CARE HOMES FOR OLDER PEOPLE
Daken House 240 Romford Road Forest Gate London E7 9HZ Lead Inspector
Sharon Lewis Unannounced Inspection 15th September 2006 08:10 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.V310909.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 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 Mrs Diana Khumalo 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.V310909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 43 BEDS ELDERLY MENTALLY ILL PERSONS - NURSING MINIMUM STAFFING NOTICE Date of last inspection 13th December 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 culturally diverse shops, services and amenities are situated on the Romford Road, Woodgrange Road and Upton Lane. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 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 the early morning and finishing in the late afternoon. The Inspection lasted approximately eight and a half 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. The Inspector spoke to nine service users currently living at the home and a relative. Individual discussions were also held with the Registered Manager, Deputy Manager, Home Liaison Nurse, Domestic Worker and two Health Care Assistants. Group discussions were also held with Health Care Assistants and two Registered Nurses. Service users and staff files, medication administration records, all health and safety records and other relevant documentation were examined. A tour of the premises was also undertaken. The Inspector would like to thank all service users, relatives and staff members for their assistance with this Inspection. What the service does well:
All service users expressed their satisfaction with the care and were comfortable in their surroundings. A relative was extremely happy stating “the place is marvellous, all the staff are marvellous, nothing can be improved here”. The Registered Manager and Deputy Manager have received management training and felt confident in their individual roles. Interviews with staff related that they felt they had “good” “supportive” management and they enjoyed working at the home. Feedback from other professionals also highlighted that the management team were “working very hard” and “communication had improved” and the home had “changed for the better”. Although this was an Unannounced Inspection all service users were well groomed and pride was taken with their appearance. Clothes were colour coordinated and expressed each service users individual style. Service users benefit from the provision of their own hairdressing room. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 6 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, Twi, Ndebele, Shona, Ibo, Turkish, Chinese and Polish. The home is able to offer a range of clinical services offered and is supported by weekly visits from the nursing home liaison nurse. The liaison nurse assists with phlebotomy, urine checks, wound care, training in clinical techniques and general medical advice. 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 benefit from a well supported staff team. Records evidenced that staff have regular supervision, staff appraisals are in progress and monthly staff meetings are held, where a range of topics are discussed. What has improved since the last inspection?
The Statement of Purpose and Service User Guide have been updated to include the details of the new Manager including their experience and qualifications. Prospective service users and their relatives now have current information to enable them to make an informed choice about where they live. A new care plan system has been introduced which is person centered and focuses on the unique individuality of each service user. The service is aware of current policy issues and topical reviews of care for older people, and works to transfer this into their daily work. Service users are protected by the home’s risk management system. Service user risk assessments are now dated. A range of assessments are in place, which includes falls. Additional manual handling equipment and other specialist equipment for service users has been provided. This has included specialist pressure relieving beds, belts and sliding sheets. All staff members including domestic staff have received adult protection training. The adult protection and whistle blowing procedures have been further developed as required from the last Inspection. Service users meetings are re-instated. Service users are able to regularly engage in a range of meaningful activities. A four weekly activity programme has been devised which includes a sing-a-long, board games, floor games, beauty sessions, cinema club, hairdressers, musical exercises, chair based
Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 7 exercises, cards and dominoes competition, memory test/quiz, sensory session, church service, musical bingo, beanbag session, travel club, nostalgia, drawing, colouring and painting. Staff files are now maintained in accordance with Schedule 2, The Care Homes Regulations 2001. A new induction form has been introduced which closely monitors each area of competence. Annual staff performance appraisals have also been introduced. During the tour of the premises it was noted all lounges had been made more homely. Flowers were on each dining table, floral arrangements, pictures and ornaments also contributed to the pleasant atmosphere. The 2nd floor kitchen worktop has been replaced and redecoration is in progress. What they could do better:
During this Inspection four legal requirements were highlighted and one recommendation. Service users health and safety must be safeguarded and promoted. Medication administration records must be accurately maintained. Fire drill records must detail the evacuation times and portable appliances must be tested. Greater care must be taken to ensure all areas of the home are free from offensive odours. Quality assurance should be further formalised by the production of a service development plan. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 8 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.V310909.R01.S.doc Version 5.2 Page 9 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.V310909.R01.S.doc Version 5.2 Page 10 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, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Daken House has the necessary information, procedures and staffing to meet the needs of service users. EVIDENCE: The Statement of Purpose and Service User Guide have been updated to include the details of the new Manager including their experience and qualifications. The organisation has produced a colour brochure and attached Statement of Purpose. Both documents when read together contain the necessary information required by regulation. Prospective service users and their relatives now have current information to enable them to make an informed choice about where they live. The brochure explains “The overriding objective of Daken House is to enable an optimum quality of life for each and every resident” Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 11 The brochure explains the care the home provides is “based on the thorough assessment of needs and the systematic and continuous planning of care for each service that user”. Assessment of a service user’s needs ensure the home can effectively meet the needs of each prospective service user. Service users files evidenced that prior to admission, assessments are undertaken by placing authorities and Daken House. Hospital reports are also produced if service users are discharged directly from hospital. ‘Getting to know you’ forms are also produced to detail the individual’s background, preferences and interests. Daken House are able to meet the diverse cultural needs of service users from a variety of racial backgrounds. Staff are collectively able to speak a variety of languages that includes Hindi, Gujerati, Malayama, Swahili, Twi, Ndebele, Shona, Ibo, Turkish, Chinese and Polish. The Deputy Manager is currently involved in translating a training pack into Turkish for informal carers. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. They also have the opportunity for staff to meet them in their own homes or current situation e.g. hospital. One relative explained they usually had a chat with relatives being showed around the home and always gives a personal recommendation. Unplanned admissions are avoided were possible. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 12 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 -11 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users personal and health needs are generally promoted at Daken House. Shortfalls in the medication administration recording must be addressed. EVIDENCE: A new care plan system has been introduced which is person centered and focuses on the unique individuality of each service user. The service is aware of current policy issues and topical reviews of care for older people, and works to transfer this into their daily work. The service users’ plan 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. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 13 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. Service users benefit from the consistent monitoring of their physical, psychological and emotional needs. This included guidance on malignant social psychology. Service users benefit from home visits from a dentist, chiropodist and relevant health professionals. Service users files evidenced that their weight is recorded regularly. A relative also highlighted the consistent care taken to treat their loved one’s ulcerated legs. This had included photographic evidence to monitor the progress. Nurses within the home have been trained to undertake various clinical practices. This includes catheter care, blood tests and tissue viability. The home is also supported by weekly visits from the nursing home liaison nurse. The liaison nurse assists with phlebotomy, urine checks, wound care, training in clinical techniques and general medical advice. The home also has additional links with the local specialist Incontinence Nurse. Regular meetings are held with the Primary Care Trust and Daken House are part of the Nursing Homes Project. The aim of this Project is to support nursing homes through training, to reduce hospital referrals. Daken House are kept up-to-date on best practice through the regular networking meetings with GP’s, district nurses and mental health teams. The home aim to keep in contact with their local community. 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. Regular medication reviews are held. Medication administration records were examined by the Inspector. Several incidents were records were not accurately maintained were found. The home must ensure medication administration records are accurately maintained. Service users must be protected by the home’s medication administration practices. The aims and objectives of the home reinforce the importance of treating residents with respect and dignity and these values are applicable to all aspects of their life and are fundamental to the philosophy of care. Observation, documentation and discussions with service users, relatives and staff evidenced the promotion of these values. The home evidenced through documentation 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. Wishes relating to death and dying have been included on the admission form. A suction machine has also been provided to assist in end-of-life care. The management team provide support
Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 14 and training for staff and there are opportunities to express anxieties and share emotional stress in this area of work. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users lifestyle needs are promoted at Daken House. EVIDENCE: During the Inspection service users were observed engaging in a range of activities. These included, listening to music, reading the newspaper and watching television. During the past few months, service users have enjoyed a theatre production and a trip to West Ham Park. Plans were also seen for an orchestra to visit the home. Daken House has a part time Activities Co-ordinator and an additional staff member takes the lead on activities and has received the necessary training. A four weekly activity programme has been devised which includes a sing-along, board games, floor games, beauty sessions, cinema club, hairdressers, musical exercises, chair based exercises, cards and dominoes competition, memory test/quiz, sensory session, church service, musical bingo, beanbag session, travel club, nostalgia, drawing, colouring and painting.
Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 16 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. Family and friends feel welcome and know they can visit the home at times convenient to them. Service users are allocated a key worker. This staff member 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. Dining tables are set attractively with flowers on each table. Meal times were observed to be unhurried. Staff assisted service users with feeding were needed, at their own pace. Service users were offered more food and were asked if they had finished before their plate was taken away. It was observed and service users related that they enjoyed their meals. Service users receive three daily meals, drinks and snacks are 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 are flexible and service users are able to eat in their own room if they wished. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Daken House effectively promotes service users rights and complaints. EVIDENCE: Since the last Inspection there have been two complaints, both unsubstantiated. Complaints were noted to be satisfactorily managed The adult protection and whistle blowing policy and procedures have been updated and the home has a copy of Newham’s adult protection policy and procedure. All staff members including domestic staff have received adult protection training. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The refurbishment and redecoration of Daken House is in progress. Greater care taken to keep the home free from offensive odours. 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. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms.
Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 19 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 available for visitors. A range of culturally diverse shops, services and amenities are situated on the Romford Road, Woodgrange Road and Upton Lane. Security is maintained through door codes and CCTV cameras are restricted to entrance areas and do not intrude on the daily life of service users. The premises was generally found to be clean, appropriately lit, ventilated and heated. One bedroom however had a strong odour of urine. This is an ongoing issue concerning a particular service user. There are plans to remove the carpet in their room and replace with flooring which is easier to be kept clean. The home must ensure it is free from offensive odours. During the tour of the premises it was noted all lounges had been made more homely. Flowers were on each dining table, floral arrangements, pictures and ornaments also contributed to the pleasant atmosphere. All lounges had orientation boards that detailed the date, staff on duty, meal choices and activities. Major refurbishment and extension works are scheduled to start in October 2006. Since the last Inspection the 2nd floor kitchen worktop has been replaced and areas within the home have been redecorated. Redecoration of the home is ongoing and will be incorporated in the overall refurbishment plan. The Registered Manager explained that the works will ensure the comfort of service users is taken into account at all times. The ground floor is scheduled to have four additional ensuite bedrooms. The communal lounge will be extended to the conservatory area. On the first floor three additional bedrooms will be built and the lounge area will also be extended. All extensions works meet environment space requirements and service users will benefit from the increase in communal areas. The home demonstrated that service users have sufficient lavatories and washing facilities. There is a choice of bathing facilities; adapted bathrooms and hoists are available. Sluices are located separately from service users toilets and bathing facilities and a designated laundry is provided. Service users have specialist equipment to maximise their independence. Consent forms are in place for the use of cot sides. Since the last Inspection additional manual handling equipment and other specialist equipment for service users has been provided. This has included specialist pressure relieving beds, belts and sliding sheets. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a stable, competent, well-supported, culturally diverse staff team. EVIDENCE: The home has good staff retention and benefit from a permanent, diverse staff team, who are occasionally supported by bank staff. 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 commented, “Everything is alright” “nothing could be better”. A relative was extremely happy stating, “the place is marvellous, all the staff are marvellous, nothing can be improved here”. The service ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving service users outcomes. Nearly 100 of staff have completed their National Vocational Qualification (NVQ). The Registered Manager explained that the staff team are “growing in confidence”. Staff have benefited from a range of training, which includes specialist dementia training. The home has access to Social Services and Primary Care Trust training. The home liaison nurse also assists with teaching
Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 21 staff clinical and care practices. Staff recently had training on the aspects of heat wave care. Due to past problems, Newham Social Services monitor the staffing rota on a weekly basis. Examination of the staffing rota evidenced that the home is sufficiently staffed. Observation of the morning shift on one floor however evidenced that staffing could be organised more efficiently. It was noted that staff were getting everyone up prior to breakfast being served. This meant service users could be sitting in the lounge waiting for over half an hour. One service user was noted to be very distressed and was shouting for their breakfast. This issue was discussed with the Registered Manager and Deputy Manager. Staff were promptly spoken to and the shift re-organised for the following morning. The home recognises the importance of effective recruitment procedures in the delivery of good quality services. Recruitment was checked by examining the personnel files for two newly appointed staff. All staff files were maintained in accordance with regulations. Interview includes literacy assessments and highlights the strengths of candidates. A new induction form has been introduced which closely monitors each area of competence. Three monthly and six monthly development reviews are also held to ensure staff are competently able to fulfil their roles. Evidence was seen of poor practice being addressed and efforts made to assist staff to improve. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Daken House is well managed however minor shortfalls in health and safety must be addressed. EVIDENCE: Daken House has a Registered Clinical Manager; the Registered Manager has been in post since October 2005. The Registered Manager has previous proven experience of nursing home management and demonstrated a vision and commitment to improving practice. The Registered Manager is service user focused and effectively led the home in an open and transparent manner. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 23 Plans to develop the service were discussed however a formalised plan had not been produced. It is recommended that a written service development plan is produced. The home is supported by Deputy Manager who maintains a presence on each floor and assists with the monitoring of daily care practices. The Deputy Manager explained that the home “aims to excel” and “keep up-to-date with what is happening”. Both Managers have received management training and felt confident in their individual roles. Interviews with staff related that they felt they had “good” “supportive” management and they enjoyed working at the home. Feedback from other professionals also highlighted that the management team were “working very hard” and “communication had improved” and the home had “changed for the better”. Service users benefit from a well supported staff team. Records evidenced that staff have regular supervision, supervision contracts have been produced and staff appraisals are in progress. Staff benefit from monthly staff meetings where a range of topics are discussed. These included care practices, procedures, complaints, training and development and Commission for Social Care Inspection updates. Service users have the opportunity to discuss their views and inform the quality of care at monthly consultation meetings. The Registered Individual visits the home regularly and completes a monthly monitoring report. The home is due to send out a questionnaire to obtain feedback from relatives. A suggestion box is also located in the front entrance area. Accidents and incidents records were examined and were appropriately maintained. Fire safety and water temperature records were also examined. The fire alarm is tested on a weekly basis and regular fire drills are held. The home must ensure fire records also detail the evacuation time. Health and safety certificates were examined and it was noted that a current portable appliances testing certificate was outstanding. Portable appliances must be tested. The health and safety of service users must be promoted by the home’s practices. Service users personal monies and financial records were examined. The home has an efficient financial management system and records were accurately maintained. Records were generally found to be appropriately maintained. Service user information is confidentially stored in locked cabinets. Examination of service users records evidenced that files are audited by management and missing information is highlighted for necessary action. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard OP9 OP26 OP38 OP38 Regulation 13 (2) 16 (2) (k) 23 (4) 13 (4) (c) Requirement Medication administration records must be accurately maintained. The home must ensure it is free from offensive odours. Fire drill records must detail the evacuation times. Portable appliances must be tested. Timescale for action 01/11/06 01/11/06 01/11/06 01/12/06 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 OP33 Good Practice Recommendations It is recommended that a written service development plan is produced. Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East London Area Office Ferguson House 109 –113 Cranbrook Road Ilford Essex IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Daken House DS0000007355.V310909.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!
