenced that assessments are undertaken by placing authorities and Daken House. Hospital reports are also produced if service users are discharged directly from hospital. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have the opportunity for staff to meet them in their own homes or current situation e.g. hospital. Since the adult protection incident was highlighted in September 2005, there have been no new referrals. Daken House does not currently offer an intermediate care service. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 13 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 , 9 & 11 Service users personal and health needs are generally promoted at Daken House. Shortfalls in risk management must be addressed. EVIDENCE: Daken House promotes Person Centered Care. The service users’ plans sets out in detail the action which needs to be taken by care staff to ensure that all aspects of their health, personal and social care needs are met. Care plans were reviewed on a monthly basis and service users files evidenced daily monitoring by trained nurses and care assistants. The new Manager is currently introducing a new care plan system. Service users are supported to take risks as part of an independent lifestyle. Risk assessments have been developed for all service users and specific risk assessments were produced. The home must ensure all service user risk assessments are dated. Service users must be protected by the home’s risk management system. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 14 Guidance on signs effecting wellbeing have been given to all units and were found on the majority of service users files. Service users benefit from the consistent monitoring of their physical, psychological and emotional needs. This included guidance on malignant social psychology and promoting service users dignity. The home has a commitment to extending the range of clinical services offered, which are not provided through the district nurse service. The Deputy Manager is trained to take blood samples and further training is available to meet service users clinical needs. The home works in partnership with nursing home liaison nurse. Nurses have received training in male catherisation. The liaison nurse assists with phlebotomy, urine checks and wound care. Regular meetings are held with the Primary Care Trust and Daken House are part of the Intermediate Nursing Homes Project. The aim of this Project is to support nursing homes through training, to reduce hospital referrals. Daken House has additional links with the local specialist Incontinence Nurse. During the Inspection the optician visited the home. Service users additionally benefit from home visits from a dentist, chiropodist and relevant health professionals. Service users files evidenced that their weight is recorded regularly. Service users routinely receive an influenza vaccine. The home has developed a comprehensive medication folder with various policies, including medication administration, security and disposal of medication. Medication is stored in locked trolleys, in a designated locked staff office. Medication is only administered by qualified nursing staff. Registered Nurses have completed NCFE Administration of Medicines training. Medication and records were examined by the Inspector and was found to be appropriately and accurately recorded. No discrepancies were found. The home evidenced through policies and discussion that service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. Palliative care is not currently provided, but there is contact with the hospice. Service users are able to spend their final days in their own rooms, unless there are strong medical reasons to prevent this. Wishes relating to death and dying have been included on the admission form. The home additionally plans to introduce this subject in current service users reviews. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Service users lifestyle needs are generally promoted at Daken House. Improvements must be made in activity planning and staff communication during meal times. EVIDENCE: During the Inspection service users were observed engaging in a range of activities both individually and as a group. These included playing dominoes, listening to music, reading the newspaper and watching television. Christmas music and popular music was played on individual units. Daken House has a part time Activities Co-ordinator. Forthcoming events included a visit from a musical entertainer, a Christmas Party and attendance at a Carol concert. Service users now benefit from orientation boards that include the date, name of staff on duty, daily menu and any proposed activities. Service users requested further activities internal activities and to be taken out. The Acting Manager explained that activities had decreased due to
Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 16 additional training and reviews relating to the adult protection allegation. The home must ensure service users are able to regularly engage in a range of meaningful activities. The home must meet service users social and recreational needs. It was observed and further evidenced by feedback from service users, relatives and staff that service users are able to exercise choice and control over their lives. Service users were observed freely making use of the home and were not confined to a particular space. Service users were observed making choices in their daily living in regards to getting up, choosing to remain in the communal lounge or retire to their rooms. Service users are allocated a key worker. A staff member who is responsible for co-ordinating the service user’s care plan, for monitoring its progress and for staying in regular contact with the service user and everyone involved. The tour of the premises evidenced that service users brought their own personal possessions with them. This included photographs, televisions and collectible items. Service users receive three daily meals. Drinks and snacks are also available throughout the day. Choices are offered at each mealtime. African/Caribbean and Asian options are available, alongside a traditional British meal. Specific dietary needs are catered for. Meal times were observed to be unhurried and all service users related and they were observed enjoying their meals. Staff should inform service users of their meals and not just place food in front of them. This recommendation is repeated from the last Inspection. Service users must be empowered with this necessary information. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 Daken House effectively promotes service users rights and complaints. Service users well-being must be more comprehensively protected by the home’s adult protection policies and practices. EVIDENCE: Evidence was seen of the home promoting service users’ right to vote and participate in the political process. Evidence was seen of a service users accessing legal advocates. Families or friends also advocate on service users behalf, if needed. Since the last Inspection there have been two complaints one was substantiated. Complaints were noted to be satisfactorily managed and the outcome and action appropriately recorded. Since the last Inspection there has been one adult protection allegation. This related to an incident were a service users had alleged a member of staff had hit them. It was concluded that it was highly probable that the abuse did happen. Unfortunately, because the proper procedures were not adhered to, there was no evidence to substantiate it. The home’s investigation highlighted staff complaints of poor care practices, that some staff manual handle service users roughly and feeling intimidated by other staff members. The staff member involved has been dismissed and a referral made to the Protection Of Vulnerable Adult (POVA) List. The home has
Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 18 additionally produced and implemented an action plan to address adult protection concerns.` The home is commended for their open sharing of information. All next of kin relatives were sent a letter informing them of the recent adult protection incident. Adult protection refresher training is in progress. The home must ensure all staff members including domestic staff receive adult protection training. In discussion with staff it was noted that although staff had adult protection training, their interpretation and responsibility was not consistently sound. All staff must have a full understanding of the adult protection procedure. The adult protection policy and procedures has been updated and the home has a copy of Newham’s adult protection policy and procedure. The adult protection and whistle blowing procedures must be further developed. The whistle blowing procedure must explain that staff may contact the Commission for Social Care Inspection anonymously at anytime. The home’s practices must further promote service users well-being and protect them from abuse. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 Daken House is a purpose built home with a range of facilities. General maintenance and refurbishment must be further addressed. EVIDENCE: Daken House is divided into three separate units located on three floors. Strevens Unit on the ground floor has 9 bedrooms, The Reeves Suite situated on the first floor has 19 beds and The Glyde Suite on the second floor has 15 beds. Each unit has its own lounge, kitchen and dining area. Additional quiet lounges are available and there is a large activities/meeting room on the ground floor. Service users have access to their own hairdressing room within the building. A conservatory and a range of patio areas with outdoor seating is also available. Daken House is situated on the Romford Road, in Forest Gate. Buses 25 and 86 run along this road to provide links to Stratford and Ilford. The nearest station is Forest Gate, British Rail Station. A small car park is
Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 20 available for visitors. A range of shops, services and amenities are situated on Romford Road and Woodgrange Road. The premises was found to be clean, appropriately lit, ventilated, heated and free from offensive odours. Security is maintained through door codes and CCTV cameras are restricted to entrance areas and does not intrude on the daily life of service users. The tour of the premises highlighted the lack of storage space in several rooms and in the Manager’s office. Items must not be stored at overhead height, as they are a potential health and safety hazard. The home must ensure items are not stored at on top of the wardrobe in service users bedrooms. Service users must be protected from any hazards to their safety. A redecoration and refurbishment programme is in progress. The following bedrooms are in need of minor retouch painting Rooms 1,3, 4, 9,12, 13, 14, 16, 17, 19,27, 32 and 38. In addition bathrooms at the end of the corridor on the ground floor and the bathroom opposite Room 33. The wall crack must also be repaired in Room 13 and an area redecorated on the second floor lounge. Carpets must be steam cleaned in Rooms 12, 16, 21 and armchairs in the second floor lounge and Rooms 12,14, 16, 24, 27,34 and 39. The home demonstrated that service users have sufficient lavatories and washing facilities. Adapted bathrooms and hoists are available. Sluices are located separately from service users toilets and bathing facilities. Toilets seats must however be secured in the bathroom opposite Room 35, the toilet next to Room 28 and in the ensuite toilet in Room 33. Service users have specialist equipment to maximise their independence. Where required there are specific aids such as Parker baths, grab rails, cot sides, hoists etc. Discussions with nursing staff highlighted the wish for further aids e.g. belts and sliding sheets. The provision of additional manual handling equipment should be considered. The 2nd floor kitchen worktop must be replaced. This requirement is repeated from the last Inspection. Service users must reside in a homely wellmaintained environment. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 29 Daken House has a diverse staff team; shortfalls relating to recruitment must be addressed. EVIDENCE: During the Inspection staff were noted to be very attentive and aware of service users individual needs. Service users were consistent in their praise for the home and had no complaints. Service users related that they were “quite happy” “Is a nice clean place, generally get on well with everyone” “Food alright and I feel alright”. “They look after me alright, do not worry myself”. Daken House have service users from diverse cultural groups, reflective of the local community. The staff team is also racially diverse. Collectively the staff team are able to speak a variety of languages that includes Hindi, Gujerati, Malayama, Swahili and Twi. The last Inspection highlighted the high dependency needs of service users and questioned the staffing arrangements. A staffing review has been undertaken and additional staffing introduced to relevant floors. Health care assistants are now rotated to promote good practice. Service users benefit from staffing which more effectively meets their needs. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 22 Interview includes literacy assessments and highlights the strengths of candidates as recommended in the last Inspection. Two staff files were examined. These included the files for the staff member involved in the adult protection allegation and a recently appointed staff member. The latter file was not maintained in accordance with regulations. The file did not contain a recent Criminal Record Bureau check, proof of identity, a recent photograph or a health declaration. A new CRB check must be applied for on appointment. Staff members must not work unsupervised without a new CRB check or Pova (Protection of vulnerable Adults) First check. Staff files must be maintained in accordance with Schedule 2, The Care Homes Regulations 2001. Service users must be protected by the home’s recruitment practices. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 & 38 Daken House is adequately managed however service users consultation, welfare, health and safety must be better promoted. EVIDENCE: Daken House has a Deputy and Clinical Manager; the Acting Manager has been in post since October 2005. The Acting Manager has previous proven experience of nursing home management and demonstrated a commitment to improving practice. The Acting Manager stated they felt well supported by senior management and she had “ a commitment to change”. Managers within the home now spend time daily on each unit and work alongside staff. The Acting Manager is
Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 24 currently going through the Commission for Social Care Inspection manager registration process. Several staff members praised the appointment of the new Manager. The Acting Manager was described as “good” “very proactive” and “She knows what she is doing, has a lovely way of talking to you and is very amenable.” The examination of staff files evidenced that they were now in receipt of regular supervision and supervision contracts were in place. Regular staff meetings are additionally held. The home must ensure annual performance appraisals are introduced for staff. Service users must benefit from a well supported staff team. The home must ensure service users meetings are re-instated. Previously monthly service user committee meetings were held. Service users must have the opportunity to discuss their views and inform the quality of care. Accidents and incidents records were examined and were appropriately maintained. Fire safety records were examined. Records evidenced a gap in the weekly alarm tests and evidence of fire drills could not be found. Weekly fire alarm tests must be undertaken and regular fire drills must be recorded. This requirement is repeated from the previous Inspection. The Inspector was not able to view the current business and financial plan. The Acting Manager was unaware of the financial resources allocated to fund the various aspects of the home. The Home Manager should be aware of the home’s financial budget. A copy of the current business and financial plan must be forwarded to the Commission for Social Care Inspection. Service users must be protected and assured by the home’s financial viability. Service users financial records were examined and found to be accurately maintained. The home does not directly manage any service users finances. Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 2 3 2 X 2 Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1) (c) Requirement The Statement of Purpose and Service User Guide must be updated to include the details of the new Manager including their experience and qualifications. Timescale for action 01/02/06 2. OP7 13 (4) (c ) The home must ensure all service user risk assessments are dated. 16 (2) (n) The home must ensure service users are able to regularly engage in a range of meaningful activities. The adult protection and whistle blowing procedures must be further developed. The whistle blowing procedure must explain that staff may contact the Commission for Social Care Inspection anonymously at anytime. 01/02/06 3. OP12 01/02/06 4. OP18 13 (2) (6) 01/02/06 5. OP18 13 (2) (6) The home must ensure all staff members including domestic staff receive adult protection training.
DS0000007355.V272536.R01.S.doc 01/04/06 Daken House Version 5.0 Page 27 All staff must have a full understanding of the adult protection procedure. 6. OP19 13 (4) (a) The home must ensure items are not stored at on top of the wardrobe in service users bedrooms. The following bedrooms must be retouched with paint - Rooms 1,3, 4, 9,12, 13, 14, 16, 17, 19,27, 32 and 38. In addition bathrooms at the end of the corridor on the ground floor and the bathroom opposite Room 33, must be retouched with paint. The wall crack must be repaired in Room 13 and an area redecorated on the second floor lounge. The 2nd floor kitchen worktop must be replaced. 8. OP21 23 (1) & (2) (j) Toilets seats must be secured in the bathroom opposite Room 35, the toilet next to Room 28 and in the ensuite toilet in Room 33. A new CRB check must be applied for on appointment. Staff members must not work unsupervised without a new CRB check or Pova (Protection of vulnerable Adults) First check. Staff files must be maintained in accordance with Schedule 2, The Care Homes Regulations 2001. 10. OP33 24 (1) The home must ensure service users meetings are re-instated.
DS0000007355.V272536.R01.S.doc 01/02/06 7. OP19 23 (2) 01/06/06 01/02/06 9. OP29 19 (4) (b) 01/02/06 01/03/06 Daken House Version 5.0 Page 28 11. OP34 25 A copy of the current business and financial plan must be forwarded to the Commission for Social Care Inspection. The home must ensure annual performance appraisals are introduced for staff. Weekly fire alarm tests must be undertaken and regular fire drills must be recorded. Timescale of 01/10/05 not met. 01/02/06 12. OP36 18 (1) 01/04/06 13. OP38 23 (4) 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations Staff should inform service users of their meals and not just place food in front of them. Repeat recommendation. Items should not be stored at overhead height in the Manager’s office. The provision of additional manual handling equipment should be considered. The Home Manager should be aware of the home’s financial budget. 2. 3. 4. OP19 OP22 OP34 Daken House DS0000007355.V272536.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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