Inspection on 20/06/08 for Danson House Residential Care Home

This inspection was carried out on 20th June 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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... 10/09/07

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Danson House Glynde Road Bexleyheath Kent DA7 4EU Lead Inspector Lorraine Pumford Unannounced Inspection 20th June,15th July 2008 09:30 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 Danson House DS0000006792.V365884.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.V365884.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 nicole.shilling@kcht.org.uk 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.V365884.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 46 10th September 2007 Date of last inspection Brief Description of the Service: Danson House is owned and managed by Kent Community Housing Trust (KCHT) 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). Each unit has a lounge/dining area, kitchenette, toilet/bathroom facilities and bedrooms. Respite care is also provided. There is parking to the side of the property with garden and patio areas at the rear. The home also provides day care for a maximum of four older people. This part of the service is not regulated. Residents pay privately for items such as hairdressing, chiropody, newspapers and social outings. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star this means that people using the service receive an adequate service. Prior to undertaking this visit the provider was asked to complete an Annual Quality Assurance Assessment (AQAA). This was completed well and contained information about the progress the home has made since the last inspection as well as their plans for the forthcoming months. This Key inspection was undertaken by one inspector who spent time in the home over a two-day period. During that time residents, visitors to the home and staff on duty were spoken with. In addition we sent surveys to a number of people living in the home and their views have also been incorporated into this report. Records pertaining to two people who have recently moved into the home were examined and the records for one person who has lived in the home for a number of years was also tracked. Some policies and procedures were examined and we undertook a tour of parts of the building. The fees are currently from £441.00 to £495.00 What the service does well: Prospective residents benefit from a comprehensive assessment and can testdrive the home for the day prior to moving in. Residents benefit from care plans that provide sufficient information for staff on how to meet peoples needs. Residents can be assured that their health care needs will be met. Residents can be assured that their dignity and privacy will be respected. Residents benefit from a well presented varied and nutritious diet. Residents benefit from staff supporting them to exercise personal choice and control over their lives. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 6 The home organises advocacy support for people when necessary. People living in the home can be confident that action will be taken to address any concerns they raise. Comprehensive safeguarding adults procedures help safeguard people living in the home. People living in the home benefit from being cared for by staff that are suitably competence and qualified. What has improved since the last inspection? People living in the home now benefit from being provided with written up-todate information regarding all of the care and services provided in the home. A requirement was made at the time of the last inspection regarding the need for the record of complaints to be available for inspection and action has been taken to address this. People living in the home continue to benefit from the ongoing refurbishment and redecoration programme. Since the last inspection the recruitment of additional cleaning staff and changing in working patterns has resulted in a good standard of cleanliness. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 7 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.V365884.R01.S.doc Version 5.2 Page 8 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.V365884.R01.S.doc Version 5.2 Page 9 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): 1,3,6 Quality in this outcome area is good.This judgement has been made using available evidence including a visit to this service. People living in the home now benefit from being provided with written up-todate information regarding all of the care and services provided in the home. Prospective residents benefit from a comprehensive assessment and can testdrive the home for the day. EVIDENCE: A requirement were made at the time of the last inspection that the Statement of Purpose should reflects all of the services provided. That it should include the fact that the home provides day care. From discussion with the manager and records seen it is apparent that actions being taken to address this issue. Records seen indicated that prospective residents enter the home on a planed admission bases are able to visit the home for a day prior to admission. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 10 There was evidence seen that letters had been sent to residents stating that following the assessment the home was able to meet their needs at the time of admission. Contracts were examined in relation to the two residents being tracked both had a copy of the KCHT terms and conditions (contract). However the space to indicate their financial contribution had been left blank. People should not be asked to sign a legal contract unless they have been provided with all the relevant information including both parties rights and responsibility the fees payable and the arrangements for paying them. At the time of the last inspection the home had a dedicated rehabilitation unit however staff stated this is not currently in use. Obtaining appropriate support from health care professionals has proved difficult and KCHT took the decision to suspend the service as they felt it was not possible to provide an appropriate level of medical cover to support residents during their stay. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9, 10 Quality in this outcome area is adequate.This judgement has been made using available evidence including a visit to this service. Residents benefit from care plans that provide sufficient information for staff on how to meet peoples needs. Residents can be assured that their health care needs will be met. Procedures regarding medication need to be improved to safeguard residents health. Residents can be assured that their dignity and privacy will be respected. EVIDENCE: KCHT are currently introducing a new care plan system into all of their care homes. Two people that we tracked had only moved into the home within the previous two weeks and therefore care plans were still being formulated. We therefore looked at the care plans of three people who had lived in the home for some time. One of these people had lived in the home for over a year and the care plan was examined in relation to staff transferring information from Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 12 the old care plan system to the new, and two care plans were examined with regards to specific issues, nutrition and medication. The care plan format is divided into three areas to enable staff to identify the residents needs. Needs identified action to be taken and outcome. Staff had recorded information in relation to residents health, well-being and social needs. The document also includes other key information such as risk assessments. Entries were written in the first person for example I love bread and marmalade I like hot chocolate and tea and lemonade during the day. The amount of information recorded as guidance for staff on how to meet residents needs varied between the care plans, however generally there was sufficient information recorded for staff on action required by them to meet the residents assessed needs. Records seen indicated that staff were less clear about setting outcomes and in a number of instances information recorded under outcome would have been more appropriately recorded under action to be taken. The new care plan record did not have a space for the person writing in the plan to sign and this must be amended so that it is clear who prepared the plan. It was good to see evidence that people had been involved in preparing their care plans and that staff were regularly reviewing these and involving residents in the process. Relatives spoken with also stated that they are involved in the process. All residents are registered with a GP and have access to a visiting district nurse and other health professionals as needed. All of the people who completed surveys stated they receive the medical support they need. The care plan for one residents indicated that they had lost a substantial amount of weight. Staff stated and records confirmed that this had occurred during the time the person had been in hospital, however when the person returned home the district nurse had requested that staff monitor the situation closely by weighing the resident on a weekly basis. There was no evidence that action had been taken by staff to address this. Fortunately the persons health has improved since returning home however records seen did not support this. Relatives spoken with stated staff kept them informed about their resident’s health and they were satisfied with how healthcare needs were met. Since our last key inspection the home has been visited by one of our pharmacy inspectors. Staff spoken with said they had found the inspection helpful and there was evidence that requirements made following the pharmacists visit had been addressed. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 13 Adequate storage was provided for medicines and each unit had a medicine trolley. Controlled medicines were stored and managed appropriately and stocks checked were correct. Medicines are supplied in blister packs and individual containers with pre-printed administration charts. Records seen for one person indicate that they administer their own medication. There was an up-to-date risk assessment in relation to this practice with evidence that staff regularly review the situation to monitor and ensure that the person remains able to manage this task independently. Some issues arose regarding medication procedures and staff were advised that action is required to address these. One person is perscribed Lorazepam on a PRN basis and discussion took place regarding the need for a protocol to be developed to ensure that staff clearly understand circumstances under which the medication would be required to be administered. Records seen for a resident recently admitted indicated they were also perscribed Lorazepam however the frequency of administration varied between two documents. Staff were asked to address this matter urgently. One person is perscribed Warfarin, the dose for this medication is variable, staff had been recording the amended details on the Medication Administration Record (MAR sheet) however it was becoming increasingly difficult to clearly see the amended dose and discussion took place about how this information could be more easily seen if recorded on the back of the MAR sheet. One person had been prescribed Temazepam (PRN) however this was being administered on a daily basis and staff were advised to ask the GP to review medication for this person. Staff signatures must match between the sample given and that used on medication documents. A number of MAR sheets were torn or staff had punched holes through written details of peoples medication and action is required to ensure that details of medication can be clearly seen. We also discussed the need for staff to develop a medication profile for each person living in the home. The manager stated that the format for this is included in the new care plan and action would be taken to address this. The manager stated she undertakes an annual assessment of staff responsible for administering medication to ensure that they remain competent to undertake this task. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 14 Residents that we met appeared relaxed and comfortable. The majority of people who completed surveys stated that staff listen to and act on what they have to say. Good interaction was seen between staff and residents, staff addressed people living in the home by their preferred name. A member of staff assisted a new resident into the garden and introduced all of the people sitting there to each other before leaving the new person sitting with her peers. Staff was seen to respect residents privacy when assisting with personal care. Danson House DS0000006792.V365884.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents would benifit from opportunities to particpate in a more varied range of activities. Residents benefit from staff supporting them to exercise personal choice and control over their lives. Residents benefit from a well presented varied and nutritious diet. EVIDENCE: Information provided at the time of the inspection indicated that the activity coordinator had retired last year. The manager stated that they have been unable to recruit to the post to date. Care staff had initially taken on this additional responsibility however more recently the manager stated she had managed to secure additional funding to enable a member of care staff to fill the role of the activity coordinator until the post can be filled permanently. In response to the question are there activities arranged by the home that you can take part in only one person who completed a survey stated always the majority of people responded usually or sometimes. Relatives spoken Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 16 with thought that people living in the home would benefit from participating in a more varied range of activities. Although the home has experienced difficulties there was evidence that residents had participated in some activities, one person spoken to stated she enjoyed doing her knitting. Other people spoken with said they had participated in quizzes and bingo and some people had been to the local town centre and a theatre production. The home benefits from having a courtyard garden and residents who are able assist with watering plants and maintaining the area. During the course of the day a number of people came into the home to visit residents. People spoken with stated that they were always made to feel welcome and were offered refreshments. A requirement was made at the time of the previous inspection regarding the need for people residing in the home on a permanent basis to be consulted about sharing their home with people coming in on the day-care basis. The manager stated that this had been addressed at residents meetings however it was not possible to locate the minutes of the meeting when this had been discussed. However, as previously stated the matter has been addressed in the homes Statement of Purpose which people are given a copy of when moving into the home. There was evidence that residents are offered choice in relation to food and refreshments. Residents can choose where they wish to sit around the house, during the course of the day some people went out on trips either independently or supported by relatives. Residents bedrooms are individually personalised and people said they had been able to bring some personal possessions and mementos from home. The home organises advocacy support for people when necessary. At the time of the last inspection a recommendation was made regarding the need to recruit designated staff to deal with catering and managing kitchen duties so that the home is less reliant on agency staff. The manager stated that though they have run an ongoing recruitment programme and it had proved difficult to find appropriate staff to work in this area of the home and they had only just recruited one person who had recently started working in the home. At the time of the last inspection some of the comments made by residents indicated that some people had raised issues in relation to mealtimes. For example there had been delays in serving food and some people had commented that the food they received was cold. However on this occasion all of the people who completed surveys and people spoken with stated that the food provided was good, some people made specific comments for example Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 17 food is good- served hot very good. People are asked the night before what they would like for the meal the following day. Some residents spoken with said they could not always remember what they had ordered the day before however staff reminded them if necessary. Tables for lunch were appropriately laid with condiments provided, for example residents were provided with tartar sauce and vinegar as well as salt and pepper to accompany their fish and chip lunch. It was good to see vegetables of the day served in terrines and placed on the table for residents to help themselves this had a number of positive effects. It created a talking point between residents, people not only served themselves but also helped each other and this practice helps to promote peoples independence it also means staff have more time to help residents that need assistance at meal times. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 18 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): 16, 18 Quality in this outcome area is good.This judgement has been made using available evidence including a visit to this service. People living in the home can be confident that action will be taken to address any concerns they raise. Comprehensive safeguarding adults procedures help safeguard people living in the home. EVIDENCE: A requirement was made at the time of the last inspection regarding the need for the record of complaints to be available for inspection and action has been taken to address this. Information regarding KCHTs complaints procedure is available in the Service User Guide and also displayed in the front hall. Records seen indicate that a record is kept of any complaints brought to the managers attention and action taken by KCHT to address these. No complaints have been made to the Commission regarding the home since the last inspection. The manager also keeps records regarding incidents that are forwarded to the local authority to be investigated under the safeguarding adults joint working procedure. From records seen and discussion with the manager it was apparent they had experienced some difficulty in deciding which format to use to record this information resulting in some issues being recorded as both a Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 19 complaint and a safeguarding adults issue. The provider needs to ensure that there are guidelines for staff on how to record this information appropriately. The majority of people who completed surveys stated that they knew who to speak to if they were not happy and knew how to make complaints. Residents and relatives spoken with stated they were happy with the care and service provided in the home and to date has not felt the need to raise any concerns. Training in relation to Safe guarding adults is included in the Organisation’s induction and mandatory training programme. Safe guarding adults is also included in scenarios used as part of the homes interview process, which enables the manager to assess prospective staff members understanding and identify any potential training needs. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate.This judgement has been made using available evidence including a visit to this service. People living in the home continue to benefit from the ongoing refurbishment and redecoration. The installation of appropriate equipment in the sluice rooms would help reduce the risk of the possible spread of infection in the home. EVIDENCE: It was noted at the time of the last inspection The décor and furnishings in the home were very tired and dated. KCHT were asked to submit an action plan showing how they intended to address the issues raised in the inspection report. Since then the home has been undergoing an internal and external programme of maintenance including redecoration and the replacement of fixtures and fittings. The home has clearly benefited from this. However two issues were discussed with the deputy manager which needed addressing urgently to reduce the risk of people being harmed. An inspection cover situated in the corridor of silver unit was slightly raised and potentially Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 21 hazardous. Water to the bath on this unit was very hot touch. The deputy manager was also asked to address the fact that kitchen doors to the units were broken and potentially hazardous and remedial work is required until the refurbishment of this area takes place. Residents and relatives spoken with stated they had been kept informed of the refurbishment taking place. The building is accessible to people using wheelchairs. There are handrails in the corridors and a lift to upper floors. There are portable hoists and bathrooms and baths are fitted with appropriate equipment to assist people using them. The majority of people living in the home use a commode at night and discussion has taken place with KCHT regarding the need to install appropriate equipment to clean and sterilise commode pans. A monthly audit report seen which was completed by a senior manager to comply with regulation 26 stated that the sluice facilities would be upgraded in April 2008 to help reduce the risk of the possible spread of infection in the home. The manager contacted the department responsible for overseeing maintenance of buildings during our visit and was informed that they had been unable to meet this original timescale. Action must now be taken to address this issue. At the time of the last inspection relatives in particular raised a number of concerns regarding on going maintenance problems and poor cleanliness. A requirement was made at the time of the last inspection that the home must be kept clean and review domestic hours provided. Information provided at the time of the inspection indicates that an additional member of domestic staff has been employed. The manager stated that the working pattern has also changed so that domestic staff finish duty much later in the day. On the day that we visited we found the home to be clean and free from unpleasant odour. None of the people spoken with raise any issues regarding the cleanliness of the building and the majority of people who completed surveys stated the home is always fresh and clean. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 22 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): 27, 28, 29, 30 Quality in this outcome area is good.This judgement has been made using available evidence including a visit to this service. People living in the home benefit from being cared for by staff that are suitably competence and qualified. Recruitment procedures must be improved to help safeguard people living in the home. EVIDENCE: A requirement was made at the time of the last inspection that a review of staffing levels in the home should be undertaken to ensure that a sufficient number of staff are available to meet the needs of the residents accommodated and that staff rosters must include the names of staff on duty at all times including agency staff. The deputy manager stated that with the closure of the rehabilitation unit the occupancy level of the home had been reduced by eight people so it had not been necessary to recruit additional care staff although some recruitment has taken place to compensate for some staff moving on. The day that we visited residents appeared calm and relaxed. Staff were seen to provide assistance to residents in a calm unrushed manner. People who completed CSCI surveys stated that there was always or usually staff Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 23 available when needed. And one person in response to this question wrote night and day. On the day that we visited the roster was an inaccurate reflection of staff working in the home. The roster indicated that the manager was working however was on leave, it indicated that the deputy was on a day off however was working and another member of staff had been brought in to cover for a member of care staff who was unable to work. Therefore the requirement in relation to this remains unmet and a second timescale has been set. Requirements were made at the time of the previous inspection in relation to recruitment practices. One was that all records in relation to staff recruitment should be in the home and available for inspection and action has been taken to address this. Four files were examined in relation to the recruitment procedure on this occasion, three in relation to care staff recently employed and one file in relation to a member of staff employed to work in the kitchen. There was evidence that all four people have completed application forms however some issues arose in relation to application forms. One had gaps in the applicants employment history which were not explained. One persons application stated their previous job was with a care agency however they have not provided details of the agency as a referee which should have been provided as their last employer. There were photographs of the three members of care staff but not a member of staff working in the kitchen. Records seen for two members of staff who have come to work in the United Kingdom raised issues in relation to information provided at the time of their recruitment, these were discussed with the manager and taken action to address these issues. There was a POVA first check for each member of staff. A CRB check for one new person has been requested but not returned, this person is required to work under supervision at all times until the CRB check is completed. A requirement was made in relation to this at the time of the last inspection (applying to a different member of staff). Therefore a second timescale has been set. New members of staff are required to work under supervision and the person designated to supervise new staff should be identified on the roster so all parties are aware of their role. On the day we visited a person from a local school arrived to spend a day in the home for the purpose of work experience. A member of staff went through the KCHT induction programme which was concluded and signed within approximately two hours. Whilst some of this information was important for example what to do in the event of fire, location of fire exits etc, other Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 24 issues were more complex or were not relevant to the person concerned, for example the induction also covers electricity at work and contractual requirements. Discussion took place around not only the fact that some of the information was not relevant, but also the person had been asked to sign the induction when it was not possible to understand all of the issues in such a short time span. It is recommended that an edited induction programme is introduced with key important information based on health and safety and good principles of care. Information provided at the time of inspection indicates that 70 of the care staff working in the home now hold an NVQ 2 qualification or above in care. The manager stated that there is no longer a staffing matrix in operation which gives an overview of training for the whole establishment. However it was possible to print an individual member of staffs training portfolio and a sample was seen selected at random. The system also enables the manager to see when staff require an update to training. Records pertaining to training for four members of staff were examined, records seen indicate that within the last 12 months staff have received training in relation to caring for people with dementia, moving and handling, managing challenging behavior and adult protection. Staff responsible for first aid and fire safety have received specific training. Proposed training for four new members of staff was examined. Records seen indicated that staff would be undertaking training in relation to induction to social care, manual handling, fire safety, food hygiene and care planning. The manager stated that there is an expectation that care staff will undertake NVQ qualifications in care and that people working in the kitchen will undertake NVQ qualifications in catering and cleaning. Staff spoken with stated they felt confident they were provided with appropriate training opportunities to meet the needs of the people they care for. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 25 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): 31, 33, 35, 38 Quality in this outcome area is adequate.This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a well run and managed home. People living in the home benefit from KCHT monitoring the service they provide. All staff working in the home must participate in appropriate fire safety training to help safeguard people living and working in the home. EVIDENCE: There is a registered manager in charge of the home on a day-to-day basis who is suitably qualified and experienced. KCHT undertake monthly inspections of the care and service provided in the home and copies of these reports were available in the home for inspection. In Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 26 addition the manager has a system in place for undertaking monthly audits and this information is provided to the senior management team on a regular basis. The provider also arranges for an independent body to undertake regular monitoring visits and information is collated, reviewed and published. Staff spoken with said that staff meetings take place every three months however it was not possible to locate minutes in relation to all the meetings. Records were seen for the meeting held in March 2008 for domestic and maintenance staff. This raised some important issues that required care staff to act upon. Although a meeting for care staff took place the following day matters raised by domestic staff were not fed back to the care staff. Discussion took place regarding the need for staff to record the person taking the meeting and who is responsible for addressing the issues raised. Residents and relatives spoken with confirmed they attended meetings regarding the home and were kept up-to-date of events affecting them. All of the people living in the home who completed surveys stated that staff listened to them and acted on what they had to say. Staff spoken with stated there were procedures in place for handling residents personal allowance. An audit of money was undertaken in relation to two people and the amount being held for safekeeping tallied with records seen. From discussion with staff and records seen it is apparent there is a system in place to process money people are depositing for residents. Receipts are given for any money received. The home has facilities to store money and personal effects given to them for safekeeping. Staff stated there is a record kept of items deposited in the safe. One person who likes spending time in their bedroom said they have been told the bedroom door must be kept shut at all times due to fire regulations. This has affected the persons independence as they are unable to open and close the door for themselves. However from discussion with staff it was not apparent whether or not this guidance was KCHTs policy or a requirement made by the community fire safety officer. This matter needs to be explored further to enable the person to move freely to and from their bedroom. Information provided at the time of the inspection indicates there are regular maintenance and safety checks to hoists used in the home, gas appliances and electrical equipment and the homes electrical wiring safety certificate was seen. Records seen indicate there are regular tests to the fire alarm. A requirement was made at the time of the last inspection regarding the need for night staff to have the opportunity to participate in fire safety training including fire drills. A tick had been used to indicate that a member of staff had participated in training and discussion took place regarding the need for staff to sign they had officially attended the training held. Further of five Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 27 regular night staff only two had participated in fire training. The manager stated that action would be taken to address this. The homes health and safety guidance in relation to the organisations policies and procedures is held centrally and available for staff to reference, copies seen were up-to-date. Scenarios around health and safety also form part of the homes recruitment process, which enables the manager to assess prospective staff members understanding and identify any potential training needs. A record is kept of any accident involving people living in the home and the manager monitors these as part of the monthly audits. Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 28 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 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 3 2 Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 29 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 OP9 Standard Regulation 13 Requirement The registered person must ensure that medication is appropriately administered and records clearly maintained. In this instance there needs to be a protocol in place for the administration of Lorazepam to be administered PRN. MAR sheets must written so that it is possible to clearly read details of medication to be administered. It must be possible to see which member of staff has administered medication. The registered person must 01/10/08 ensure that appropriate sluice facilities are provided to minimise the risk of the spread of infection within the home. A registered person must ensure 20/08/08 that water to baths is maintained at a safe temperature. That the inspection cover situated in the corridor of silver unit is realigned as it is currently a potential trip hazard DS0000006792.V365884.R01.S.doc Version 5.2 Page 30 Timescale for action 30/08/08 2 OP26 23 3 OP38 23 Danson House 4 OP27 18 The registered person must ensure that the staff roster includes the names of staff on duty at all times including agency staff. 09/11/07not met. The registered person must ensure staff that start work 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. 09/11/07 not met 30/08/08 5 OP37 19 20/08/08 6 OP38 13 30/09/08 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. OP2 2. 3. 4 OP7 OP7 OP29 Refer to Standard Good Practice Recommendations People should not be asked to sign a contract unless it contains accurate information regarding their terms and conditions of residency including all parties responsibilities in terms of fees payable Staff need to complete the care plan format that the provider has introduced. The care plan format should have space for the person writing the care plan to sign. It is recommended that the induction programme be edited to a more suitable format for people who are not employed as full-time staff working in the home. Action should be taken to enable people to move freely to and from their bedroom. 5 OP38 Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. Extracts may not be used or reproduced without the express permission of CSCI Danson House DS0000006792.V365884.R01.S.doc Version 5.2 Page 32 - 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. 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