Inspection on 12/11/07 for Flaxen Road

This inspection was carried out on 12th November 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

Flaxen Road 18/01/07

Flaxen Road 17/02/06

Flaxen Road 13/06/05

Flaxen Road 02/02/05

Flaxen Road 12/07/04

Similar services:

Clovelly House Residential Home Ltd

Cherry Orchard Nursing Home

Coppermill Care Centre

Fountains Care Centre (The)

Eleanor Palmer Trust Home

Elmstead House

Bridgeside Lodge Care Centre

Dalemead

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

CARE HOMES FOR OLDER PEOPLE Flaxen Road 1 Flaxen Road Chingford London E4 9TF Lead Inspector Peter Illes Unannounced Inspection 12th November 2007 09:20 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 Flaxen Road DS0000058687.V354234.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. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Flaxen Road Address 1 Flaxen Road Chingford London E4 9TF 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) 0208 524 4422 0208 524 9656 London Borough of Waltham Forest Ms Mary Lee Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2007 Brief Description of the Service: 1 Flaxen Road is registered to provide care to 24 older people who have a diagnosis of dementia. The home is managed by L.B. of Waltham Forest as part of the borough’s in-house residential care resources for older people. The home was purpose built in 1989, and is a single storey bungalow style building with wheelchair access. Access to the grounds is through electric gates with an intercom system. There are 24 single rooms each with its own sink unit, and two with en-suite facilities. The home is divided into two units, each with 12 bedrooms, a lounge, dining area, kitchenette, bathroom, 3 toilets and a shower room. A large bright entrance foyer connects the two units and the home also has a separate main kitchen, laundry, office accommodation, staff facilities and attractive gardens. The home is situated in a quiet residential area in North Chingford and is near local bus routes, shopping facilities, library and a leisure centre. The statement of purpose describes that the core purpose of the home is to: “Provide quality care and support for people in the community by empowering service users. We will support older people with dementia”. The provider organisation must make information about the service, including CSCI inspection reports, available to people living at the home and other stakeholders. The current weekly charge is £621 per week. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took approximately eight hours with the registered manager being present or available throughout. There were twentyfour people accommodated at the time and no vacancies. The inspection activity included: meeting and speaking with the majority of people living in the home, six of them independently, although conversation with people was limited to varying degrees because of the individual’s assessed needs; detailed discussion with the registered manager; discussion with a number of staff members, four of them independently; independent discussion with a community psychiatric nurse and a social worker, both of whom visited the home during the inspection; independent discussion with one relative that visited the home during the inspection and discussion by telephone with the responsible individual. Further information was obtained from: an Annual Quality Assurance Assessment (AQAA), submitted by the home to the Commission prior to the inspection; a tour of the premises and documentation kept at the home. What the service does well: The home provides good quality care and support for older people with a diagnosis of dementia. People living at the home were well presented and generally appeared relaxed during the inspection. Staff were observed interacting sensitively and patiently with people and staff spoken to were aware of people’s individual assessed needs. A visiting health care professional stated that the staff were approachable and good at identifying issues and referring (to relevant agencies) when necessary. The home provides a calm, bright and comfortable environment for people living there, which people seemed to enjoy and appreciate. Flaxen Road DS0000058687.V354234.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. Flaxen Road DS0000058687.V354234.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 Flaxen Road DS0000058687.V354234.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): 1&3 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has up to date information about the services it provides so that people can know what to expect from the home. The needs of people seeking to live at the home are properly assessed before they are admitted. Once admitted their needs are reviewed to help staff in meeting these needs although further attention is needed to make sure that an initial review is carried out in a timely manner after every person’s admission to the home. EVIDENCE: At the last inspection a requirement was made that the home’s Statement of Purpose accurately reflects the service provision. This related to amendments to the Commission’s address, the frequency of relatives’ meetings and staff qualifications. These amendments were seen to have been made at this inspection. A good practice recommendation had also been made that personal details of identified managers are removed from the statement of purpose and this was also seen to have been acted upon. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 9 The files of four people living in the home were inspected. These were for three people who had been admitted to the home since the last inspection and one for a person who had lived at the home for a longer period. The files of the three people who had been admitted to the home since the last inspection contained detailed assessment information about the person that was available to the home at the point of admission. This included a community care assessment from the placing authority for all three, a specialist assessment from the North London Mental Health Trust (NELMET) in one case and a hospital discharge summary for the other two people. The home had also undertaken its own pre-admission assessment and the registered manager had written to the three people prior to admission indicating that the home could meet the person’s needs at that time. The home’s admission process also includes planned reviews of the placement, normally after six weeks and then annually. Evidence was seen that these reviews had taken place or had been planned for two of the people who had recently been admitted to the home. A relative of the third person visited the home during the inspection and was spoken to independently. The relative stated that they visited the home three or four times a week and was very complementary about the home, the staff and the care their person had received since admission. However, the person the relative was visiting had been living in the home for nearly three months and the relative stated they were not aware of any review having taken place. After querying this with the registered manager it transpired that the home was still waiting for a date from the referring social worker for the six-week review. The registered manager stated that she would pursue this as a priority. Although there was evidence from documentation seen that the required initial six-week and annual reviews were generally undertaken by the home a requirement is made about this. This is because it is the home’s responsibility to review the needs of the person whether a representative from the placing authority is present or not. The registered persons must ensure that initial reviews are planned and undertaken following the admission of a person to the home in accordance with the home’s admission procedures, this is to ensure that the home and other stakeholders can be assured that the person’s assessed needs are being properly addressed. The files of the other person that had lived at the home for a longer period also showed that the home had satisfactory assessment information at the time of the person’s admission. The file also indicated that assessment information had been reviewed regularly, with appropriate stakeholders including external health and social care professionals where appropriate, to assist the home in meeting the person’s changing needs. Evidence was seen that the home also tries to identify information about the life history, including the likes and dislikes of the individual, both on and after admission to the home. This is to assist in undertaking orientation and reminiscence work to assist people living at the home, all of whom have a diagnosis of dementia. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 10 The home does not provide intermediate care. Flaxen Road DS0000058687.V354234.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans record people’s needs and preferences and give guidance to staff on how to meet these. People are appropriately supported regarding their health care needs with access to a range of healthcare professionals as needed. Satisfactory medication policies and procedures are in place to safeguard people living in the home. People are also treated with respect and dignity by staff, which they and other stakeholders appreciate. EVIDENCE: At the last inspection three requirements were made to improve people’s care plans. These related to: ensuring care plans contained sufficient information about how people’s health care needs will be met, ensuring that risk assessments contain all identified risks and that care plans are updated when a person’s needs change. The files of the four people inspected all contained satisfactory care plans and indicated that the above three requirements had been complied with. The care plans were divided into sub-headings including: mobility, dressing, toileting (and other issues relating to personal care), night Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 12 time needs, moving and handling, family involvement and leisure and social preferences. Evidence was also seen that the provider organisation was in the process of developing a new care plan format for all of its homes although the registered manager informed me that this remained work in progress. The care plans were informed by a range of assessment information and information about the person’s previous occupation, interests and preferences. Evidence was seen that the plans were reviewed regularly, evaluated and updated where appropriate. The care plans were also informed by up to date risk assessments that gave guidance to staff on how to minimise identified risks, there was also evidence that the risk assessments were also regularly reviewed. A requirement was made at the last inspection that moving and handling risk assessments were in place for those people who needed this assistance. This requirement had been complied with and there was an up to date moving and handling assessment on one file inspected for a person who required moving and handling tasks to be undertaken. At the last inspection a requirement had been made relating to people’s health needs. This was to ensure that advice/ direction from any health professional was recorded and adhered to. Evidence was seen on the files inspected to indicate that this requirement was being complied with. Evidence was seen that people living at the home are registered with a G.P. and evidence of appointments with G.P.’s was seen. Evidence was also seen on a separate record of people attending appointments with a range of appropriate health and social care professionals including the district nursing service, optician, chiropodist and mental health professionals where appropriate. A community psychiatric nurse and a social worker from the North London Mental Health Trust (NELMET) both visited the home during the inspection and were spoken to independently. They both stated that they felt the home was good at identifying unmet or changing needs and referring to specialist agencies where necessary. They were attending the home to see a person living there following such a referral. They went on to say that in their experience they found the staff approachable and that staff were trying hard to meet the needs of the person they had come to see. Other records seen related to monitoring health were clear and up to date. These included up to date records of skin vulnerability, daily food and liquid intake and a record of the person’s weight. The registered manager stated that although a number of people living in the home had vulnerable skin no one had any pressure ulcers at that time. I sat in on the staff handover between the morning and afternoon shift staff. I was pleased to hear a personalised and individual discussion about each person living in the home and an overview of how each person had been during the morning including any health related issues. The home has a clear medication policy and procedures that were seen to have been reviewed and updated by the provider organisation in May 2007. Medication is supplied from a local pharmacist in a monitored dosage system. As I arrived at the home I was introduced to the dispensing pharmacist that supplies medication to the home. He confirmed that he undertook monthly Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 13 monitoring visits to the home and had just completed such a visit. Records of these visits were also noted in the home. At the last inspection a requirement had been made that the home ensures that medication is accurately administered and recorded at all times. Evidence seen at this inspection indicated that this requirement was being complied with. Three people’s medication and medication administration record (MAR) charts were inspected and were accurate and up to date. Records of medication received into the home and medication disposed of were seen and up to date. Medication is suitably stored in the home, including in a dedicated fridge and the temperature that medication is stored at is regularly recorded. Evidence that staff had received training in the safe administration of medication was seen during the inspection and confirmed by staff spoken to. Staff were observed interacting with people living at the home in a relaxed and appropriately professional manner throughout the inspection. An example of this was my observation of two staff using a hoist to move a person from their wheelchair into an armchair in one of the lounges. The person appeared apprehensive about this at the start and the two staff were seen to be explaining to the person what was happening and what was going to happen next throughout the transfer. They were also talking to the person throughout to reassure them and spent time at the completion just talking to the person to help reassure them. The person smiled and appeared relaxed and comfortable following the transfer. One of the members of staff was spoken to independently later during the inspection and was clearly familiar with that person’s needs regarding moving and handling tasks. The staff member also confirmed that they had received up to date moving and handling training. People living at the home, care professionals and a relative spoken to independently on the day were all generally complimentary about the staff and the way they worked. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 14 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home enjoy a range of appropriate activities that meet their needs and that they enjoy. Relatives and other visitors are made welcome at the home, which they and people living there appreciate. People are encouraged to exercise as much choice and control over their lives as they can to maximise their independence. They are also provided with a range of healthy and nutritious meals that they enjoy. EVIDENCE: A daily programme of activities is in place for people living at the home. This included activities such as gentle exercise e.g. throwing a soft ball, games, crafts, music, dancing and a range of reminiscence work. At this inspection people were observed undertaking gentle exercise with a softball and individual work being undertaken with people. At the last inspection a good practice recommendation was made that staff liaise with each other to check what activities have been provided on the previous shifts. This was being acted upon and reference made to individual activities was noted at the mid-day staff handover. A record is now also kept for all people living at the home of Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 15 activities offered to them on a daily basis and whether they participate or not. The home had also arranged visits over the previous months including to Southend, Epping Forest and Newham City Farm, and photographs of these visits were displayed in the home. I was pleased to learn that the television in the lounges in each unit were only put on during the day time when there was something that people wanted to watch. Televisions were not left on as background noise and I was told that this was to assist in providing a more settled and less distracting environment for people with dementia. All the current people living at the home at the time were white with no specific cultural needs identified although the registered manager stated that the needs and preferences of people from different cultures could be met. There was a poster of the flags of the world displayed in the communal area of the home. The registered manager stated that one of the senior staff was undertaking a project involving music from different countries and that information about different festivals and community events are also displayed when appropriate. The registered manager also stated that representatives from the Catholic Church attended the home to give communion and a representative from the Anglican Church attended the home monthly to hold a service for those who wished to attend. The majority of people living in the home have contact with friends and relatives, many having weekly visits or more. The home operates an open visiting policy. One relative who visited the home during the inspection was spoken to independently. They stated that they visited three or four times a week and were made to feel welcome at anytime by staff including being offered a cup of tea during their visit. The home holds regular relatives meetings and records of these were seen. Records also showed that the home had a significant number of visitors and feedback from satisfaction feedback forms from relatives that were sampled were overwhelmingly positive. People living at the home are not generally able to manage their finances, which are managed through the local authority as a corporate appointee or via relatives. People living at the home are able to bring their personal possessions into the home and rooms seen during a tour of the building showed bedrooms personalised to varying degrees. The home has a four-week menu that was seen to contain a range of healthy meals and alternatives. I was told that the home can cater for a range of cultural diets, including Kosher and Halal although none of the people currently living in the home required these. The home can also provide for a range of special diets although currently only vegetarian diets were required. The main meal of the day is served in the evening with a lighter meal provided at lunchtime. I was invited to have lunch with people in one of the units, which consisted of a range of appetising sandwiches and a pudding. One person with communication difficulties was assisted by means of a prompt board to indicate which sandwiches they would like and this was done in a patient and reassuring manner. The cook presented as being very competent and Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 16 knowledgeable about the home and the likes and dislikes of the people living at the home. Feedback from various sources indicated that the meals provided at the home were of a high quality. The cook stated that she had worked at the home for a number of years although was employed through an agency. She stated that she would very much like to work directly for the home although I was informed that the home had a recruitment freeze for ancillary staff. A good practice recommendation is made that the home should consider employing a permanent cook to assist in maintaining good personal and professional relationships with staff. The kitchen was clean and tidy with a good supply of food with regular health and safety checks being undertaken. The kitchen equipment was generally of good quality although a fridge needed replacing because of rust forming along one edge and this had been identified in an environmental health officer’s report undertaken prior to this inspection. The registered manager stated that the fridge was due to be replaced although a requirement is made as my judgement is that the fridge was a potential health and safety hazard and had already been identified as such in the environmental health officer’s report. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has satisfactory procedures for dealing with concerns and complaints that is made known to stakeholders to assist in dealing with any concerns or complaints in a timely manner. The home’s safeguarding adults’ policy and procedures has been further reinforced with staff to assist the home deal more robustly with any allegations or disclosure of abuse that may be made. EVIDENCE: The home uses the L.B. of Waltham Forest Social Services complaints procedure that was seen in the home and had been updated since the last inspection. A summary is displayed in the home and in the revised Statement of Purpose with both having the Commission’s correct details included. The complaints procedure has three stages and a 28-day timescale for dealing with complaints. Request for copies of the complaints procedure is written in 6 languages. The home has not received any complaints since the last inspection and neither has the Commission. The home has received a number of compliments from relatives and others and some of these were seen displayed in the home. A copy of the L.B. of Waltham Forest’s safeguarding adults policy was seen in the home. At the last inspection the L.B. of Waltham Forest had received an allegation of abuse about the home and was in the process of investigating this at that time. This allegation had been submitted to the Borough’s central Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 18 human resources team and had not been made known to the registered manager at the time. A requirement was made at the last inspection that the responsible individual must forward a full report of the investigation to the Commission when it was completed. This had been complied with and showed that the allegation contained seven elements. One of these was partially upheld and the other six were not, evidence was seen that the partially upheld element had been satisfactorily addressed. Two other requirements were also made at the last inspection regarding safeguarding adults and related to the allegation above. These were that the home’s whistle blowing policy is adhered to by the responsible individual at all times and that all staff receive training in safeguarding adults. These two requirements had also been complied with. Evidence to support this included: a discussion with the responsible individual, that staff had received a briefing by the Borough’s Safeguarding Adults Coordinator at a staff meeting, that the registered manager had completed a staff training needs analysis and an ongoing training programme had been put in place regarding safeguarding adults. Staff spoken to were able to describe the actions that needed to be taken should an allegation or disclosure of abuse be made to them. No other disclosures or allegations had been made to the home or to the Commission since the last inspection. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 19 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): 19, 20 & 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is well decorated, well furnished, well maintained and that meets their needs. However, an improvement is needed in the areas that people are permitted to smoke in. The home was clean and tidy throughout, creating a pleasant environment for people accommodated, staff and visitors. EVIDENCE: The home was purpose built in 1989 and is a single storey bungalow style building. It comprises two twelve-bed units each with twelve single bedrooms each with its own sink unit, and two with en-suite facilities. Each unit also contains a communal lounge, dining area, adapted toilets and bathrooms and also has a conservatory. One of the conservatory’s is designated as a smoking Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 20 area. A large bright entrance foyer connects the two units. Those bedrooms seen during a tour of the building were well equipped and decorated, had personal call bells and had been personalised according to the wishes of the people living in them. People spoken to during the inspection stated that they were happy with their bedrooms. It was noted that there are suitable signs and pictures on doors to bedrooms and to other communal areas to assist people to find where they want to go. The registered manager stated that the home was considering how to improve the signage to further assist people living in the home. The home also has a satisfactory central kitchen, laundry and staff facilities. Overall, the home is bright, comfortable and meets the needs of people living there. At the last inspection a requirement was made that the home forwards a programme of planned work for the environment and this had been complied with. The home has satisfactory maintenance systems that the registered manager stated worked well. It was noted that the conservatory on one unit is the home’s designated smoking area. This has an extractor fan fitted, a door to the garden and a sliding door that connects the conservatory to the communal lounge. However, since 1st July 2007 the Health Act 2006, Smoke-Free (Premise & Enforcement) Regulation 2006 has come into force, which includes requirements for smoking areas in residential care homes. Since the last inspection an environmental health inspector had undertaken an inspection of the home and required that the door that connects the designated conservatory to the lounge must be selfclosing. Although the current sliding door works effectively it is not self-closing. A requirement is made that the home complies with the environmental health officer’s requirement, and the new legislation, for the home’s smoking area to have a self-closing door. The laundry and laundry equipment was satisfactory and the home had the necessary infection control procedures in place. The registered manager stated that all staff were up to date in infection control training and evidence of staff certificates from a recent infection control course was seen. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 21 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are supported by a sufficient number of staff to meet their needs and who have a range of skills, qualifications and competencies. People accommodated are also protected by the home’s effective recruitment policy and procedures. EVIDENCE: An up to date staffing rota was seen and correctly recorded the staff on duty during the inspection. The rota indicated that four care staff were on duty, two on each unit, and an additional senior member of staff was on duty throughout the day. At night there are two staff on duty with a designated on call manager and senior manager available for advice and support. I was informed that if any of the people living at the home needed more attention at night time additional staff would be put on the rota. The registered manager’s hours are in addition to the above. The home also employs administrative staff, a laundry assistant, domestics and a cook. The home has nineteen care staff, thirteen whole time equivalent, although had four vacancies at the time of the inspection that were covered by regular Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 22 agency staff. Of the permanent staff twelve had achieved the national vocational qualification (NVQ) level two in care or above. The files of two care staff that had been appointed since the last inspection were inspected. Both files contained: an enhanced criminal records bureau (CRB) clearance and protection of vulnerable adults (POVA) check, a clear application form, two references, proof of identity with a photograph and evidence of entitlement to work where appropriate. At the last inspection a requirement was made that the home ensures that staff receive appropriate health and safety training as some staff at that stage had not received up to date fire safety or first aid training. This requirement had been complied with. Evidence was seen that staff had received fire safety training following that inspection and evidence was seen of other health and safety training records, including first aid, being current. Staff spoken to confirmed that they had undertaken recent training in fire safety, safeguarding adults, first aid, infection control and were due to undertake training on dementia the day following this inspection. A further requirement was made that that staff had a clear individual training plan to ensure that staff were equipped with the skills and knowledge to meet the needs of people living at the home. Inspection of training records and observation of, and discussion with, staff provided evidence that this requirement was being met. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 23 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, 36 & 37 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from the service being managed by a competent, qualified and experienced registered manager. People accommodated and other stakeholders are regularly consulted to promote and monitor the quality of the service they receive although people may benefit further by the home reviewing its operational policies and procedures more regularly. People’s financial interests are safeguarded while living in the home. The home is continuing to monitor and further develop its systems for providing staff supervision to support staff meet the needs of people accommodated and to assist in their own development. A range of effective health and safety procedures protect people living in the home. EVIDENCE: The registered manager has twenty-seven years experience working in services for older people including working at management level for nine Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 24 years. She has attained her registered managers award, national vocational qualification (NVQ) level 4 in management and the City & Guilds advance management for care. She presented as being competent and knowledgeable about the service she is managing. A community psychiatric nurse and a social worker, both of whom were spoken to independently when they visited the home, indicated that they felt the home was well managed. The home sends out satisfaction feedback forms to relatives and other stakeholders on an annual basis with the last having been sent out to be returned by the end of September 2007. These were sampled and those seen provided useful feedback, the majority of which was positive. The registered manager stated that these were being evaluated and would contribute to the homes aims and objectives for the coming year. A development plan for the home was seen that related to the overall stated objectives of the L.B. of Waltham Forest. The home holds regular residents’ meetings and minutes of these were sampled. Staff spoken to stated that people living at the home are encouraged and supported to express their views to the best of their abilities, both at residents’ meetings and through everyday contact with staff. At the last inspection a requirement was made that the responsible individual must ensure that unannounced visits were completed on a monthly basis. This was being complied with and reports of these visits were sampled in the home and judged to be satisfactory. It was noted in the Annual Quality Assurance Assessment (AQAA), submitted by the home before this inspection, that a significant number of the home’s policies and procedures had not been reviewed since at least 2003. A good practice recommendation is made that the home’s policies and procedures should be regularly reviewed in light of changing legislation and of good practice advice from the Department of Health, local/health authorities, and special/professional organisations. The AQAA also states that the finances of people living at the home are dealt with by the L.B. of Waltham Forest’s receivership department or by their relatives. People’s personal allowances are kept securely at the home in individual wallets. The personal allowance and related records for one person were inspected and found to be satisfactory. A requirement was restated at the last inspection that all staff working in the home are suitably supervised and records are maintained. Another requirement was made at that inspection that aspects of practice are addressed and recorded within individual supervision sessions. Supervision records were sampled at this inspection and the range of issues recorded in the supervision notes included practice issues as appropriate. The registered manager stated that she was working hard to ensure that all staff were supervised at least six times a year. Records seen and staff spoken to indicated that most staff were being supervised at least six times a year. However, it was noted during the inspection activity that two staff had not Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 25 received supervision in the last two months and the registered manager acknowledged this. She stated that this had already been identified by the home and was being addressed as a matter of priority and that all staff now had planned supervision dates. The registered manager went on to say that the frequency of staff supervision was now being specifically monitored by the responsible individual, both through the registered manager’s own supervision and through a standing item in the responsible individual’s monthly unannounced visits to the home. Evidence of this was seen in the latest reports of those visits sampled. I also spoke to the responsible individual by telephone who confirmed this and assured me that regular staff supervision was now a priority for the home and that she would continue to monitor compliance with this. A requirement was made at the last inspection that the Commission is informed of all incidents of a serious nature without delay as required by Regulation 37 of the Care Homes Regulations 2001. The Commission has received notification of serious incidents since the last inspection in a timely manner. A range of satisfactory health and safety documentation was seen. This included: gas safety certificate, electrical installation certificate, portable appliance certificate and water tank maintenance to minimise the risk of legionella. The home’s fire log was inspected and showed: up to date servicing of fire fighting equipment, a record of regular fire drills being undertaken at different times of day and that a visit from the fire officer had been undertaken in January 2007 and that the report of this visit was satisfactory. A requirement was made at the last inspection that the safety systems intended to preserve life are not over-ridden. This was as a result of the inspector that undertook that inspection noting that an identified fire door was wedged open. No fire doors were seen to be wedged open at this inspection and evidence was seen that staff had undertaken fire safety training since the last inspection. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 26 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation 14(2) Requirement The registered persons must ensure that initial reviews are planned and undertaken following the admission of a person to the home in accordance with the home’s admission procedures. This is to ensure that the home and other stakeholders can be assured that the person’s assessed needs are being properly addressed. The registered persons must replace a fridge that had been identified by the environmental health officer, to eliminate an identified health and safety hazard. The registered persons must ensure that the home complies with the environmental health officer’s requirement, and the new legislation, for the home’s smoking area to have a selfclosing door. Timescale for action 10/12/07 2. OP15 13(4) 10/12/07 3. OP19 13(4) 31/01/08 Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 28 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 OP15 OP33 Good Practice Recommendations The home should consider employing a permanent cook to assist in maintaining good personal and professional relationships with staff. The home’s policies and procedures should be regularly reviewed in light of changing legislation and of good practice advice from the Department of Health, local/health authorities, and special/professional organisations. Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Flaxen Road DS0000058687.V354234.R01.S.doc Version 5.2 Page 30 - 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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