Inspection on 18/01/07 for Flaxen Road

This inspection was carried out on 18th January 2007.

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

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

Other inspections for this house

Flaxen Road 12/11/07

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 Kristen Judd 18 th & 25 th Unannounced Inspection January 2007 10:35 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.V318474.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.V318474.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.V318474.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th February 2006 Brief Description of the Service: 1 Flaxen Road is a purpose built, single storey bungalow style building with wheelchair access. It was built in 1989 and houses 24 elderly frail people, including dementia. Access to the grounds are through electric gates with intercom system. There are 24 single rooms each with its own sink unit, and one with en-suite facilities. The premises is divided into two units, each with 12 bedrooms, a lounge, dining area, kitchenette, bathroom,3 toilets and a shower room. There is a main kitchen where freshly cooked meals are provided daily, including special diets and cultural foods where requested. Service users are encouraged to join in activities, which also include those suitable for people with dementia. This is a Local Authority provision. Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was completed in two days on the 18/1/07 and the 25/1/07.This inspection followed up the requirements made at the unannounced inspection held on 17/2/06. The inspector spoke with service users, relatives, staff and the registered manager during the inspection. A tour of the environment was undertaken and samples of records were examined. There have been nineteen requirements and two recommendations made following this inspection. Verbal feedback was given at the end of the inspection and a comment card left for completion. It was noted that the manager continues to receive the verbal findings positively, and responded positively to resolve those areas where action is now required. For example the manager completed a full audit on medication following the findings of the inspection on day one. The inspector wishes to thank the management team, staff and service users for facilitating this unannounced inspection and actively contributing to the regulatory process. What the service does well: What has improved since the last inspection? What they could do better: The service will need to ensure care plans are used as working documents to guide staff in sufficient detail to ensure service users individual needs are met. It was concerning that there was a lack of documentation on the files of two new admissions within a timely fashion. The manager must ensure that all staff are supervision in line with regulation. Please contact the provider for advice of actions taken in response to this Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 6 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.V318474.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.V318474.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 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector believes that staff are clear about the service and what is expected to be provided to service users. Pre admission assessments are completed prior to people moving into the home to ensure that the service provision can meet all there assessed needs. However the statement of Purpose must accurately reflect the service provision. EVIDENCE: The home has a Statement of Purpose, which is a comprehensive document, and includes all the information required by the National Minimum Standards. The document was updated in December 2006; the inspector spoke with the registered manager who stated that since the document was updated in line with the last inspection there have been no other changes required. However the inspector noted that the document has not been updated with the new contact details for the Commission for Social care Inspection. Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 9 Additionally the inspector cross referenced statements made in the document such as relatives meeting are held three monthly, the inspector was informed that no meeting have been held for at least six months, staff were unable to state the date of the last meeting held. The document also states that all staff have achieved NVQ Level 2 however this is not correct. It is required that the Statement of Purpose be updated and accurately reflects the service provision. It was raised in the previous inspection that the registered providers information was lengthy and it was recommended that this information be summarised to make a more service user-friendly document. This has been completed however the inspector noted that personal information regarding the registered provider has also been included and it is recommended that this be removed. The inspector examined the files of the most recent admissions that were made to the home. Pre admissions assessments are completed prior to admission. The registered manager writes to the prospective service users separately with regards to the outcome of the assessment and if suitable offers a place. The home does not provide intermediate care. If, at a future date, the registered provider should wish to provide such care, consideration would need to be given to staffing levels, appropriate staff training and the provision of dedicated space for this purpose. Flaxen Road DS0000058687.V318474.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): 7,8, 9 &10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans still do not provide accurate detail and clear guidance for staff; as such staff are unable to deliver appropriate care to service users in line with assessed health and social care needs. This potentially places service users at risk. Staff must ensure that medication is administered and recorded accurately. EVIDENCE: The inspector examined a random sample of service users care plans; some were not signed by the service user, relative or advocate or dated. The care plans cover issues such as mental health and cognition, continence, sleep patterns and day-to-day issues such as activities and leisure. The files of the two newest admissions were examined. The first file examined by the inspector raised concern as it was noted that the care plan was completed 10 days after admission. Additionally there had been a major change in health needs however the care plan had not been amended with the information. The health information was blank, and specific allergies were Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 11 blank. The inventory of clothing was not completed and there was no weight recorded on admission. The second file examined on the 25/1/07 was of the service user admitted on the 17/1/07.There was no care plan on file. The health information was blank. The missing persons profile was blank, the likes and dislikes form was blank. It is concerning as daily records reflected that the service users was agitated at times and the pre admission assessment indicated that the service user was at risk from falls however there was no risk assessment in place for either of these issues. It is extremely concerning that the service users files were not in place in a timely fashion. The registered manager must ensure relevant information is in place to ensure that service users needs are clearly recorded and how those need are to be met. The inspector also noted that there were inconsistencies in relation to the care plans and actual care being provided. For example of one service user had attended medical appointments and the advice/further action given by the GP was that the service user must be hoisted from bed to wheelchair and chair to commode. There was not a moving and handling assessment in place and the mobility aspect of the care plan had not been updated .The inspector spoke with staff about the care that the service user concerned received. The inspector was informed that they did not use a hoist with the service users unless ‘he was really bad’. The service user was observed being assisted to eat; the inspector was informed that this is because he often falls asleep however the care plan clearly stated that the service user eats independently but sometimes requires prompting. The observations made by the inspector during the two-day inspection clearly indicate that the care plan does not adequately reflect the service users needs. Daily records observed also indicated that X was at times uncooperative however this issue was not recorded on the care plan or risk assessment and there were no guidelines or strategies for dealing with the service user for staff. It was concerning that the medical information on the service users file clearly indicated that he was deteriorating and had been for some months although the review of the care plan contradiction the information and stated ‘ there is no change with X physical /mental state. The file of the most recent admission was examined the inspector was extremely concerned to note that the risk assessment had not been completed until 23 days after admission. The service users assessment had clearly highlighted risks and as such relevant documentation should have been in Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 12 place. As such there remains an outstanding requirement that the registered manager must ensure that all unnecessary risks to the health and safety of service users are identified are so far as possible eliminated. This requirement will be reinstated with a new timescale for compliance. Clear and comprehensive records are maintained of medical appointments. Staff record when visits are undertaken recording the outcome of the appointment and any further action required. These evidenced that service users have access to a variety of health professionals such as G.P and chiropodist. However as highlighted earlier any advice received from a health professional must be adhered to. The inspector conducted a random check on medication the home uses the Nomad system for storing and administering medications. It is the home policy to records all medications entering the home, however medication received win respect of one service user following a hospital admission had not been entered. Medication Administration Record (MAR) charts are maintained but some of the recording was poor for example errors crossed through and corrected but no explanation written on the back of the MAR sheets. Mrs X was prescribed ‘Aspirin tablets’ 75 mg 1 x daily, signatures were present on the MAR sheet to indicate that the medication was administered on 11/1/07 and 12/1/07 however the medication was present in the blister pack. Additionally the same service users ‘Ferrous Sulphate’ tablets 200mg 1x daily on the MAR sheet an ‘E’ was entered which indicates that the medication was refused and destroyed however the medication was present in the blister pack. The service user had been in hospital, following their return the hospital omitted to return some of the service users medication. Staff contacted family who agreed to collect the medication later in the evening. When the medication in question should have been administered at 18.00 hours it was not present in the home however the staff administering medication entered the code ‘C’ on the MAR sheet that indicates that the service user was in hospital. Daily records clearly indicated that the service users had returned to the home in the afternoon. The correct code should have been ‘F’ for ‘other’ and a clear explanation entered in the MAR sheet notes. The inspector also questioned whether any professional advice was sought to determine whether the medication could be given to the service once it was delivered later that evening however it was not. As a result the service users did not receive prescribed medication.A further three random checks were conducted of the generic packaged medication. Two of which were incorrect by one tablet. The registered manager instructed that a complete audit be undertaken on the first day of inspection. Flaxen Road DS0000058687.V318474.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): 12,13,14 &15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector continues to be satisfied that staff provide service users with the opportunity and support to take part in activities in the home however this must be varied. EVIDENCE: There was evidence of a structured activity programme, however there was limited evidence to show that it was being adhered to. Staff were observed doing simple exercise games with a soft ball however this was the same exercise completed in the morning as in the afternoon, staff should try to vary such sessions. As in previous inspection there was no interest in television (which was not on during the two days) as service users were encourage to interact both with staff, visits and relatives visiting the home. The inspector spoke with service users and relatives during the inspection. The two sets of relatives spoken to all of whom were very positive both about the care provided and the staff. Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 14 The staff do endeavour to involve the relatives and under take to invite then to special occasions and events at time such as Christmas. The photographic evidence in the home show that these events are clearly successful. Service users finances are managed through the local authority as a corporate appointee or via relatives. The administrator requests money when needed for service users. Records seen at the time of inspection were well maintained and deemed correct. The inspector questioned how service users would know how much they had in savings. The administrator stated that this information was easily accessible and would be requested from the head office. Menus seen reflected that the breakfast, lunch and evening meals provided were healthy and appetising. The cook takes a lot of effort to ensure that the food is presented to a high stated. The meals were all home made with fresh vegetables. The cook prepares home made cakes and scones to have with afternoon tea. Service users spoken to commented that the food was very good. The inspector saw the food storage facilities; fresh, frozen and dry stocks were appropriately stored. Food provision continues to be of a high standard. The cook is commended for maintaining high standards. Flaxen Road DS0000058687.V318474.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): 16,17 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are serious concerns raised in this report with regard to how allegations/whistle blowing is investigated. All allegations must be investigated in line with the local authority procedure and notified to the Commission without delay. EVIDENCE: The home maintains a complaints log, this evidenced that complaints have been appropriately recorded and investigated in the past. There have been no complaints since the previous inspection. There is a leaflet provided by the Local Authority available in the home stating the complaints procedure, which 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 complaints procedure was displayed within the home, and this made appropriate reference to the Commission for Social care inspection (CSCI ) but requires updating with the new office details. The home is run by the Local Authority, and has a copy of their adult protection procedure. Additionally there are the home guidelines for staff on adult abuse. The inspector spoke with staff about Adult protection. Some of the agency staff (who have been working in the home for many years) were not fully aware of procedure and in one case it was concerning that when given a Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 16 scenario by the inspector where a service user may have been physically abused, the staff member did not respond appropriately with regard to the service user safety. Such issues are basic Adult protection issues. As such there remains an outstanding requirement that the registered manager must ensure that all staff employed at the home receives appropriate training in adult protection issues. This requirement will be reinstated with a new date for compliance. The inspector became aware of an allegation that has been made through the local authorities ‘whistle blowing procedures’. The letter dated 21/12/06 was sent to the central human resources team and was not received by relevant line management until 2/1/07. However it was not made known to the registered manager until the week prior to the inspection. There was no notification made to the Commission. The inspector raised concern, as staff named in the letter were made aware of the content, prior to investigation, which is not in line with the whistle blowing policy. Such practice is concerning. The responsible individual must forward a full copy of the investigation to the Commission. The inspector continues to be satisfied that the legal rights of service users are protected. Service users are on the electoral register. Service users finances were seen which were being recorded accurately and were deemed correct. Flaxen Road DS0000058687.V318474.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): 19 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home provides adequate communal and private space for service users to meet assessed needs. However the home is still in need of a ongoing redecoration programme to maintain standards. EVIDENCE: Flaxen Road is a purpose built bungalow style premises, which is divided into two intercommunicating units each housing 12-service users. Paths, hedgerows and gardens surround the building. Since the previous inspection the external area has been greatly improved. Additionally new carpets in the communal areas have been installed. There is signage throughout the home to remind service users of their individual bedrooms and toileting facilities. Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 18 The inspector observed the new lighting that was being installed in the corridors to make them brighter. There are some bedrooms that are looking ‘tired’ in particular on the yellow side Y1, Y2 and Y8 and on the red side R10 and R9. In Y1 there was ‘duck tape’ being used as a repair on a cupboard. The conservatories on each of the units are used as smoking areas for service users. All of the individual rooms seen had been personalised and were comfortable and service users were able to bring their personal belongings into the home. Rooms had adequate furniture including wardrobes and chest of draws. There is a laundry facility, which was clean and tidy. The laundry assistant aloes does the home ironing and all the clothes were nicely laundered. The home was very clean and tidy on both days of the inspection. There was no mal odour in the communal areas although a couple of the bedrooms were being aired due to odour. Flaxen Road DS0000058687.V318474.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): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector continues to be satisfied that the home has an effective staff team who appeared to work well together to provide a good level of care to service users. However all mandatory training must be up to date to ensure that service users are not put at undue risk. EVIDENCE: Rotas indicated that staffing levels are satisfactory and there is sufficient staff on duty to meet the needs of the service users. There is always at least four staff and one senior on shift. Nights there are two staff on duty. Additionally there are administrative staff, a laundry assistant, domestics and a cook. The home produces a staffing rota, and on the day of inspection this accurately reflected the actual staffing situation. However it is noted that there is a high level of agency staff currently being used. The Statement of Purpose states that there are 13 posts for care workers eight of which are vacant and coved by agency staff. The registered manager does endeavor to use the same staff and staff confirmed this. One agency staff stated that they had been working in the home for many years and another stated in excess of a year and as such knew the service users well. During the first day of inspection one of the agency staff member was observed throwing a soft ball to service user in turn as an activity/exercise. Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 20 The inspector confirmed that the staff member in question has been working in the home in excess of a year and was aware of service users names. However during the exercise she was getting the attention if service user by saying ‘you you’. It is in the inspector view that this was inappropriate in any circumstance but particularly when working with people with dementia who may forget their own and others names. This issue was addressed with the staff member at the time of inspection. The inspector observed the meals service on both days of the inspection it was relaxed and service users were enabled to time their time. However it was concerning that much of the service was in silence, whilst the inspector acknowledges that sometimes staff react differently when inspections are being conducted staff must interact with service users at all times. It is recommended that such issues be addressed with individual supervision sessions. The files of permanent staff contained evidence of CRB disclosure. The registered manager also maintains records for agency staff however CRB were not available for all the staff on the current rota. The staff were able to evidence all the CRB’s by the end of the inspection. However these are pre employment checks and the registered manager must be satisfied that all relevant checks are in place for all staff prior to commencing work. The inspector examined a spreadsheet of training received. These evidenced that staff have undertaken received training in animate manual handling, food hygiene, and specialist courses such as diabetes. Records indicated that of the fourteen permanent staff,twelve have at least NVQL 2 qualification. The previous inspection highlighted that not all not all statutory health and safety training was up to date, records examined during this inspection indicated that staff still have had no recent training in fire safety. Some staff received first aid training in 2006. Therefore there remains an outstanding requirement that the registered manager must ensure that all staff receive all appropriate health and safety training. This requirement will be reinstated with a new date for compliance. Whilst the spreadsheets maintained clearly reflect the training received staff do not have individual training and development plans to equip staff with the skills and knowledge to meet service users needs appropriately. Staff spoken to by the inspector demonstrated a good understanding of their roles and responsibilities, and most staff were observed to interact with service users in a friendly and supportive manner. There were a couple of concerns regarding individual staff and these have been highlighted within this report. Flaxen Road DS0000058687.V318474.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): 31,33,35, 36,37 &38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that is a well run and well managed home. However, concerns have been raised with regard to staff supervision, adult protection and care planning and these issues must be addressed as a matter of urgency. EVIDENCE: The registered manager has attained her NVQ level 4 in Management and the City & Guilds Advance Management for Care. She has 25 years experience in the care industry in various capacities. The inspector continues to be satisfied that the home is managed in an open and positive way however there are some key issues in this report that must be addressed. The inspector acknowledges that some of these issues are for higher management to address. Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 22 The inspector examined the monthly visits conducted under regulation 26. It was noted that two visits were undertaken in August 2006 however there was no visit for July 2006. As such there remains an outstanding requirement that the responsible individual must ensure that the monthly visits are conducted in the actual month. This requirement has been reinstated with a new date for compliance. As previously stated the inspector had been informed of an allegation that has been received that is currently being investigated. The allegation was received by the Local Authority on the 21/12/06. This should have been notified without delay to the Commission. The Commission received some information of the allegation( as stated previuosly in this report) on 11/01/07 however the inspector became aware of concerning additional information only on the first day of this inspection. Additionally a service user was admitted to A & E however this incident was not notified to the Commission. Such information is notifable with out delay under Regulation 37. The previous inspection raised concern that records seen indicated that this is not being completed to the minimum standard of six times a year. The inspector examined a random sample of supervision records. Of the four files checked one had received no supervision at all, one had received one supervision session in October 2006 and had an appraisal, and one had received three supervision sessions since January 2006. The registered manager was the fourth file checked which evidenced eight supervision session in the last year which is in line with the National Minimum Standards however is not in line with the local authority policy which states that all staff must be supervised once monthly. The inspector was also concerned that the agency staff who have been working at the home in some cases for years do not received supervision. As such there remains an outstanding requirement that the registered manager must ensure that all staff working in the home are suitable supervised and records are maintained. This requirement will be reinstated with a new timescale for compliance. It was highlighted in the previous report that this must be addressed as a matter of urgency and it is concerning that this has not been addressed. The commission will consider further action to see compliance. The service users’ finances and petty cash were seen which were being recorded accurately and were deemed correct. The following health and safety checks have been evidenced: Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 23 The last recorded fire drill is recorded as 02/11/06 Alarm system/emergency light 24/12/06 Gas certificates were seen dated 03/06 valid for one year. Electric certificates were seen dated 04/04 valid for five years Portable Appliance Test were completed 06/06 Fire extinguishers were last checked September 06 Insurance valid until 31/3/07 It was noted during the inspection that the door to the offices was being wedged open. This is a fire door. As such this comprises the safety of service users and staff. The registered manager should install ‘Dorguards’ where necessary. Fire doors must not be wedged open at any time. Flaxen Road DS0000058687.V318474.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 1 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x 1 2 2 Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4.1 Requirement Timescale for action 31/03/07 2 OP7 15 3 OP7 13.4 (c) The responsible individual must ensure that the Statement of Purpose accurately reflects the service provision. The registered manager must 31/03/07 ensure that care plans are in place and reviewed for all service users and contain sufficient details to adequately describe how staff will meet their health, personal and social care needs. The registered manager must 31/03/07 ensure that all unnecessary risks to the health and safety of service users are identified are so far as possible eliminated. (Timescale of 31/08/05 not met) The registered manager must ensure that service users care plans are updated when service users needs change. The registered manager must ensure that all advice/direction received from any health professional is recorded and adhered to. 4 OP7 15.2 31/03/07 5 OP8 13.1 31/03/07 Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 26 6 OP8 13.4 7 OP9 13.2 8 9 OP18 OP18 24.1 13.6 10 OP18 13.6 The registered manager must ensure the moving and handling assessments are in place for service users with relevant needs. The registered manager must ensure that medication is accurately administered, recorded at all times. The responsible individual must adhered to the whistle blowing policy/procedure at all times. The responsible individual must forward a full report of the investigation as stated in this report. The registered manager must ensure that all staff employed at the home receive appropriate training in adult protection issues. (Timescale of 30/06/06 not met) The responsible individual must forward to the Commission a programme of all planned work for the environment with timescales for completion. The registered person to ensure that no person commences works in the home unless a satisfactory CRB disclosure has been obtained and is made available for inspection. The registered manager must ensure that all staff receive all appropriate health and safety training. (Timescale of 30/06/06 not met) The registered manager must ensure that all staff have a individual training and development plan to equip staff with the skills and knowledge to meet service users needs DS0000058687.V318474.R01.S.doc 31/03/07 28/02/07 28/02/07 15/03/07 31/03/07 11 OP19 23.2 31/03/07 12 OP29 19.1(b)(i) 28/02/07 13 OP30 18.1 30/04/07 14 OP30 18.1(c ) 30/04/07 Flaxen Road Version 5.2 Page 27 15 OP33 26 16 OP36 18.2 appropriately. The responsible individual must 31/03/07 ensure that unannounced visits are completed on a monthly basis. The registered manager must 31/03/07 ensure that all staff working in the home are suitable supervised and records are maintained. (Timescale of 31/3/06 not met) The registered manager must ensure that aspects of practise are addressed and recorded within individual supervision sessions The registered manager must ensure that all incidents that are notifable are forwarded to the Commission without delay. The registered manager must ensure the safety systems intended to preserve life are not over-ridden. 17 OP36 12.5 31/03/07 18 OP37 37 31/03/07 19 OP38 23.4 31/03/07 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. Refer to Standard OP1 OP12 Good Practice Recommendations It is recommended that the registered providers personal details be removed from the Statement of Purpose. The staff liaise with each other to check what activities have been provided on the previous shifts. Flaxen Road DS0000058687.V318474.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 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.V318474.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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