Inspection on 08/08/07 for Eastham

This inspection was carried out on 8th August 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Eastham 13/09/06

Eastham 31/12/05

Eastham 29/06/05

Eastham 12/01/05

Eastham 19/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Eastham Main Road Woodham Ferrers Chelmsford Essex CM3 8RF Lead Inspector Diana Green Key Unannounced Inspection 8th August 2007 10:00 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 Eastham DS0000028664.V348238.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. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastham Address Main Road Woodham Ferrers Chelmsford Essex CM3 8RF 01245 320240 01245 427243 eastham@runwoodhomes.co.uk www.runwoodhomecare.com Runwood Homes Plc 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) Mrs Marion Linda Hatcher Care Home 25 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (25) of places Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 25 persons) One named person, over the age of 65 years, who requires care by reason of dementia, whose name was known to the Commission in February 2006 The total number of service users accommodated in the home must not exceed 25 persons 13th September 2006 Date of last inspection Brief Description of the Service: Eastham is a detached period property situated in the rural village of Woodham Ferrers, approximately two miles from the town of South Woodham Ferrers with all its main amenities. This home cares for a total of 25 older people with a range of dependency levels from semi-independent to high dependency. The aim of the home is to provide a homely environment where service users are supported and encouraged to exercise their rights by suitably trained staff. The home has been adapted to meet the needs of older people that include the provision of ramps for easy access and a full passenger lift. Bedroom accommodation is on the ground, first and second floors and consists of nineteen single and three shared rooms. The house is set in well-maintained gardens with views over open countryside and has adequate parking facilities at the front. The fees range from £412.93-£463.00 weekly. Additional costs apply for chiropody, toiletries, sundries, hairdressing and newspapers. This information was provided to the CSCI on 8/08/07. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 8/08/07, lasting 5.5 hours. The inspection process included: discussions with the registered manager, care team manager, three staff, the cook, laundry assistant, nine residents and one relative; a partial tour of the premises including a number of residents’ rooms, bathrooms, communal areas, the clinical room, the kitchen and the laundry; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Surveys were distributed to residents, relatives, care managers and health care professionals and the views from those completed and returned to CSCI have been included in the report. Information from the home’s Annual Quality Assurance Assessment has also been included in this report. Twenty-four standards were inspected and five requirements and four recommendations made. The manager and staff were welcoming and helpful throughout the inspection. What the service does well: Easthams provides a friendly and homely environment for residents. Standards of personal care are good. There is very good access to health care services with prompt referrals made to GPs and district nurses. There is low turnover of staff and agency staff have not been used for two years. Staff receive regular training and supervision and are respectful and caring towards residents. Social activities and outings are arranged and efforts are made to involve relatives and the local community. Summer fetes and barbeques are arranged mostly in the summer months to which relatives and friends are invited. A Christmas meal has been held at the local pub and residents as able go to the pub for lunch. There is good communication with relatives who said they were confidant in the care and management of the home. Relatives also stated that they were kept well informed and any issues were quickly addressed. Regular audits are undertaken including health and safety, medication cleaning etc.. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Eastham DS0000028664.V348238.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 Eastham DS0000028664.V348238.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): Quality in this outcome area is good based upon sampled inspected standards 1, 3, 4 and 5. Residents were well informed and had their needs assessed prior to moving in to the home. The service does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a recently reviewed statement of purpose and service user guide that met regulatory requirements. Prospective residents and or their representatives were provided with copies prior to admission. Copies were displayed in the entrance of the home for visitors’ information. Feedback from relatives indicated they were able to view the home without an appointment and found the manager and staff very helpful. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 9 Pre-admission assessments were carried out by the manager or care team managers and information used to complete a full assessment following admission. A sample pre-admission assessment form was seen, and included a basic dementia assessment (mental status questionnaire). The home does not provide intermediate care. Eastham DS0000028664.V348238.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): Quality in this outcome area is good based upon sampled standards 7, 8, 9, 10 & 11. The health and personal care needs of residents are well met through care planning that is closely monitored and regularly reviewed. Residents’ privacy and dignity is in the main upheld but closer monitoring of individual residents is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of five residents’ files were viewed. All files contained an assessment form completed on admission and used to inform care plans. This form contained standard categories of need, each with a range of descriptors selected by tick boxes. The assessments detailed the residents’ wishes for funeral arrangements and additional individual assessments had been completed in regard to specific needs (e.g. risk of falls, moving and handling, dependency, continence, nutrition, pressure areas, etc.) that had been regularly reviewed. The manager stated that care plans were drawn up within 48 hours of admission and agreed with the relative and/or their representative. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 11 This was also confirmed from the care plans sampled. Several examples of good quality, preventative care were observed, for example, one resident enjoyed a period of bed rest in the afternoon to protect their skin from breakdown, but this had not been recorded in the care plan. Care plans included nutritional assessments with regular weight monitoring and most confirmed appropriate action had been taken, i.e. referral to dietician, specialist diets, supplements provided. A relative stated that their loved one had been underweight on admission and with the care, attention and nourishing food provided, their weight had increased and was no longer of concern. The records confirmed that residents received health care, for example by district nurses, GPs, dentists, chiropody and opticians, and that emergency services were called when required (e.g. when someone had a fall). This was also confirmed from completed surveys received from residents and their relatives. Feedback from health and social care professionals indicated that prompt referrals were made and recommendations always followed. Relatives were unanimous in their view that the home provided good care. Comments received were “ I could not have picked a better home”; my relative “is well cared for”. The home had a key worker system that was confirmed from the policy and care plans viewed. However feedback from a relative indicated this was not always followed rigidly and their loved ones residents’ requirements for toiletries etc. sometimes waited until the next visit from them. The home had medication policy and procedures that were available for staff guidance. The procedures provided clear guidance to staff.The home had a medication/clinical room located on the first floor of the home. An air conditioning unit had been installed and monitoring of room temperatures showed that temperatures were within recommended levels (25°Centigrade). A drug fridge was available and monitoring of temperatures was undertaken, recorded with appropriate action taken as necessary. Care team managers administered all medication at the home and had all received appropriate training. A list of authrorised staff names with signatures and initials was available and included currently employed staff only. Medication was supplied through a local pharmacy in pre-dispensed packs and appropriate ordering and disposal procedures were followed. Five residents records were inspected. Medication profiles were recorded for individual residents. All residents supplies were checked and confirmed that the prescribed medication was available and medication administration records (MAR) were well recorded. Regular medication audits were undertaken and suprevision provided by the manager. Some prescribed medication with a limited shelf life had no date of opening and care plans did not include the reason for the administration of prescribed creams but otherwise standards were good. Care files contained clear information and indicated each person’s preferred name. Staff were observed to treat residents with courtesy and dignity. All residents’ rooms had locks and residents were able to have a key should they wish. Health and social care professionals who completed surveys stated that Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 12 residents’ privacy and dignity was usually or always upheld. However one said an assessment had not been undertaken in private, but in front of other residents and visitors. This standard was not fully assessed. However from the care files viewed, discussion with the manager and feedback from health and social care professionals, it was evident that at the end of life, residents and their relatives would receive care and comfort. The assessment process took into account the wishes of residents in the event of their death. Since the previous key inspection a bereavement pack had also been developed for residents’ and relatives’ information. The manager said that one relative had said they found it very helpful when making arrangements following the death of their loved one. Eastham DS0000028664.V348238.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): Quality in this outcome area is good based upon sampled standards 12, 13, 14 & 15 The social and therapeutic activities provided enhanced residents’ daily lives and met their cultural expectations. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet with choices acommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The resident’ files inspected contained a social history or family tree, providing a good profile on the person, and information on their past interests. Care files also contained care plans relating to activities. The home employs a part-time activities coordinator, who arranged a variety of activities during the week (e.g. games, art and crafts, bingo, etc.). Information received from the manager stated that care staff provided activities in the abscence of the activity co-ordinator and encourageg interaction in groups and individual conversations. Evidence of an activities programme was seen displayed in the home, and individual records were maintained of residents’ involvement in the activities. Outings had also been provided i.e. to see the Christmas lights at Southend, pub lunches, visits to a butterfly sanctuary etc. and entertainment Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 14 provided for example a singer, visiting pantomime. Most relatives who completed surveys were positive about the activities at the home, but some relatives said there were not enough stimulating activities provided in the winter months. One said “more time should be spent in the fresh air” and “the grounds are only used once a year for fetes”. Another said ”the Christmas party was excellent”. Residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. A church service is held in the home each month, and staff reported that some local community groups had visited the home at Christmas (e.g. bell ringers, local school children carol singing). Residents had also taken part in a church flower festival where they made flower arrangements and were taken up the view the flowers. Residents spoken with were clear that they had choices about their daily life in the home, especially in regard to what clothes they wore, where they spent their day, meals, etc. Choices offered to residents were also confirmed from the care plans viewed and from discussion with residents. One resident said “I don’t have to take part in activities if I don’t want to”. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them. Information on advocacy services was included in the statement of purpose and available on display in the home. Residents and relatives spoken with were very positive about the meals served at Easthams. The main meal served on the day of the inspection looked appetising and comprised roast lamb served with potatoes, swede and cabbage with gravy followed by spotted dick and custard. Residents spoken with said they enjoyed the meal. Liquidised food was provided for residents who had difficulty swallowing/chewing. However this was served with meat and vegetables mixed, rather than separately so that residents could see and taste the different foods on their plate. Hot and cold drinks were seen being served during the day. The menu of the day was observed displayed on the notice board in a dining room. The home operates a four weekly menu: this was a corporate menu that had been developed for Runwood Homes following an analysis of the nutritional content of a sample of menus previously in operation at various homes, in order to ensure an appropriate nutritional input for residents. The home had consulted with residents since the previous key inspection and changed two days of the menu to suit their preferences. Relatives and residents who completed surveys stated the home “provides well cooked and attractive meals”; “I always enjoy the meals”. The kitchen was clean and well organised. Action had been taken since the previous key inspection to repair the ventilator and provide a fly screen for the serving hatch. Eastham DS0000028664.V348238.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): Quality in this outcome area is good based upon sampled standards 16 & 18 Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The manager actively promoted awareness of protection issues through staff supervision, training and recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that was displayed in the reception area of the home. A suggestion box was also available for feedback from relatives and visitors. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. The homes’ record of complaints detailed the investigation and action taken as a result. A record of all compliments was also maintained. Seven complaints had been received since the previous key inspection regarding concerns with the condition of furnishings and one regarding a resident’s bruises. All had been investigated and appropriate action taken where relevant. The home had comprehensive policy and procedures for safeguarding vulnerable adults and a whistle blowing policy. The records confirmed that most care staff had received training in protection of vulnerable adults and some ancillary staff were due for updated training. From discussion with the manager it was evident that any allegations of abuse made would be appropriately referred and relevant procedures followed. A manager was always on call for advice in the event that an allegation of abuse is made. One Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 16 allegation of abuse had been made regarding medication that was under investigation. Evidence was received following the inspection that the allegation had been investigated in line with procedures and found not proven. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 17 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 good based upon standards 19, 22 & 26. Easthams was well maintained and had a homely environment; residents’ rooms were individually furnished and equipped for their safety, comfort and privacy. The home was clean and hygienic throughout; additional staff hand washing facilities provided in residents’ rooms will ensure staff and residents are not placed at risk of infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, several bathrooms, a number of residents’ rooms, the kitchen, clinical room, the sluice and the laundry. Easthams provided a friendly and homely environment, was furnished in accordance with the client group and was well maintained. The entrance hall was small but welcoming with photographs of past events on display and a suggestion box for anonymous feedback. Notice boards with full information for residents and a separate one for staff were Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 18 displayed in the hall. Communal rooms were in need of some decoration and the manager confirmed that this was scheduled on Runwood Homes’ refurbishment programme. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. Relatives who completed surveys stated, “The home makes a happy, comfortable atmosphere”; “Easthams attempts to provide an environment as near as possible to that which they were accustomed”. The home had stairs and a passenger lift to enable access to the first and second floors of the premises. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided. Call systems were provided throughout all individual and some communal rooms, but none were available in the dining room. The manager stated that an order had been placed for their purchase. Pressure relief equipment was assessed and provided by the district nursing service to meet the needs of residents. Specialist moving and handling equipment was also available for example banana boards. All equipment was serviced as per manufacturers recommendations and confirmed from the records inspected. Ramps were provided to enable access to the patio and gardens. The home had policies and procedures for infection control available for staff guidance and all staff received training during induction and at regular updated sessions. The manager stated that she had consulted with the health protection agency in order to develop a plan to be used in the outbreak of infection. The home was clean throughout with no malodorous smells. However some attention was needed to ensure daily dusting of window ledges in the dining room. Also the rear exit to the patio was covered in pigeon droppings that were a potential health hazard. The laundry room was clean and well organised. There were two washing machines and two driers that were in working order. Systems were in place to minimise risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines and washing machines had the capacity to carry out sluice wash cycles. One pedal bin located in the clinical room did not have a footoperated lid and hand washing facilities (liquid soap and paper towels) were not provided in all areas where staff provided personal care, i.e. residents’ rooms. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate based upon standards 27, 28, 29 & 30. People living at Easthams can expect to be cared for by experienced and caring staff but current staffing levels do not ensure they do not have to wait unduly to receive personal care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a stable staff team with low staff turnover. There were 25 residents (including one male resident and one receiving respite). There were no male care staff employed at the home; future recruitment should take into account the gender needs of residents. Care staff comprised one care team manager and 3 care staff plus one on induction. Residents looked well cared for and relatives spoken with and those who completed surveys said that the care was good. However there were periods during the day when staff were not available in communal rooms: monitoring should be undertaken to ensure residents are supervised at all times and staff deployed accordingly. Several relatives who completed surveys raised concerns that their loved ones were required to wait to receive assistance with personal care, some stating this was up to half an hour. Most feedback from residents and their relatives indicated staff were cheerful and were caring towards them, although one suggested they could spend more time in the sitting room talking with residents. Ancillary staff were employed for domestic, laundry and catering duties. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 20 The home had 10 care staff with NVQ level 2 qualifications (including 2 bank staff). A further 11 staff had registered to undertake NVQ level 2. The percentage of staff with NVQ level 2 training was therefore less than 50 needed to meet the standard. The recruitment files of two recently employed staff were inspected. Both had evidence that the required checks had been obtained (two satisfactory references, POVA first checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. Applications had been made for CRB disclosures. Both staff had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards (records were not inspected). The home had an established training programme. The training records seen confirmed that staff had completed training on fire safety, health & safety, first aid, basic food hygiene and moving and handling. The manager reported that some staff were completing courses in medication, dementia, and infection control with Chelmsford College and all domestic staff had enrolled on NVQ level 1 training. However from the training schedule viewed, some ancillary staff needed to have updated protection of vulnerable adults training and only two care team managers had undertaken dementia care training. There had been no training in care conditions, issues for example Parkinson’s’ Disease and diabetes. Eastham DS0000028664.V348238.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): Quality in this outcome area is good based upon sampled standards 31, 33, 35, 36 & 38 Easthams is well managed with good health and safety standards that are well adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager had managed the home since June 2005 and had several years experience in working in care of older people. She had completed the Registered Managers Award training and had undertaken regular updated training relevant to a care home for older people, comprising dementia care, first aid, effective communication, Mental Capacity Act and Common Induction Standards. Residents, relatives and health and social care professionals who completed surveys stated they found the manager very approachable, helpful Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 22 and addressed issues quickly. One relative stated “I have faith in the skills and experience of the management team”. There is a corporate quality assurance programme whereby an annual audit is undertaken of Runwood care homes. An annual quality audit had been undertaken in April 2006 from which an annual plan had been developed. The home monitored all complaints and compliments and also had a suggestion box for residents and visitors. Relatives meetings had been held monthly since the home was registered. Visits required under regulation 26 had been undertaken and reports sent to the CSCI. The home has secure facilities for the storage of any money looked after on behalf of residents. There were clear individual records of this, with receipts kept and cash held individual purses. Two residents’ records were inspected, and records, receipts and cash all balanced. Records held on behalf of residents were kept up to date and stored safely in secure facilities in a locked office in accordance with the Data Protection Act 1998. Records viewed at this inspection included: care plans, medication records, statement of purpose, service user guide, staff recruitment and training records, maintenance records, accidents/incident records and fire safety records. All had been regularly reviewed and updated. The home had a health and safety policy and procedures. Records confirmed that all staff had attended relevant health and safety training. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. evidence of electrical certificate, PAT testing, hoists, lift etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment and door closures, fire alarms and emergency lighting, hot tap water temperatures, etc.). Eastham DS0000028664.V348238.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 2 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 X X 3 X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 4 3 Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 24 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. Standard OP9 Regulation 13(2) Requirement Timescale for action 15/09/07 2. OP10 12(4)(a) 3. OP22 23(2)(n) 4. OP26 13(3) All medication with a limited shelf life must have the date of opening recorded to ensure residents receive medication that has not deteriorated. Residents’ assessments must be 15/09/07 undertaken in private to ensure their privacy and dignity is upheld. To ensure residents are able to 30/11/07 call for assistance, call bells must be provided in all communal rooms. To ensure infection control risks 15/09/07 to residents and staff are minimised: 1. Staff hand washing facilities must be provided where personal care is provided (i.e. residents’ rooms) 2. A foot operated pedal bin must be provided for disposal of clinical waste in the clinical room. 3. Pigeon droppings must be removed from the patio/exterior of the building. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 25 5. OP27 18(1) To ensure residents do not have to wait unduly to receive personal care, staffing levels must be reviewed and additional staff provided as necessary. 30/09/07 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. 2. 3. 4. Refer to Standard OP7 OP15 OP19 OP28 Good Practice Recommendations Care plans should be kept under review to ensure they are contemporaneous to the care being provided. Liquidised meals should be served with separate portions of meat /fish and vegetables to ensure they are attractive and residents are able to taste the different foods. The registered person should provide planting and seating in the rear garden with access for wheelchair users. To ensure residents are cared for by skilled care staff: 1. 50 of care staff should undertake NVQ level 2 training. 2. Training should be provided in Parkinson’s Disease & diabetes and dementia care. Eastham DS0000028664.V348238.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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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