Inspection on 07/11/07 for Firlawn

This inspection was carried out on 7th November 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Firlawn 04/11/08

Firlawn 07/11/06

Firlawn 09/06/06

Firlawn 09/12/05

Firlawn 03/05/05

Firlawn 11/11/04

Firlawn 28/04/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

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Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Firlawn Firlawn 402 Chessington Road West Ewell Surrey KT19 9EG Lead Inspector Helen Dickens Unannounced Inspection 7th November 2007 10:15 Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 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 Firlawn DS0000013642.V349745.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 Adults 18-65. 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. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firlawn Address Firlawn 402 Chessington Road West Ewell Surrey KT19 9EG 020 8786 0514 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) EMAS Limited Company Mrs Jess Puah Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: Firlawn provides services for up to four service users. The property is a bungalow, which has a large lounge/dining room and small separate sitting area, single bedroom accommodation, kitchen, laundry and two bathrooms. One room has en-suite facilities and the three other bedrooms are sited near to the bathroom. The cost per resident per week is £884 and holidays, personal items, one-to-one support and complementary therapies are extra and charged separately. The bungalow is located on a main road, with parking for 4 cars. There is a large garden to the rear of the property which is shared by the companys sister home Oaklawn next door. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 7 hours. The inspection was carried out by Mrs. Helen Dickens, Link Inspector for the service. Mrs. Jess Puah, Registered Manager, and Mr. Charlie Puah, the Responsible Individual, represented the establishment. A tour of the premises took place and a number of files and documents, including resident’s assessments and care plans, staff recruitment files, quality assurance information, and the annual quality assurance assessment were examined as part of the inspection process. Two questionnaires returned to CSCI from relatives were also used in writing this report. Only three residents live at Firlawn at the moment and all three were spoken with during the day. The inspector would like to thank the residents and staff, and Mr. And Mrs. Puah for their time, assistance and hospitality. What the service does well: Firlawn offers a very homely and friendly environment which is clean and pleasant throughout. Furnishings and fittings are domestic in character and there are many homely touches including plenty of well cared for plants, an aquarium in the larger lounge, and a variety of pictures on the walls. Residents were well cared for and two relatives of one of them were very complimentary about the premises, the care on offer, and the manager. The owner and registered manager had an honest and open approach and shared with the inspector a number of areas already identified for improvement. The health needs of residents are particularly well documented and monitored at this home. There is an equal opportunities policy in place and some policies, e.g. the complaints procedure, have been translated into easier formats for residents. The home has purchased a computer package which will enable them to translate more documents, for example care plans, into more user friendly formats. The premises have been adapted to suit the mobility needs of existing residents and this is kept under review. Firlawn DS0000013642.V349745.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. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are assessed prior to moving into the home but more work is needed to ensure all relevant needs are identified. EVIDENCE: Two resident’s files were sampled. One resident had been there for a number of years and his original assessments have since been archived. These were checked at a previous inspection and found to be satisfactory. The file of a new resident was checked and found to contain an assessment from the home and a number of other documents and assessments relating to this resident’s needs. However, the home’s own assessment was incomplete, for example in relation to likes and dislikes. The manager also said it had taken three weeks (after the resident was admitted) for an assessment to come from the care manager at social services. This assessment was not available on the day of the inspection but was found and faxed to CSCI the following day. It was also noted that the home’s own assessment format concentrated on health and nursing needs, with less emphasis on the social aspects of care. It is recommended that the home review their assessment format. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are reflected in their care plans but one resident did not have a fully documented care plan on the day of the inspection. Residents are given some opportunities to make decisions and to take risks. EVIDENCE: Residents at this home have a 24-hour care plan in place, relating to all activities of daily living, and these plans are regularly reviewed. One care plan was sampled and found to have been reviewed in January and June of this year. Where a resident has particularly high needs there is an additional more detailed care plan, for example with regard to specific illnesses or risk factors, such as choking. Care plans incorporated guidance from other professionals for example from the speech therapist and occupational therapist. The registered manager is currently working on more person centred plans and demonstrated significant progress on the new format. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 10 However, one resident did not have a completed care plan, covering their needs throughout the 24-hour period; though they did have some very specific needs covered in a specialist care planning format. The manager said this was because their needs were constantly being reviewed and staff were given verbal instructions at each handover regarding any changes. The home does have a small and regular group of staff working there, and it is likely, as the manager said, that staff are now knowledgeable about this resident’s needs. However, all residents must have a comprehensive documented care plan in place. The manager compiled a care plan covering the 24-hour period for this resident, and faxed it to CSCI the following day. Residents have some opportunities to make decisions and the manager gave examples of how residents would demonstrate their disapproval or dislike in certain circumstances. A relative confirmed that the manager in particular knows the residents very well and knows how they wish to be supported. A questionnaire returned from a relative said that the care service always supports people to live the life they choose. The home already have some user-friendly formats for policies such as the complaints procedure which is available in pictures or widget form. They have also purchased a software package to enable them to set up the person centred plans using a widget/pictorial format. Residents are supported to take risks and a number of risk assessments are in place, for example in relation to the radiators, some of which do not have covers, and choking, which is a particular hazard for some residents. The Requirement to carry out a risk assessment in relation to toiletries which are left out in the bathroom, had not been met from the last inspection, and the manager did this immediately. Further risk assessments were identified, for example in relation to moving and handling for one resident, and this was done and faxed to CSCI the next day. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have some opportunities to take part in activities and be part of the local community. Residents are treated with respect and are offered a healthy diet. EVIDENCE: Current residents at this home cannot take part in employment or further education, though some have certificates from courses and activities they have participated in some time ago. However, residents have the opportunity to take part in some therapeutic activities, for example they have music therapy once a week and one resident was having a foot massage on the afternoon of the inspection. The manager said there is also an aroma therapist and a hairdresser who visit the home regularly. Two residents also attend day centres, and all three residents are visited very regularly by their families. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 12 The current activity plans for residents needed up dating as they did not closely match the activities they actually participated in, and one resident had no documented plan at all, though they did have a number of regular activities including day care. It is recommended that a note is kept of the actual activities each resident does each day as evidence that residents have sufficient opportunities to take part in appropriate and fulfilling activities. The manager said residents use some community facilities including health services, and local pubs and restaurants; and they also have a weekly takeaway on a Saturday evening. Residents are taken out for drives in a specially adapted vehicle and one relative who completed a questionnaire stated that the home provides day trips and holidays which their relative enjoys. Residents are encouraged to maintain family and friendship links and the staff were very knowledgeable on each resident’s family contacts. Family members are welcomed to the home and the manager said they often use the larger living room area for family visits. Both questionnaires returned from relatives were very complimentary about the home, one saying the care their relative received was ‘second to none.’ Staff were observed to communicate well with residents, and residents could choose whether to be alone or in company. Staff were accustomed to each resident’s method of communication and could easily ascertain if they wanted to join in with an activity or not. The inspector raised concerns about the flexibility of daily routines as for example, with only one member of staff on duty, one-to-one activities such as meal times, had to be staggered and carried out in a particular order. The manager did not see any particular issue with this as she said routines had been devised around each resident’s needs. The menus were sampled and these are drawn up by staff with limited involvement from residents. The manager said staff have ascertained what residents like to eat and they have then planned the menus accordingly. As some residents have difficulty with eating, specialist assessments have been carried out and there are clear guidelines on file to assist staff. Resident’s weights are monitored and two files sampled showed they had been weighed every month since they first moved into the home. A third resident cannot use the home’s scales and the manager was asked to explore alternatives for ensuring this resident was weighed. It was also noted that residents do not always have what is on the menu and the manager was asked to make a note when residents had alternatives to the main menu so that any person inspecting the record could determine whether the diet is satisfactory. The inspector queried whether some lunchtime meals were sufficiently nutritious, for example sausage rolls, pasties, and pies. However, the manager said these menus had been seen by the dietician when she looked at the menus for the other two sister homes and only minor recommendations were Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 13 made. One resident is on a weight reducing diet and the manager said they had lost some weight already as a result of the home offering them healthier options, less carbohydrate, and more fruit and vegetables. Residents need one-to-one supervision at mealtimes and therefore rarely eat together when they are at home. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s receive support in the way they prefer though better documentation is needed to ensure all staff are working in a consistent way. Healthcare needs of residents are identified and met, and there are good arrangements in place for the administration of medication. EVIDENCE: Two resident’s files were sampled and one contained a care plan covering the 24-hour period and had noted how the resident liked to be supported. All three residents have, in addition to their care plan, more detailed guidance on some specific areas, for example arrangements for food and mealtimes to prevent choking, and on challenging behaviour. There are some aids and adaptations in place, and advice has been sought from occupational therapists, speech therapists, dieticians and physiotherapists. The manager has a good relationship with resident’s families and as a result has got to know the new resident very well. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 15 However, on the day of the inspection one resident did not have a fully documented care plan, and this was drawn up and sent to CSCI the next day. A Recommendation regarding care plans has been made under Standard 6. Residents do not have any choice about who works with them as there is only one member of staff on duty for each shift; this also limits flexibility for residents with regard to the care they receive and the manager and responsible individual were asked to review staffing arrangements. Resident’s healthcare needs are identified by the home and there is welldocumented evidence that specialist advice has been sought and is being followed. Current residents are not able to manage their own healthcare so this is monitored by staff in relation to specific health conditions for example diabetes. Guidance is in place for staff in relation to particular health conditions and specialist training, e.g. dementia awareness training, has been arranged. Daily records confirmed that health conditions are monitored e.g. one resident who had had a chest infection had progress noted until it had cleared up. Resident’s have a health action plan in place, drawn up by the local Community NHS Trust. Arrangements for the administration of medication are good at this home. Medicines are all in blister packs from the local pharmacy. The home was in the process of changing the local pharmacy service – the new arrangement will include training for staff and an annual inspection of their medication arrangements. Current staff have had medication training by a specialist training consultant and only those staff who have had training can give medication. Medicines were kept securely and the cabinet was clean and tidy. Two medication administration records were checked and there were no unexplained gaps. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s complaints would be acted upon and they are protected from abuse. EVIDENCE: The home has a complaints book though the manager said none had been received. There are guidelines for staff in the front of the book about how to deal with and record complaints. The manager had changed the CSCI address on their complaints procedure, to reflect the move to Oxford. There is a userfriendly complaints procedure in place though at this home if residents had any complaints they would have to rely on staff or relatives to take these up for them. The manager said staff know residents very well and would soon pick up if they were unhappy about something. All three residents have relatives who visit regularly, and would highlight any concerns. No complaints have been received to CSCI regarding this home since the last inspection. There is a protection of vulnerable adults policy in place, and all staff receive information on this subject as part of their induction. The home has a copy of the local Surrey procedures for safeguarding vulnerable adults, as well as the ‘Safeguarding Alert’ cards with contact information and brief guidelines on what to do in the event of suspected abuse. The manager said all staff have now completed training on this subject, though with no centralised training list it was difficult to provide evidence of this. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 17 Two staff files were checked. One did not have the relevant training certificate but the staff member was spoken with and confirmed she had done the training two years ago. A Requirement regarding training and training records will be made later in this report. The home are currently working on a written ‘gifts’ policy though staff were clear that they could not accept gifts from residents. All residents at this home are clients of the local authority and, in the absence of anyone willing and able to manage their finances, the owner said the local authority has asked him to do this via the Court of Protection. The owner said that where he does have responsibility for a resident’s finances, the books are checked periodically by an auditor from the Court of Protection. He said from October 2007 he will also get his accountant to independently audit these records. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Firlawn offers a very homely environment for residents though more work is needed to ensure their safety. The home is clean and hygienic throughout. EVIDENCE: Firlawn offers a very homely environment which is clean and pleasant throughout. There are extra homely touches such as a well-kept aquarium, plenty of plants and pictures, and the furnishings and fittings are all domestic in character. Residents now all have special armchairs, in addition to the sofas in the small and large sitting rooms. Resident’s bedrooms were personalised with photos and ornaments, and one had a framed certificate. A summerhouse, built since the last inspection, provides extra space and interest for residents of both homes (Oaklawn next door) in the warm weather. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 19 There is now a risk assessment in place for toiletries in bathrooms and all basins have thermostats fitted to prevent scalding. The kitchen was clean and tidy. However, the risk assessment required at the last inspection on radiators without covers had not been done; the manager did this immediately. The large mat in the lounge/dining room was causing a potential trip hazard as the edges were curling up, and wires trailing on the floor from two electric armchairs in the small lounge had to be removed. Two residents did not have an armchair in their bedrooms and the manager said this was their choice. The inspector reminded the manager that any choices made by residents which were in conflict with the minimum standards expected, should be clearly documented on their files. Though the laundry room is kept locked, the hazardous substances cupboard in the laundry is not; the manager was asked to review this by carrying out a risk assessment and then taking any follow-up action deemed necessary. The manager did not have a copy of the last environmental health officer’s visit and thought this was about 2 years ago. It was recommended that she follow this up with the local council to see when the next visit is due. The home is clean and tidy throughout and all areas, including bathrooms and toilets were fresh smelling and there were no offensive odours in the property. The laundry room is kept locked and is sited where laundry does not have to be carried through food preparation or storage areas. The laundry was clean and tidy with an easily washable floor. The washing machine has a hot wash facility. Staff have done infection control training though again, without a central training list, it was difficult to demonstrate that all staff had done this course without going through every staff file. Both staff whose files were sampled had a certificate on file for this course. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent staff but the policy of having one staff on duty needs to be reviewed. Recruitment and staff training arrangements have improved but more work needs to be done. EVIDENCE: Residents are supported by qualified and competent staff. The manager and the one staff member on duty demonstrated a good knowledge of resident’s needs and communicated well with them. Guidelines have been introduced regarding the challenging behaviours of one resident and the techniques for managing their care. Apart from the registered manager there are six regular staff who work at this home, and two bank staff from their other two sister homes. Of the regular staff, two are trained nurses, two have NVQ Level 2 and the remaining two staff are now registered to start on an NVQ Level 2 course in the New Year. The manager said only bank staff who already have at least an NVQ Level 2 would be used in the home. Service users were being adequately supported on the day of the inspection but the inspector expressed concern about the practice of having only one Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 21 member of staff on duty in the home. This was highlighted at the last inspection and the responsible individual said it was due to be reviewed when the home completed their extension and a fourth resident was admitted. The new extension is now in use but only two of the other three rooms are occupied, therefore no extra staff have been taken on. The registered manager and responsible individual were asked again to review this, using a risk assessment format. It was also noted that the manager was about to go outside through the garden to get someone from the home next door to come to the telephone. This would have left one resident alone without any member of the home’s staff in attendance. This practice was discussed with the manager as it is unacceptable. Recruitment arrangements continue to improve and of the two staff files checked, both had CRB and pova checks, an application form and two references. One had a full employment history and the other had a small gap of three months which was addressed immediately as the member of staff was on duty. The responsible individual confirmed that the project to retrospectively check all recruitment files had the correct information had now been completed at Firlawn. Though residents at this home could not take an active part in recruitment, the manager said any potential new staff are invited to the home to see how they communicate with residents, before being offered permanent employment. Responsibility for training is shared between the manager and responsible individual and there is evidence of improvements in staff training at this home and training certificates are kept on staff files. The review of training arrangements recommended last year has been carried out. All staff who give medication have had medication training provided by a specialist medication training company, and the new pharmacy arrangements made by the home will include staff training on this subject from now on. There is evidence of staff training on protection of vulnerable adults, infection control and manual handling. However, without a centralised training list it was not possible to demonstrate that all staff had been trained in all the essential training courses such as first aid and manual handling without going through each file – two files sampled did not have all the relevant certificates – one who had their manual handling certificate missing had this faxed to the CSCI office the next day. The service needs a centralised training list covering all essential training and there should be a system in place to highlight when refresher training is due. It was also noted that those staff who did an external manual handling training in August last year now needed up-dates as their certificates only lasted for one year. Staff have an induction course and the two files sampled showed these had been signed off by the manager. The service should review their induction arrangements in line with the Skills for Care Common Induction Standards, and a recommendation will be made in this regard. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well managed home. Their views and those of their families are taken into account, and their safety is promoted. EVIDENCE: The registered manager is a trained nurse (RMN, RMNH) with a Diploma in Community Nursing. She has had twenty-six years experience of managing and an NVQ4 qualification in management. Some of the management responsibilities (e.g. the budget) are shared with the responsible individual, Mr. Puah. The home currently has one staff member on duty for most shifts and during the week this is usually the registered manager; she demonstrates a very high level of commitment to the home and to the current residents. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 23 One responsibility of the registered manager is to ensure all CSCI Requirements are complied with. During discussions it became clear that not all incidents affecting the well-being of residents had been reported to CSCI though they were clearly documented at the service. The manager said she had misunderstood Regulation 37 notifications, believing that only incidents resulting in hospital admission need be reported to CSCI. She said that from now on all incidents affecting the well-being of residents will be reported to CSCI on the home’s own incident form. There are a number of quality assurance systems in place for example a monthly health and safety audit and an in-house audit of quality standards. This covers resident’s care needs, record keeping, activities and staff development. Though it is difficult to get feedback from residents, their relatives are consulted and a monthly parents/relatives meeting forum is due to start on the Saturday following the inspection. The previous inspection asked the home to review arrangements for quality assurance to ensure the home is meeting all aspects of Standard 39, including an annual development plan. Whilst there is still no documented annual development plan, the manager and responsible individual highlighted a number of developments over the last year, including more work on person centred plans and the building of the summer house, as well as planned developments for the coming year. A recommendation will be made that this development plan is in a written format and shared with residents and relatives. The service will also need to bear in mind that their own quality assurance systems should have picked up and addressed the Requirements made at the end of this report and therefore current arrangements may need to be reviewed. There are a number of systems in place to promote the health and safety of residents at this home including a monthly health and safety audit, annual legionella checks, the laundry room being kept locked. There is guidance for staff on avoiding and managing potentially hazardous incidents, for example residents at risk of choking. There are also risk assessments in place in relation to environmental risks. The kitchen is kept very clean and tidy and there are instructions for staff on the cleaning regimes for worktops etc, and on the use of the colour coded chopping boards to prevent cross contamination. A Requirement regarding the security of the hazardous substances cupboard, and the trip hazard in the lounge has been made under Standard 24. Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 X 2 X X 2 X Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA2 YA24 Regulation 14(1) (a)(b)(c)(d) 13(4) (a)(b)(c) Requirement Residents must only be admitted following a full written assessment of their needs and aspirations. Risk assessments must be carried out and follow-up action taken in regard to: 1. The large mat in the lounge which may cause a trip hazard 2. The security of the hazardous substances cupboard as discussed in the report and during the inspection. The policy of having only one member of staff on duty per shift must be reviewed, and an updated risk assessment carried out, for the safety of residents and to allow them sufficient flexibility in their daily activities. The registered person must ensure staff training records are up to date and that all staff are trained for the work they are asked to perform. All incidents affecting the wellbeing of residents must be reported to CSCI as per this Regulation. DS0000013642.V349745.R01.S.doc Timescale for action 14/11/07 14/11/07 3. YA32 13(4) (a)(b)(c) 07/12/07 4. YA35 18(c )(i) 07/12/07 5. YA37 37 07/11/07 Firlawn Version 5.2 Page 26 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. Refer to Standard YA6 YA12 Good Practice Recommendations Each resident must have their care plan in a comprehensive and clearly documented format as discussed in this report. It is recommended that activity plans are up-dated and a note is kept of the actual activities each resident participates in as evidence that residents have sufficient opportunities to take part in appropriate and fulfilling activities. It is recommended that the manager keep a record when residents have alternatives to the main menu so that any person inspecting the record could determine whether the diet is satisfactory. It was recommended that the manager follow up the local council to see when the next environmental health department visit is due. The service should review their induction arrangements in line with the Skills for Care Common Induction Standards, and a recommendation will be made in this regard. A recommendation will be made that the annual development plan is in a written format and shared with residents and relatives. 3. YA17 4. 5. 6. YA24 YA35 YA39 Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Firlawn DS0000013642.V349745.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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