Inspection on 10/09/07 for Danson House Residential Care Home

This inspection was carried out on 10th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Danson House Residential Care... 20/06/08

Danson House Residential Care... 10/10/06

Danson House Residential Care... 12/01/06

Danson House Residential Care... 21/07/05

Danson House Residential Care... 05/01/05

Danson House Residential Care... 07/07/04

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

CARE HOMES FOR OLDER PEOPLE Danson House Glynde Road Bexleyheath Kent DA7 4EU Lead Inspector Ms Pauline Lambe Unannounced Inspection 09:20 19 & 24th September 2007 th 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 Danson House DS0000006792.V344208.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. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Danson House Address Glynde Road Bexleyheath Kent DA7 4EU 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 8304 3762 020 8301 2646 www.kcht.org Kent Community Housing Trust Mrs Nicole Sandra Shilling Care Home 46 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (45) of places Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration for 1 service user in category DE(E) (female) for named service user only. 10th October 2006 Date of last inspection Brief Description of the Service: Danson House is owned and managed by Kent Community Housing Trust which is a charitable not for profit trust. The home was purpose built and provides accommodation on two floors. It is located in a residential road within walking distance of shops, a mainline railway station and bus routes. The home is registered to provide personal care and accommodation for 46 older people. The building is divided into five separate units, Silver (10 beds), Katie (9 beds), Family (10 beds), Royal Blue (9 beds) and Rehab (8 beds). Each unit has a lounge/dining area, kitchenette, toilet/bathroom facilities and bedrooms. Respite care was also provided. One of the units in the home provides short-term care for eight service users who require rehabilitation. Specialist advice, assessment and equipment are provided for the service users on this unit. There is parking to the side of the property with garden and patio areas at the rear. The home also provides day care for older people. This part of the service is not regulated. The current fees range from £425.67 - £443.73. Residents pay privately for items such as hairdressing, chiropody, newspapers and social outings. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced key inspection was completed over two visits, one on 19th September 2007 and one on 24th September 2007. The assistant manager, residents and staff assisted with the inspection. Thirtyseven residents were in the home and there were nine vacancies. The last key inspection for the service was completed on 16th October 2006. The inspection process included a review of information held on the service file, a tour of the premises, a review of records, talking to residents, staff and obtaining feedback from relatives and residents and reviewing compliance with previous requirements. The home had a stable management team but had a number of vacancies for permanent team leaders, care staff and domestic staff. Residents and relatives were generally satisfied with the care provided but had concerns about staffing levels, the high use of agency staff and the standard of cleanliness in the home. Management must review care and domestic staffing levels in the home and ensure these are adequate to meet the needs of all residents and improve the standard of cleanliness to the satisfaction of the residents. What the service does well: What has improved since the last inspection? Improvements had been made to medicine management such as a new medicine fridge was provided, the temperature of the medicine storage room was being monitored and internal and external medicines were stored separately. Efforts had been made to recruit permanent staff and a recruitment drive was ongoing. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 6 The smoking room was uncluttered and available to residents. Fire drill records seen included comments about staff response to the exercise. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information was provided for prospective residents about the service. Residents were admitted based on a pre-admission assessment of need. The rehabilitation unit met the needs of the residents. EVIDENCE: A statement of purpose and service user guide was provided and copies seen in some of the bedrooms viewed. A copy was left in the front entrance. The statement of purpose did not include reference to the provision of day care services. Completed survey forms received from seven residents and seven relatives showed they had been provided with adequate information about the service. Requirement 1. The organisation had a full time assessment officer who completed preadmission assessments for most of the residents. Staff from the home completed these for residents admitted to the rehabilitation unit. Care plans Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 9 seen included pre-admission assessments and some had the care manager assessment papers. Based on the outcome of the pre-admission assessment the person completing the assessment gave a letter to the prospective resident confirming that the home was suited to meeting their needs. Copies of these letters were not seen in the files viewed. Recommendation 1. A separate rehabilitation unit was provided. Staff worked with residents and other professionals from the Primary Care Trust (PCT), such as occupational and physiotherapist’s to promote independence and to assess resident’s ability to return home. Residents spoken with on this unit said they were satisfied with the help and support they received while in the home to enable them to return home. PCT staff seen explained how they worked with residents and staff in this unit and said that staff followed advice and care plans prepared for residents. They said the unit provided a valued service for residents leaving hospital who were unable to return home immediately. Residents seen agreed with this statement. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care records seen reflected resident’s needs but lacked detail as to how these were to be met. There was evidence in night care plans only to show that residents were involved in preparing these. Resident’s healthcare needs were met but medicine management required improvements. Residents and relatives were satisfied with the care provided and the way their privacy was respected. EVIDENCE: Three care plans were viewed and included assessments and care plans. Care plans seen were based on a needs assessment however they lacked detail as to how assessed needs were to be met. For example many of the care plans seen said ‘needs assistance’ and ‘staff to observe’. This was not considered adequate guidance for staff, especially agency carers as to how an identified need was to be met. Night care plans were generally well-written and provided adequate information on how to care for the person. Only night care plans included evidence to show they were agreed with the resident. Care plans were reviewed monthly and six monthly with relatives, staff and staff Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 11 said with the resident. However care plan documentation did not include any way to evidence that residents were involved with preparing their care plans. Feedback received from residents and relatives indicated satisfaction with how care needs were met. Requirement 2. Residents were registered with a GP and supported by staff to access routine and specialist healthcare services as needed. The home had a good working relationship with the district nurse service and made direct referrals for nursing care and advice. Care records seen included a reference to resident’s contact with other professionals such as the GP, district nurse, optician, dentist and chiropodist and hospital appointments. Residents spoke with confirmed they could see health care professionals when needed and were satisfied with how their health needs were met. Feedback from relatives showed that staff kept them informed about their resident’s health and satisfaction with how healthcare needs were met. Adequate storage was provided for medicines and each unit had a medicine trolley. Records were kept for medicines received into the home and administered and but not for all medicines returned to the chemist. Controlled medicines were stored and managed appropriately and stocks checked were correct. Medicines were supplied in blister packs and individual containers with pre-printed administration charts. The temperature of the medicine storage fridges and rooms was recorded and the record for Silver unit showed these were generally satisfactory. However the room temperature reached 30C degrees on occasions and staff were asked to ensure the radiator in the room was fully turned off, which was a problem currently. Internal and external medicines were stored separately. Medicines were checked for Silver Unit and the rehabilitation unit and some concerns were noted. For example it was not possible to do an audit trail on the rehabilitation unit’s medicines as the number of doses received or carried forward was not recorded, on Silver unit two medicines checked did not tally with the amount received and administered, only one person signed and checked hand written entries made by staff on administration charts, some residents were self medicating but the risk assessments completed were inadequate. The risk assessments seen did not refer to how the resident stored the medicines and how they were assessed as capable of managing this task. The inspector has requested a separate pharmacy inspection and the provider will receive a report following the inspection. Requirement 3. Feedback from residents and relatives and comments made by residents during the inspection indicated that they were satisfied with the way staff treated them. Residents said staff listened to them, involved them in their care and decisions about their dress and appearance. One comment made was “I never had a bad word said to me”. However a number of comments were made about the amount of agency staff used in the home. Management must ask the long stay residents how they feel about day care service users coming into their home on a regular basis and if this affects their lives and privacy. A Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 12 record of the residents who may be affected by the day care service must be maintained. Requirement 4. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents seen were satisfied with the activities provided. Visiting arrangements in place suited residents and enabled them to maintain contact with family and friends. Menus seen showed a varied diet was provided however currently the service used a high number of agency staff in the kitchen. EVIDENCE: Since the last inspection the activities organiser had left and a carer was covering the post for the long stay residents. The process to fill the post had commenced and the position advertised. A part time activity organiser was allocated to the rehabilitation unit to work with residents on regaining independent life skills. Activity staff organised and facilitated activities, social events, entertainment and outings. Activities such as gentle exercises, quizzes, board games, arts and crafts, bingo, reminiscence sessions and cooking were provided. Residents said that most of the activities were organised for the mornings with occasional events arranged for evenings and weekends. Social events such as coffee mornings, themed days, visiting entertainment and day trips were arranged and a mobile shop enabled Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 14 residents to purchase small items such as toiletries, birthday cards and sweets. Residents were encouraged to join in all activities provided, not just in their allocated unit. A fixed activity programme was not implemented and staff said they responded to resident’s requests and preferences for the activity session. Day care service users were included in activity sessions and during the inspection a number of residents and day care service users were observed enjoying an arts and craft session. The carer responsible for activities at the time of this inspection was positive and committed to the role. She had the benefit of knowing the residents and their interests from her role as a carer. Residents seen and feedback received from residents and relatives’ showed that they were satisfied with the activities provided. An open visiting policy was provided. Relatives and residents were satisfied with visiting arrangements and from observation staff welcomed visitors to the home. Residents seen said they could make decisions about their life. However not all residents had this ability. Staff said that at the time of admission they worked with relatives to become familiar with resident’s preferences. Residents said they had a choice of meal, could choose what to wear, some said they could choose the time they wanted to go to bed and also whether they wanted to join in the activities. Staff were observed encouraging residents to make decisions such as where they wanted sit, if they wanted to join in activities and what meal to have at lunch time. There was little or no evidence in the care plans seen that residents were involved with preparing these or that their preferences were recorded. (See requirement 2). Resident’s opinion about the food provided varied with some being positive and others negative about it. Comments made included “the food is ok”, “the food is good, we get three cooked meals a day”, “we get a good roast lunch on Sunday” and one resident said, “lunch is always late and cold”. Residents said they had a choice of meal and could have a cooked breakfast. Lunch was observed on Kate unit. Although lunchtime was 12.30 the carer was not able to start serving until 13.00 due to assisting residents with personal care. Meals were brought to the unit in a heated trolley and on this occasion residents said the meal was hot when they got it. A choice of meal was provided and residents were observed to enjoy their food. Progress made to employ kitchen staff was slow and currently a high percentage of agency staff was being employed. The home currently had only one full time cook and relied on ban and agency staff to cover a high percentage of shifts. Recommendation 3. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to manage complaints and safeguarding adults. Residents and relatives seen or spoken with said they knew how to make a complaint. EVIDENCE: A complaints policy and procedure was provided and a copy included in the service user guide. A system was in place to record complaints made about the service. At the last inspection the complaint records were seen but these could not be located on this occasion. The provider pre inspection information did not include information about complaints made about the service but did indicate that one complaint was being investigated. No complaints had been made to the Commission about the service. Requirement 5. The home had a policy and procedure relating to safeguarding adults. Staff spoken with had a good awareness of this topic and how to manage such a situation. Safeguarding adults was one of the topics included in the Organisation’s mandatory training for all staff. Allegations or suspicions of abuse were referred to the Local Authority for investigating. Two such allegations were referred to the local authority since the last inspection. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A number of residents and relatives expressed dissatisfaction with the standard of cleanliness in the home. The environment was adequately clean and the décor and furnishings were satisfactory though tired and dated. Adequate bathing facilities were provided. EVIDENCE: Systems were in place to monitor safety in the home. A full time maintenance technician was employed and ensured day-to-day maintenance issues were addressed. The décor and furnishings in the home were very tired and dated and comments made by residents and relatives in the feedback surveys sent to the Commission included “maintenance could be better, one toilet was not working for days”, “the lift was out of order for about a week”, “carpets are dirty”, “the TV is very small and cannot be seen by all residents in the lounges” and “the home needs modernising”. A number of residents spoken with did not raise concerns regarding the environment. Speaking with some residents Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 17 it was evident management had discussed refurbishment plans with them. The planned refurbishment programme was not available to view therefore the Commission have required a copy. Issues noted in relation to the environment were the flooring in the area of the laundry room under the basins needs to be replaced, lots of towels seen in the laundry were badly worn and frayed, some corridor carpets were stained and in Kate unit the carpet in lounge was stained, the seal behind the bath needs to be replaced and the kitchen units need to be repaired or replaced. The patio area of the garden was well maintained with potted plants, shrubs and seating and provided a pleasant and relaxing area for residents to use. Requirement 6. Adequate bathing and toilet facilities were provided and areas seen were clean and tidy. Assisted baths had up to date service certificates. Hot water temperatures checked were within safe limits. The home was adequately clean and no unpleasant odours were noted. The domestic and care staff felt there was not enough cleaning hours provided. Feedback received from residents and relatives indicated dissatisfaction with the standard of cleanliness. Comments made included “could be cleaner”, “needs more efficient cleaning of rooms” and one resident said they had been in the home for some years and their curtains had never been washed in that time. Other residents indicated they were satisfied with the standard of cleanliness or did not raise this as an issue. The rosters showed that the home was regularly short of domestic staff particularly at weekends. The rosters also showed that the laundry did not have cover on a number of days and domestic staff had to include this in their work despite being short of staff themselves. Based on the information provided and comments made domestic staff did not have enough time to clean the home properly or to address additional cleaning such as washing curtains, high dusting and spring leaning bedrooms and communal areas routinely. Staff had access to protective clothing and hand washing facilities. Requirement 7. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were not maintained at all times. Staff had access to training relevant to the work they did and some improvements were needed to recruitment procedures. EVIDENCE: As mentioned the service provides day care for up to five people from Monday to Friday. The day care service users were allocated to Silver unit, which is the ground floor unit. A requirement was made at the last key inspection for management to review staffing levels in the home. In response to that inspection management said, “staffing levels within the home at the time of the inspection were to the required level, and have always been maintained at this level” The inspector was informed that the current staffing levels were one team leader and six care staff on duty for the morning shift and one team leader and five care staff for the afternoon shift. Rosters seen for a two-week period showed that on 5 morning shifts there were less staff on duty that the numbers quoted above and 12 of those shifts were covered with agency staff. Over the same period of time 3 afternoon shifts had less staff on duty that the numbers quoted above and 26 of these shifts were covered with agency staff. One care assistant was allocated to each unit with one care ‘floater’ to assist across the service as needed. A number of care plans viewed indicated that Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 19 the resident required the assistance of two care staff to enable some of their care needs to be met. On the day of this inspection there was one care assistant on duty on Silver Unit to provide care to the long stay residents and the additional three day care people. Care staff had a half hour unpaid break during their shift but due to the staffing allocation they had to stay on their allocated Unit and they remain available to assist residents if needed. Staff were observed attending to residents during their break. One team leader and two care staff were on duty at night and an on-call backup system provided for emergencies. Night duty rosters showed that staffing levels were as stated above and that 16 shifts in a two-week period were covered with agency staff. Staff rosters did not always have the name of the person on duty particularly when the person was an agency employee. This presented difficulties interpreting rosters and calculating staffing levels. From the evidence provided adequate staffing levels were not always maintained in the home. The high agency use affected continuity in care for residents and put added stress on permanent staff that had to support and induct agency staff on a regular basis. Management said and rosters seen showed that where possible regular agency staff were employed. Currently the home had vacancies for permanent team leaders, care assistants, kitchen and domestic staff. A recruitment drive was in progress to address this issue but the process took time to ensure all pre-employment checks were completed. Team leaders were part of the care team but as they had specific responsibilities including administering and managing medicines this made it difficult for them to be involved with hands on care. Relatives, residents and staff raised concerns about staff shortages and the number of agency staff employed. Requirement 8. The provider information showed that 41 care staff were employed and 21 had achieved NVQ level 2. A further 13 care staff were working towards this qualification. Four employee files were viewed and the employment information included varied. For example three applications forms seen had gaps in employment which were not explained, one had a handwritten reference which had not been verified and one had two references written by the same person. One file for an employee transferred from another home within the Organization did not have any proof of identity. One file had no had evidence to show a CRB check had been completed for an employee who started work in the home on 19/6/07. A POVA first check had been done however the employee was not working under supervision when on duty. Management agreed to rectify this situation and to have the person supervised at all times when on duty and to record this on the staff rosters. Requirements 9 and 10. Training records for three employees were viewed and showed that the people had attended 3 days training in the last year. The training sessions they Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 20 attended included medicine management, moving & handling, infection control, dementia care and rehabilitation. Staff spoken with said they had access to training relevant to their role. They said they had access to regular update training on areas such as moving & handling, fire safety and safeguarding adults. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a stable management team and a quality assurance system in place. Resident’s personal allowances were safely managed and attention was given to providing a safe environment. EVIDENCE: A stable management team was maintained and the manager was registered with the Commission. Staff were happy with the level of support they received and indicated that the management team were approachable and helpful. Feedback received supported this comment. The home had a recognised system in place to monitor the quality of care provided in the home. The manager completed reports for head office about significant issues such as accidents and complaints monthly. An internal audit Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 22 system was in place to review areas such as pre-admission, care plans, meal provision, management of resident’s money and staff training and development. Completed audits in relation to medicines and resident’s personal were finances were seen on this occasion. Senior management or managers from other homes participated with the audit process. An external auditor assessed the home to ensure the requirements for ISO accreditation were met. The Organisation prepared an annual report of their services. Unannounced visits were undertaken to comply with regulation 26 and reports sent to the Commission. Staff meetings were held and minutes kept. A meeting held with care staff on 18/7/07 showed staff raised concerns about the standard of cleanliness of the environment. There was no evidence to show that meetings had been held with kitchen and night staff since 2005. The last relative meeting was held in 2003 and the last resident meeting was held on 6/9/07. Residents spoken with confirmed they attended these meetings. It was difficult to assess how staff responded to resident request’s made at meetings. For example one resident said they had requested that the ice cream provided was changed but this had not happened. However management said that based on resident request the ice cream provided had been changed. Management assisted residents to maintain and manage their personal allowance only. Safe systems were in place to manage this and the inspector was informed that all residents had access to personal allowance. Records were kept for money received and spent. Individual records were maintained on the computer and were made available to residents and relatives. The records for two residents were checked and found to be correct. A large and small safe was provided for safe storage and the administrator kept a list of the safe contents. A random selection of health and safety records were viewed. All records seen complied with health and safety requirements, were well organised and up to date. Records seen included those for fire safety, service of moving & handling equipment, gas safety and lift service. Systems were in place to ensure that daily, weekly and monthly health & safety checks were undertaken. Fire drill records were not timed but were dated and included comments on staff response. There was no evidence to show that fire drills were held at times to include night staff. There was no evidence to show when staff last received fire safety training. Accident records seen for residents were well written and audited by the home manager monthly however there was no evidence to show that accidents sustained by residents when receiving care were followed up. Requirement 11. Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 23 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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 3 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 24 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 Requirement Timescale for action 16/11/07 2 OP15 7 3 OP9 13 The registered person must ensure the statement of purpose reflects the services provided. This includes the provision of day care service. The registered person must 09/11/07 ensure care plans prepared to show how resident’s identified needs will be met provide adequate guidance for staff and where possible to include the resident in this process. The registered person must 09/11/07 ensure that adequate systems are in place to safely store medicines: Accurate records must be kept for medicines received into the home to enable an audit trail to be completed. Accurate records must be kept for all medicines returned to the pharmacy from the home. Two staff must check and sign hand written entries they make on administration charts. Risk assessments completed for residents who wish to manage their own medicines must be fully completed in relation to DS0000006792.V344208.R01.S.doc Version 5.2 Danson House Page 25 4 OP10 12 5 OP16 17 6 OP19 23 7 OP26 23 8 OP27 18 9 OP29 19 10 OP37 19 ability and safety. The registered person must ensure the views of long stay residents are obtained in relation to day care service users coming into their home on a regular basis and ensure this information is recorded. The registered person must ensure complaint records are available for inspection at all times. The registered person must keep all areas of the home clean and well maintained. Corridor and other carpets identified must be replaced or cleaned. Repairs identified in this standard must be addressed. A copy of the planned refurbishment programme must be sent to the Commission and include start and ends dates for the work identified. The registered person must ensure the home is kept clean and must undertake a review of the domestic hours provided and inform the Commission of any changes made. The registered person must maintain adequate staffing levels at all times and must review and increase the staffing hours as needed to meet residents needs. Staff rosters must include the names of staff on duty at all times including agency staff. The registered person must ensure that all information required by regulation and schedule 2 is obtained for employees prior to commencing work in the home. (Timescale of 04/12/06 was not met). The registered person must ensure staff that start work DS0000006792.V344208.R01.S.doc 16/11/07 09/11/07 09/11/07 09/11/07 09/11/07 09/11/07 02/10/07 Page 26 Danson House Version 5.2 11 OP38 13 without a CRB check are supervised at all times when on duty and that the supervisor is identified on the staff roster. The registered person must ensure • all staff including night staff have the opportunity to attend fire drills. • all staff receive regular fire safety training. • accidents sustained by residents when receiving care are investigated and action taken to prevent a recurrence. 09/11/07 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 OP3 Good Practice Recommendations The registered person should ensure evidence is provided to show compliance with regulation 14. A copy of the letter to residents confirming that based on assessment the home is suited to meeting their needs should be kept on file. The registered person should prepare a medicine profile for every resident and provide evidence to show that staff managing medicines are assessed annually as to their competency to undertake this task. The registered person should review their recruitment efforts to employ permanent kitchen staff. 2 OP9 3 OP15 Danson House DS0000006792.V344208.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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