Inspection on 04/12/07 for Forest Drive Rest Home,

This inspection was carried out on 4th December 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 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

Forest Drive Rest Home, 28/07/06

Forest Drive Rest Home, 28/04/05

Forest Drive Rest Home, 30/11/04

Forest Drive Rest Home, 02/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Forest Drive Rest Home, 2-4 Forest Drive East Leytonstone London E11 1JY Lead Inspector Alison Ford Unannounced Inspection 4th December 2007 10:40 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 Forest Drive Rest Home, DS0000007239.V356209.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. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Forest Drive Rest Home, Address 2-4 Forest Drive East Leytonstone London E11 1JY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8925 4805 020 8281 2343 forestdrive@hotmail.co.uk Mr Nadeem Diwan Mr Nadeem Diwan Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (19) of places Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. These categories to be used flexibly between 19 beds. Date of last inspection 28th July 2006 Brief Description of the Service: Forest Drive care home is registered to provide personal care and accommodation for up to 19 people over the age of 65. The home is registered to provide care to both physically frail older people and those with dementia. The home is not registered for nursing care. The home is a family run concern and a number of family members work in the home. The registered manager and deputy are brothers and their parents are involved in the running of the home. The property consists of two adjoining house which have been adapted for the purpose. The home is situated in a residential area close to Whipps Cross Hospital. There are good public transport links and there is limited car parking to the front of the property. Since the last inspection the development of the adjoining property and the refurbishment of the original property have been completed. There are now 19 single rooms of good size, with 17 rooms having en-suite facilities. There are several lounges and one dining room. There is an accessible garden. The homes Statement of Purpose and a copy of the latest inspection report can be obtained from them. The inspection report can also be downloaded from the Commission for Social Care Inspection website. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced visit to the service by two inspectors, Mrs Alison Ford and Ms Claire Taylor, and contributes to the inspection process for the year 2007/2008. The visit began at 10:40 and lasted for five and a half hours. The Registered Manager, Mr Nadeem Diwan was on duty during this time. During the visit a tour of the premises was undertaken and the staff on duty were spoken with. A good deal of time was also spent talking with the seventeen people currently living in the home, asking them about their daily lives and gaining their views of the home and the staff who support them. Residents care plans, medication procedures and various records, required to be kept by the home as evidence of their commitment to the welfare, health and safety of residents, were also assessed. In addition, the Registered Manager had completed an Annual Quality Assurance Assessment which is a document that they are now obliged to return to let us know about their service and how well they consider that they are meeting the needs of those people that they are caring for. When writing the report consideration has also been given to information received throughout the year such as complaints, concerns and the notification of incidents. At the time of the inspection, fees payable ranged from £525-£600 per week with some extra charges for personal items. These would be discussed prior to admission. What the service does well: Most of the residents living in the home were spoken with during the inspection. Feedback obtained from them was generally very positive and included comments such as ‘the staff are very helpful’, ‘the food is very good’ and ‘the manager takes me out shopping when I need things’. The entrance hall is welcoming and the atmosphere of the home is very relaxed and open. Residents were observed to move about the home freely, going to and from their rooms and the communal areas. The large hatch between the kitchen and dining room / lounge means that everyone can watch meals being prepared and chat with kitchen staff and this all contributes to the overall homely feeling of this service. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 6 Staff were observed to interact with residents in a manner which respected their individuality and enabled them to make their own decisions. They appeared to be very kind and caring. Careful assessments of potential residents are undertaken before a placement is agreed and the people who live here need relatively little support. Many of them are ambulant and articulate and they obviously enjoy each other’s company. On the day of this visit some of them were sitting around the table playing dominoes while others chatted together. A limited range of activities are offered for those who wish to participate The home was clean and tidy and generally free from odour. What has improved since the last inspection? What they could do better: Some concerns were raised about the staffing numbers in the home, which seemed quite low, although there was no evidence available to suggest that this was having any adverse effects on residents. It was noted however, that not all incidents that had occurred were being reported. It was also felt that having more staff members on duty would improve resident / staff interaction and allow the provision of more organised activities. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 7 A discussion was held with the manager and this situation will continue to be monitored carefully. It was also noted that in several areas in the home, both resident’s bedrooms and communal areas, there was no way to summon assistance. The manager explained that some residents remove the pull cords. If this is so, an alternative call system must be installed. Records indicated that staff training is ongoing however most of this is done using videos with a short test afterwards. Given that for many staff English is not their first language it was felt that this was not an ideal method of teaching. This view was supported by the fact that staff members were not always able to explain the procedure to be followed should they have any concerns about practices that they saw in the home. A requirement was made for the manager to explore other ways of training his staff. Throughout the home it was noted that several relatively minor repairs etc needed to be done. This included replacing light bulbs, drawer handles and a curtain rail. Some method of carrying out routine maintenance procedures must be put in place. 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. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards1,3,6 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people who use this service are able to access all of the information that they might need to help them choose if the home will suit them although, it is not all produced in a format that makes it easy for them to read. A pre-admission assessment is undertaken by the homes manager to ensure that the home will be able to meet their healthcare needs. This home does not offer intermediate care therefore this standard does not apply. EVIDENCE: Prior to their moving in, the manager visits all potential residents to make sure that the home will be suitable for their needs. He completes a pre-admission assessment form, which was seen in their folders and there was also a copy of the Care Managers assessment. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 10 5 residents’ files were sampled including the most recently admitted person’s. The needs assessment included information about their medical and social history background and details of specific care areas such as dietary plan, psychological, healthcare and mobility needs. The newest person commented, “Only been here a few days but I find it a very pleasant place”. In addition, a personal profile questionnaire is completed with the resident or someone close to them to determine details about family history and any other significant events. This is good practice as such information can be particularly useful to staff when engaging with people who have dementia or memory loss. Potential residents would then be invited to the home, for a visit, to see if they liked it and look at the room that they would have and meet other residents. Only people who are considered to need relatively little support are admitted and all of the current residents are able to walk around the home and require minimal help with their personal care. There is a Statement of Purpose for the home, which sets out the aims and objectives, and how it is intended that care will be delivered. A Service User Guide has also been produced and most residents have a copy of this in their bedrooms. This is intended to be a “guide Book” to the home and sets out all of the services that will be provided. Given that many of the residents in this home have some degree of dementia, a recommendation is made that consideration should be given to producing this and any other information intended for them to read, in a format that is more suitable for them and that they will be able to understand. Forest Drive Rest Home, DS0000007239.V356209.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): Standards7, 8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service say that they are having their healthcare needs met in a way, which suits them and that staff are kind and caring. Systems in place to record information could be improved and made easier to monitor. There are medication policies and procedures in place to minimise the risk of errors. EVIDENCE: Each resident has an individual care plan and a sample of these was seen during the inspection. It was possible to “ case track “five of the residents throughout the inspection by looking at the records of the care being delivered specifically to those residents that had been spoken with. The care plans assessed were in good order and well organised and presented and there was evidence of input from other healthcare professional as required. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 12 Resident’s healthcare needs are monitored regularly and any changes are identified and addressed. Regular reviews take place on a monthly basis with a more formal review every six months. However, daily notes about the residents are kept separately in a collection of files. Some consist of a series of tick boxes indicating various activities that have been undertaken and in others care staff make an observation about each resident every two hours to indicate how they are spending their days. In practice, this has lead to a confusing amount of information and a collection of generalised statements of limited value, such as “walking around” or “sitting quietly”. Risk assessments that consider how to protect residents’ health and safety were up to date and informative. They covered key areas such as fall prevention and reflected the individual mobility needs of each person. Another care plan included specific risk assessments for supporting one person’s social behaviour. Ideally, each care plan should provide a complete profile of the care and support that resident’s need and a comprehensive guide as to how they are spending their days. In this way all of those staff that are supporting them will know exactly how this should be done and it will provide a complete record of their care. It was therefore recommended that some thought should be given to collating all aspects of the information into one file for each person. Medication storage and administration were generally in good order. The manager said that none of the residents are able to take their medication independently although lockable facilities are available in each bedroom should a person want to do this and have been appropriately assessed. The home uses a monitored dosage system, with most medication being delivered in blister packs by the dispensing pharmacist from “Boots”. Medicines are stored appropriately in a mobile locked cabinet; sampled administration records were up to date and signed accurately. Likewise, medication for return or disposal is recorded appropriately in a book. The pharmacist visited in July of this year to complete an audit of the procedures and medication practices. Some recommendations were made and these have been addressed. One staff member confirmed that Boots provided their medication training four months ago. She was able to describe clearly what they had learnt and had some good knowledge of the medicines that people were prescribed. Staff were observed to administer medication in a safe manner. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 13 Care is all delivered in resident’s own rooms although most of them need minimal help with their personal care needs. Staff, on duty on the day of the inspection, were observed to be very kind and caring although, for some, communication was difficult due to English not being their first language. One resident was consulting with a domiciliary optician on the day of the inspection and a concern was raised about the fact that this was happening in someone else’s bedroom. In order to maintain the privacy of those people living in the home consultations such as these must be undertaken in the room of the resident who is being seen or in another private area. Forest Drive Rest Home, DS0000007239.V356209.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): Standards 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. People who use this service enjoy a lifestyle, which suits them and their remaining capabilities. They are encouraged to make choices within their daily lives, their friends and relatives are always welcome and they enjoy meals, which suit their preferences. EVIDENCE: Residents are encouraged to make decisions regarding how and where they spend their day and they are able to socialise with other residents and with staff. An activity programme is offered although activities do not always correspond to the timetable, which is on the wall. On the day of the inspection the atmosphere in the lounge was very friendly with some residents playing dominoes while others chatted together. They said that in the summer they enjoyed sitting out in the garden. Life history books have been developed with the help of residents and their family and it was evident that staff put a lot of effort into making these very personal to the resident. Those seen were of an excellent standard and Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 15 included pictures and photographs. The manager and staff are commended for the effort that they have put into these. The manager displayed an understanding of the benefit of undertaking this sort of life history work and the books are used both as the basis for reminiscence and also they have allowed staff to gain an in-depth knowledge of the people that they are caring for. Residents are encouraged to maintain contact with family and friends and it was evident from the numerous photos seen that many residents are able to do this. There is a quiet lounge where residents could take their families if they wished to be alone with them. All of the residents that were spoken with said how much they enjoyed the food served in the home. Menus were seen and are varied and there is always a choice. Picture menus are being developed to help people who have difficulty understanding what is being offered to them. Additional snacks such as soup and a sandwich can be served at any time of the day if a resident is hungry. The evening meal was seen and was well presented and hot. It is considered that mealtimes seem to be a pleasant experience for the people who live in this home. One resident asked if a menu could be available on the table or on the wall and a recommendation has been made in line with this request Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 16 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): Standards 16,18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use this service have access to a clear complaints procedure and are generally confident that their concerns will be taken seriously and acted upon. EVIDENCE: There is a complaints procedure and some residents knew that they can raise any concerns with the manager or with other staff. The procedure is available in the entrance hall or in the manager’s office. Some staff have a limited ability to understand English and did not seem to understand the concept of adult abuse and were not able to explain the action they should take if they suspect or witness abuse. Some concerns were raised about the methods used for teaching staff these topics in Standard 30. A requirement has been made to improve training so that all staff understand the steps that must be taken should they have any concerns relating to adult abuse. Recruitment procedures are in place to ensure that people who have been judged as unsuitable to be working with vulnerable adults are not employed in the home. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 17 Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 18 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): Standards 19,22,24,26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people who use this service live in a home, which generally meets their needs and remaining abilities. EVIDENCE: A tour of the premises was undertaken. The home is registered to provide care to people who are physically frail and who may have a diagnosis of dementia. During the planning and development of the extension thought and attention was given to the layout and design of the communal areas in order to ensure that people are able to walk round both the house and the grounds in safety. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 19 The entrance to the home is welcoming, with photographs of the residents living in the home and the staff who work there, handrails and ramps are in place and a passenger lift ensures accessibility throughout the home. A large serving hatch separates the kitchen from the dining room/lounge and this has helped to promote a friendly atmosphere where residents are able to talk to the kitchen staff and smell and see the cooking going on. A concern was raised about the fact that the door from the conservatory, a designated fire exit, is locked although all staff members have a key. Since the inspection advice has been taken from the Fire Safety Officer who agreed that it is acceptable due to the confusion of some of the residents. It was also noted that a bedroom door was wedged open. Automatic door closers must be put onto doors if residents wish to keep them open. These will operate in the event of a fire to close the door and help ensure their safety. An issue was also raised about the call bell system. Although it is in place, many of the pull cords are missing in both communal areas and in resident’s bedrooms. It is understood that there are problems with people who are confused removing them. This being so an alternative system must be considered; it is not acceptable for residents or staff not to have a way to call for assistance. Some minor issues were raised; light bulbs not working, furniture handles being missing, one resident’s bathroom floor needing to be replaced and a curtain that had fallen down. The carpet in the dining room is also quite soiled and needs to be replaced. The radiator in the 1st floor bathroom was not guarded and this must be attended to or residents may be at risk of scalding At the time of the inspection no routine maintenance appeared to be being carried out. The home manager must put an ongoing redecoration and refurbishment plan into place so that these issues are addressed and he must appoint someone to take responsibility for undertaking routine repairs and maintenance on a daily basis. It was noted that bottom sheets are put straight onto the mattress and in one case it was actually a duvet cover that was used. The duvets in use were also quite thin. Given the frailty of the residents in this home and their susceptibility to developing pressure sores, consideration should be given to supplying coverings over the mattress and also to replacing duvets with others that might be warmer. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 20 There is a pleasant garden, which is enjoyed by residents in the summer. New garden furniture was purchased this year and a new patio and water feature were built. The home was clean and mainly free from odour on the day of this inspection. Forest Drive Rest Home, DS0000007239.V356209.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): Standards 27,28,29,30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The people who use this service are not having their needs met by sufficient numbers of suitably trained staff. Robust recruitment practices are in place to help protect the people who live in this home. EVIDENCE: Staffing levels are at a bare minimum and the manager agrees that it is difficult to recruit new staff with appropriate skills and abilities to care for this client group. However, there did not appear to have been excessive numbers of complaints or accidents occurring in the home resulting from this. In order to address the problems of recruitment of new staff, only residents who need very little help and support are admitted to the home. Many of the current residents only need prompting to wash and dress themselves. They are all able to move around the home with minimal assistance and some have been judged to be completely self-caring. It is considered that the appointment of extra staff would enhance the lives of the residents, enable an increase in the range of activities that are offered and Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 22 allow more time for resident / staff interaction. This is an issue that should be considered and if resident numbers or dependency increases must be addressed. The situation will continue to be monitored closely and, as noted in standard 38, there must be evidence available to show that levels of accidents and incidents are being audited carefully to prove that the health and safety of residents is being protected. Of particular concern is the fact that there is only one member of staff on duty at night with another one “on call”. This person is the administrator for the home although it would seem that she has been able to attend some of the training that has been organised for the care staff. She would be called in the event of assistance being needed. It was difficult to understand exactly what her role in the home was and the manager has been asked to provide some clarity of this. Staff files provided evidence that appropriate pre-employment checks are done to protect residents from those people who have been judged as being unsuitable to care for vulnerable people. Staff training is in place however; much of this is undertaken using videos followed by a written “multiple choice” test. Given that for most of the staff English is not their first language this system is not ideal. Those that were spoken to on the day were unsure about procedures to be followed if they suspected abuse was happening and it was perceived that they might experience problems understanding the training and remembering it in the future. Consideration must be given to finding a more suitable method of training and using the current method as a periodic refresher. Very few of the staff have attained an NVQ qualification although the manager is aware that this is an issue that needs to be addressed. Forest Drive Rest Home, DS0000007239.V356209.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): Standards 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use this service can be sure that it is run in their best interests and that their health and safety are generally well protected. EVIDENCE: The registered manager has run the home for some years and is very knowledgeable about the client group, including those people with dementia. The residents were obviously very comfortable with him and engaged him in conversation constantly. There are regular meetings for staff so that they are aware of what is happening the home and also with residents so that they can air their views and influence that care being provided. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 24 Visits are also made by independent consultants in line with regulation 26 in order to monitor the standards of care in the home. If the resident is not able to manage their own affairs the home encourages their relatives to take responsibility for financial management although, in a number of cases the home manages residents’ finances. There is a system in place to account for all monies received or spent on behalf of residents and a sample of these accounts were checked during the inspection. They were easy to understand and accurate. There is a quality assurance programme in place and questionnaires are sent both to relatives of people recently admitted to the home and also to the residents. It is intended that any adverse comments or concerns raised would be discussed with the resident’s key worker although as yet this does not seem to have happened. There must be some evidence available to show that the results of theses questionnaires are collated and action is being taken to address any concerns. Records of accidents and incidents occurring in the home were seen and it was noted that some of these have not been completed fully. Also records of any incidents affecting the wellbeing of residents are not being forwarded to The Commission as required. This was discussed at the time of the inspection and appropriate documentation to ensure that this happens was left with the manager. As noted previously, records of any untoward incidents must be kept and monitored as a part of the audit to provide evidence that there are sufficient members of staff on duty to support residents. The Annual Quality Assurance Assessment document states that all equipment and services are appropriately maintained and policies and procedures are in place. Requirements issued by Environmental Health regarding the kitchen have all been complied with. Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 2 X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 X X X X X 2 Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 26 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 OP10 Regulation 12(4)(a) Requirement Consultations between residents and other healthcare professionals must not be undertaken in other resident’s bedrooms. All staff must receive training in adult abuse issues delivered in a way that ensures that they understand the process to be followed. If residents wish to keep their bedroom doors open an automatic closer must be fitted so that the door shuts in the event of a fire. There must be an operational call system in all residents bedroom and in communal areas so that assistance can easily be summoned. There must be procedure in place to ensure that routine maintenance is dealt with in a timely manner. Training must be improved so that more staff have achieved at least NVQ level 2, in order to ensure that residents are receiving the best possible care DS0000007239.V356209.R01.S.doc Timescale for action 01/03/08 2. OP18 18(1)(c) 01/03/08 3. OP19 13(4)(c) 01/03/08 4 OP22 13(4)(c) 01/03/08 5 OP19 23(2)(d) 01/03/08 6 OP28 18(1)(c) 01/03/08 Forest Drive Rest Home, Version 5.2 Page 27 7 8 OP30 OP33 18(1)(c) 24(1) 9 OP38 37 10 OP38 37 and support. The methods for delivering staff training must be improved to ensure that staff understand it. Results of surveys undertaken to monitor the satisfaction of residents must be collated and used to influence the service that they receive. Any untoward incident affecting the health or well being of a resident must be reported to the Commission for Social Care Inspection as in regulation 37. Untoward incidents and accidents must be monitored as part of the audit to show that the home is sufficiently well staffed. 01/03/08 01/03/08 04/12/07 04/12/07 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 Refer to Standard OP1 Good Practice Recommendations It is recommended that the Service User Guide and any other information that is intended for residents should be produced in a format that is more suitable for their abilities. It is recommended that consideration should be given to the consolidation of information into a care plan that provides a complete profile of the daily lives of residents and the care and support that they need. It is recommended that there should be a copy of the day’s menu available in the dining room for residents to see. It is recommended that consideration should be given to replacing bed linen to make it more comfortable for residents. It is recommended that staffing levels should be increased to provide more opportunity for staff / resident interaction. 2 OP7 3 4 5 OP15 OP24 OP27 Forest Drive Rest Home, DS0000007239.V356209.R01.S.doc Version 5.2 Page 28 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 Forest Drive Rest Home, DS0000007239.V356209.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. 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