Inspection on 01/05/07 for Forest Lodge

This inspection was carried out on 1st May 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

Forest Lodge 11/05/06

Forest Lodge 19/08/05

Forest Lodge 05/05/05

Forest Lodge 11/11/04

Forest Lodge 28/04/04

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 Lodge, 1 Hartley Road Leytonstone London E11 3BL Lead Inspector Robert Sobotka Key Unannounced Inspection 1st May 2007 09:40 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 DS0000007232.V337210.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. DS0000007232.V337210.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Forest Lodge, Address 1 Hartley Road Leytonstone London E11 3BL 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 8530 2009 020 8530 1242 Mr Imteyaz Hussein Taleb Mrs Cliona Taleb Mr Imteyaz Hussein Taleb Mrs Cliona Taleb Care Home 9 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (9) of places DS0000007232.V337210.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on the 21st August 2006, one (1) named service user with Dementia can be accommodated. The CSCI must be informed if this service user no longer resides at the home. 11th May 2006 Date of last inspection Brief Description of the Service: Forest Lodge was first registered as a care home in 1995 but was bought by the present owners in April 2001 as a going concern. Many of the current residents and staff therefore transferred with the new registration. The proprietor/managers, Mr and Mrs Taleb, are both qualified nurses but nursing care is not offered by staff in the home. Mr and Mrs Taleb aim to offer a family style environment. The home has comfortable accommodation for nine elderly people, currently aged from their late 60s to their early 90s. The home has got an exemption to accommodate one service user with dementia. The house is decorated in a homely and attractive manner. There is a large lounge/dining area downstairs and two bedrooms on the ground floor including one double with an en-suite shower. Two of the single rooms have en-suite toilet facilities, one with a shower. There is no lift and so the residents using the first floor bedrooms need to be able to negotiate stairs. The paved rear garden is accessed via steps, although a ramp is planned. DS0000007232.V337210.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and was unannounced. It included speaking with some of the people who use the service and staff working there. The inspector also spent some time with both of the registered managers/providers during which he reviewed various records. A tour of premises was also conducted. The aim of this unannounced visit was to check the home’s progress towards full compliance with the National Minimum Standards and the Care Homes Regulations. The inspector would like to thank all service users and staff who contributed to the inspection. What the service does well: What has improved since the last inspection? Since the last inspection the registered managers have ensured that a new assessments and care planning format has been implemented. There has been an improvement in the frequency of supervision sessions and staff now receive a minimum of 6 supervision sessions per year. The registered managers have submitted an application to the Commission for a variation to the registration in respect of a service user with dementia, as previously required. There has been an improvement in the way the medication systems are managed. The registered managers have ensured that an offensive odour in one of the service users’ bedrooms was eliminated and that all parts of the home are reasonably decorated. DS0000007232.V337210.R01.S.doc Version 5.2 Page 6 Evidence in a form of training certificates has been obtained to demonstrate that staff have received all mandatory training and any other training required for the job. The registered managers have ensured that fire drills are carried out on a regular basis. They have also obtained the electrical wiring certificate. What they could do better: There were 7 requirements, which remain unmet from the previous inspection. These were: - Care staff to have NVQ 2 or 3 in care or be working to obtain one by an agreed date. A minimum level of 50 of care staff to have NVQ Level 2 qualification. - The proprietors/managers to ensure that their qualifications are equivalent to level 4 in management and care. - The present written policy and procedures for staff recruitment, including POVA checks, to be revised to ensure that Standard 29, Regulation 19 and Schedule 2 of the Regulations are met. - A written annual development plan for quality assurance to be available based on a cycle of planning, action and review and involving residents and staff. - The registered managers must ensure that each care plan includes a photo of a service user. - The registered managers must ensure that all perishable food products are labelled once opened, to avoid food poisoning. - The registered managers must ensure that staff personnel files contain all information listed in Schedule 2 of the Care Homes Regulations. Failure to comply with the National Minimum Standards and the Care Homes Regulations has a negative impact on the quality of care offered to those accommodated in the home. Further non-compliance will result in the Commission considering taking an enforcement action against the provider. In addition the following 7 requirements were made following this inspection visit: DS0000007232.V337210.R01.S.doc Version 5.2 Page 7 - The registered managers must ensure that the home’s statement is reviewed to reflect the exemption granted to the home to accommodate one service user with a clinical diagnosis of dementia. - The registered managers must ensure that all care plans are reviewed on a monthly basis or more often when required in order to comply with the National Minimum Standards. - In order to demonstrate that the service user’s healthcare needs are fully met, the registered managers must ensure that recording in relation input from any healthcare professionals, including any appointments attended by service users is improved. This included any outcomes from any medical appointments attended. - The home’s Whistleblowing Procedure must be improved. Contact details of the Commission for Social Care Inspection must also be included. - Stains on the carpet in one of the service user’s bedrooms must be eliminated and/or the carpet should be replaced. - The registered managers must ensure that all staff receive foundation training to National Training Organisation specification within the first six weeks of appointments to their posts, including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group, and the influences and particular requirements of the service setting. - Confidentiality Policy must be drawn up and implemented. 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. DS0000007232.V337210.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 DS0000007232.V337210.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): 1, 2, 3, 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s statement of purpose required minor amendment. Each service user had a contract in place. There has been an improvement in assessments of prospective service users. Further work was required to demonstrate that the assessed needs of those accommodated in the home were being met. EVIDENCE: The home’s statement of purpose required minor amendment to reflect the exemption granted to the home to accommodate one service user with a clinical diagnosis of dementia. Each service user has a costed contract/statement of terms and conditions in place. There has been two new admissions to the home since the last inspection. Following the review of documentation in respect two of the most recently DS0000007232.V337210.R01.S.doc Version 5.2 Page 10 admitted service users the inspector was satisfied that the new assessment document has now been implemented, as previously required. The assessments viewed demonstrated that the registered managers have carried out appropriate assessments to ensure that the home was suitable and appropriate in order to meet the needs of the prospective service users. Since the last inspection the registered managers have submitted an application to the Commission for a variation to the registration in respect of a service user with dementia, which subsequently has been approved. The requirement from the previous inspection has therefore been met. Although it was noted that all care plans have been updated and rewritten since the last inspection visit, they were not being updated on a monthly basis, in accordance with the National Minimum Standards. As at the time of this visit not all care plans were up-to-date, the inspector was therefore unable to ascertain whether the assessed needs of those living in the home were being fully met. Standard 6 is not applicable, as intermediate care is not offered in the home. DS0000007232.V337210.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff working in the home were aware of the service user’s needs, however care plans must be reviewed more frequently. Health care needs are met appropriately, but recording of any healthcare appointments and any outcomes required improvement. Medication systems were appropriately managed. Staff treat service users with dignity and respect and personal care needs are met with sensitivity and privacy. EVIDENCE: As part of this visit, four randomly chosen care plans of people who used the service were checked. It was noted that all care plans have been rewritten since and the new care planning format has been implemented, however not all care plans were being reviewed on a monthly basis in line with the National Minimum Standards. The registered managers must ensure that all care plans are reviewed on a monthly basis or more often when required. The registered from the previous inspection that the registered managers must ensure that each care plan includes a photo of a service user remains unmet and has therefore been repeated. It must be met without any further delay. DS0000007232.V337210.R01.S.doc Version 5.2 Page 12 Although both registered managers are qualified nurses, the home is not registered to provide nursing and it is therefore not provided. Based on discussion with the registered managers and staff working in the home the inspector was satisfied that local healthcare facilities are utilised and staff working in the home ensure that service users received appropriate care from outside healthcare professionals, however the recording in relation to healthcare appointments attended by the people who use the service required improvement. In order to demonstrate that the service user’s healthcare needs are fully met, the registered managers must ensure that recording in relation input from any healthcare professionals, including any appointments attended by service users is improved. This included any outcomes from any medical appointments attended. None of the service users were assessed as being able to administer their own medication at the time of this inspection visit. Staff administer medication using the Boots blister pack, measured dosage system. Staff receive medication training on a yearly basis, which is facilitated by the local pharmacist. Medication is stored in a medicines trolley, which is securely locked and chained when not in use. There was a list of staff authorised to administer medication. Medication systems were found satisfactory and there was evidence that all medication administered to the people who used the service was appropriately signed for once administered, as previously required. The inspector cross-checked medication stocks, which were found to be correct. He also observed a member of staff administering medication. Staff employed in the home were observed to work with service users in a courteous and professional manner. Service users who spoke with the inspector said that they were treated with dignity and respect. Their right to privacy was upheld. DS0000007232.V337210.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 adequate. This judgement has been made using available evidence including a visit to this service. Those who use the service are encouraged and supported to be part of the local community and to develop and maintain friendships and family links. Service users enjoyed food offered by the home, however storage of food required improvement. EVIDENCE: Care plans viewed showed that service users are encouraged and supported and encouraged to become a part of the local community, as well as taking part in appropriate leisure activities. Following discussions with several service users and staff working in the home, the inspector was satisfied that the proprietors and staff encourage and support service users to take part in age and culturally appropriate outings and activities. The registered manager stated that outings offered to the service users included: trips to the seaside, barbeques (weather permitting), there is an entertainer who visits the project on a weekly basis (Wednesdays), shopping trips (Walthamstow Market) and bingo. Service users who spoke with the inspector felt that there was a wide range of activities offered to them, which they said they enjoyed. As previously mentioned, care plans have DS0000007232.V337210.R01.S.doc Version 5.2 Page 14 recently been updated and they now contain a section about leisure activities, as well each service users religious and cultural needs. The registered manager stated that two extra staff are employed in during summer period to support service users in taking part in activities. Visitors are welcome to the home. Visitors book was maintained. Staff working in the home encouraged and supported service users to maintain contact with family and friends. Some of the service users confirmed that the home encouraged them to maintain relationships with their relatives and old friendships. Those who live in the home are encouraged to be as independent as possible and make choices about times to get up or go to bed, colour schemes in their rooms etc. They are able to bring small items of furniture for their rooms and have their personal possessions around them. Residents are encouraged to make decisions about their own financial affairs for as long as possible, although most are assisted by relatives. Residents were encouraged to maintain their independence in personal care, but assisted in sensitive way, when necessary. The inspector was invited to have lunch with the service users. Lunch served on the day of this visit was attractively presented and nutritionally balanced. There were 3 different meal options given. Mealtimes were unhurried and service users were given sufficient time to eat and there was a relaxing atmosphere in the dining room. Those who spoke with the inspector said that they liked the food served in the home. Record of food served to service users was maintained. There were sufficient quantities of food in the home, however not all products were being labelled once opened, as the inspector found some corned beef, which was left in the fridge without any label to indicate as to when it was opened and when it should be used by. The registered managers must ensure that all perishable food products are labelled once opened, to avoid food poisoning. This is a repeated requirement and must be met without any further delay. DS0000007232.V337210.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 good. This judgement has been made using available evidence including a visit to this service. Appropriate complaints system was in place. Service users’ legal rights are protected. The inspector was satisfied that relationships in the home between the staff and the service users were sufficient to protect the safety and wellbeing of those accommodated at Forest Lodge. EVIDENCE: There have been no complaints made to the home since the last inspection. Appropriate complaints policy was in place. Those who spoke to the inspector were confident that their complaints would be heard and promptly resolved. Service users are registered and enabled to vote in elections by post and the registered manager confirmed that those who live in the home were on the electoral register. Appropriate adult protection policies and procedures were in place. It was noted however that the home’s Whistleblowing Procedure was very brief and required expanding. Contact details of the Commission for Social Care Inspection must also be included. Staff working in the home were aware of adult protection issues. The adult protection procedure for the London Borough of Waltham Forest was also available for guidance to staff. Records of accidents/incidents were appropriately maintained. DS0000007232.V337210.R01.S.doc Version 5.2 Page 16 The registered manager stated that at the time of this inspection they did not manage any finances on behalf of service users. DS0000007232.V337210.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, 20, 21, 22, 23, 24, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean, comfortable, homely, generally well maintained. The premises meet the standards for a pre-existing home is relation to the washing and bathing facilities and the number and size of bedrooms. The lack of a lift and steps to the garden limits the type of residents who can be accommodated in the home. The proprietors are working, in a planned way, towards meeting areas such as this, where the home does not fully meet the standards. Carpet in one of the service users’ rooms required replacement. It is recommended that the proprietors consider providing additional storage facilities in the home. EVIDENCE: The home is situated in a residential area, blending in with the surroundings. The new office building has been completed and was in use at the time of this inspection visit. Further planned improvements to the premises included DS0000007232.V337210.R01.S.doc Version 5.2 Page 18 provision of a level access to the garden and installation of a lift enabling service users who use wheelchair and/or have mobility needs to be able to access the upstairs part of the building. These changes should allow the home to extend the range of residents’ needs that can be accommodated and meet all the current standards. The double bedroom and five of the single bedrooms are above the minimum sizes of 16 and 10 square meters. Two single bedrooms are below 10 square meters, but meet the standard, as the home was registered before the current National Minimum Standards were introduced. The home has toilets on the ground and first floor, accessible to bedrooms and communal rooms. Some bedrooms have ensuite facilities. The bathroom is fitted with a chair to enable residents to be assisted in and out of the bath. One of the toilets (in a service user’s room) has recently been fitted with a macerator. In the past occupational therapists and physiotherapists have assessed and made recommendations to the home in order to meet the needs of specific service users. The owners have also sought guidance from an OT regarding the design of any extension and ramp, however no written report was available for inspection. The garden area has a large table and chairs and a barbeque. Some of the service users were seen using the garden area on the day of this inspection. The recommendation that an Occupational Therapist should assess the building and facilities and provide a report in order how the premises could be further improved to meet the needs of those accommodated in the home remains outstanding. The registered manager stated that although an Occupational Therapist has visited the project since the last inspection, no written report has been provided. The inspector suggested that individual occupational therapy reports should be requested by the registered manager. As part of the inspection, a random selection of bedrooms was viewed, with permission from the people who used the service. Rooms appeared to be personalised and reflected individual tastes and interests of service users. One of the bedrooms where wallpaper was peeling of the wall has now been redecorated. An offensive odour in another service user’s bedroom has also been eliminated and alternative flooring has been provided. The recommendation that lockable facilities be provided in residents’ rooms has now been met. It was noted however that there is a shortage of storage space in the home, as at the time of the inspection some wheelchairs, which were no longer being used were being stored in the front lounge. The inspector recommended that the registered manager should consider utilising some of the home’s garden behind the office to provide additional storage area. The premises were found to be clean and hygienic and free from offensive odours, with the exception of one room, in which a carpet required cleaning/replacing. DS0000007232.V337210.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. Staffing levels were sufficient to meet the needs of the current service users group. Further work is required to ensure that at least 50 of staff have NVQ Level 2 or above qualification. Staff recruitment procedures required improvement. EVIDENCE: Duty rosters were checked as part of this inspection visit. The inspector was satisfied that there were sufficient numbers of staff on duty to meet the needs of the current service user group. The duty rosters showed that there were two care staff on duty between 8 am and 9 pm each day and one staff awake at night and one person sleeping in. In addition at least one of the managers works during the daytime. The home does not use agency staff. Any staff shortages are covered by an existing staff team. Four members of staff had NVQ in Care qualifications and/or were in the process of obtaining one. This falls short of the required percentage (50 ). The requirement in relation of NVQ qualification has therefore been repeated and must be met without any further delay. Three new staff have been employed since the last inspection. Files of all three newly recruited staff were checked during this visit. The inspector noted that they did not contain all information required by law. 2 out of 3 files viewed DS0000007232.V337210.R01.S.doc Version 5.2 Page 20 only contained one reference. This required improvement. It was noted, however that all staff have received the Criminal Records Bureau checks. The registered managers must ensure that staff personnel files contain all information listed in Schedule 2 of the Care Homes Regulations. This is a repeated requirement and must be met without any further delay. Further noncompliance may result in the Commission considering an enforcement action against the registered managers. The previous requirement that the present written policy and procedures for staff recruitment, including POVA checks, is revised to ensure that Standard 29, Regulation 19 and Schedule 2 of the Regulations are met remains outstanding and has therefore been repeated. Staff receive appropriate training. Since the last inspection the following training has been offered: Medication, Infection Control, Health and Safety, Dementia, Fire Safety Awareness, First Aid, Food Hygiene, Moving and Handling, and Oral Care. Evidence in a form of training certificates to demonstrate that staff have received all mandatory training and any other training required for the job has now been obtained. It was noted during this inspection that record of induction offered to new care staff was being kept. The registered managers must ensure that all staff receive foundation training to National Training Organisation specification within the first six weeks of appointments to their posts, including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group, and the influences and particular requirements of the service setting. DS0000007232.V337210.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, 32, 33, 35, 36, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The ethos of the home is open and positive. Both managers must ensure that they obtain the relevant qualification in management, as required by law. Further work is required to implement quality assurance systems in the home, record keeping and ensuring that care plans are reviewed on a monthly basis. Health and safety checks were found to be satisfactory, however as previously mentioned food storage required improvement. EVIDENCE: The proprietors are involved in the day-to-day running of the home and are both registered as registered managers/owners of Forest Lodge. They share roles and tasks usually undertaken by the manager and proprietor e.g Mr Taleb: invoicing, finances, GP/hospital visits, pharmacy, maintenance, staff DS0000007232.V337210.R01.S.doc Version 5.2 Page 22 rota; Mrs Taleb: staff supervision/appraisal, policies and procedures, recording and documentation. Both of the proprietors/managers demonstrated that they are sufficiently competent and experienced to run the home and to meet it’s stated purpose, aims and objectives. Both Mr and Mrs Taleb are registered nurses, however they must obtain relevant qualification in management, as required by law. This is a repeated requirement and must be met without any further delay. Minutes from staff supervision sessions were available for inspections and the inspector was satisfied that the previous requirement for staff to receive supervision in line with the National Minimum Standards (at least 6 times a year) has now been met. The requirement in relation to the quality assurance systems also remains unmet. Ways of implementing quality assurance systems were discussed in more detail with the proprietors during this inspection visit. As both proprietors and also the registered managers of the home, monthlyunannounced visits to the homes were therefore not required. As previously required, the home’s Whistleblowing Policy as well as the Recruitment Policy required improvement/updating. Confidentiality Policy must be drawn up and implemented. Health and safety checks were found to be satisfactory. There was evidence that fire drills and now being carried out on a regular basis and the home’s electrical wiring certificate has now been obtained. Electrical wiring certificate was issued on 24/06/06 and is valid for 3 years. All portable appliances were tested on 14/07/06. Appropriate fire safety checks were carried out on regular basis. Fridge/freezer temperatures were being recorded. DS0000007232.V337210.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 18 2 2 3 3 2 3 2 x 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x 3 2 x 2 DS0000007232.V337210.R01.S.doc Version 5.2 Page 24 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 OP28 Regulation 18 Requirement Timescale for action 01/12/07 2. OP31 10 3. OP29 19 4. OP33 24 Care staff to have NVQ 2 or 3 in care or be working to obtain one by an agreed date. A minimum level of 50 of care staff to have NVQ Level 2 qualification. (Previous timescales of 01/01/06 and 01/09/06 were not met.) The proprietors/managers to 30/12/07 ensure that their qualifications are equivalent to level 4 in management and care. (Previous timescales of 01/01/06 and 01/09/06 were not met.) The present written policy and 15/07/07 procedures for staff recruitment, including POVA checks, to be revised to ensure that Standard 29, Regulation 19 and Schedule 2 of the Regulations are met. (Previous timescale of 15/07/06 was not met.) A written annual development 15/07/07 plan for quality assurance to be available based on a cycle of planning, action and review and involving residents and staff. (Previous timescales of 01/05/05, 01/12/05 and 01/08/06 were not met.) DS0000007232.V337210.R01.S.doc Version 5.2 Page 25 5. OP7 17(1)(a) Sch 3.2 6. OP15 16(2)(i) 7. OP29 7, 9, 19 Sch 2 8. OP1 6(a) 9. OP7 15(2)(b) 10. OP8 17(1)(a) Sch 3.3.m 11. OP18 13(6) The registered managers must ensure that each care plan includes a photo of a service user. (Previous timescale of 01/07/06 was not met.) The registered managers must ensure that all perishable food products are labelled once opened, to avoid food poisoning. (Previous timescale of 15/06/06 was not met.) The registered managers must ensure that staff personnel files contain all information listed in Schedule 2 of the Care Homes Regulations. This includes satisfactory evidence of entitlement to work in the United Kingdom. (Previous timescale of 01/07/06 was not met.) The registered managers must ensure that the home’s statement is reviewed to reflect the exemption granted to the home to accommodate one service user with a clinical diagnosis of dementia. The registered managers must ensure that all care plans are reviewed on a monthly basis or more often when required in order to comply with the National Minimum Standards. In order to demonstrate that the service user’s healthcare needs are fully met, the registered managers must ensure that recording in relation input from any healthcare professionals, including any appointments attended by service users is improved. This included any outcomes from any medical appointments attended. The home’s Whistleblowing Procedure must be improved. Contact details of the DS0000007232.V337210.R01.S.doc 01/07/07 01/06/07 01/07/07 01/07/07 01/07/07 01/07/07 01/07/07 Version 5.2 Page 26 12. OP26 23(2)(d) 13. OP30 18(1)(c) 14. OP36 12(5) Commission for Social Care Inspection must also be included. Stains on the carpet in one of 01/07/07 the service user’s bedrooms must be eliminated and/or the carpet should be replaced. The registered managers must 01/07/07 ensure that all staff receive foundation training to National Training Organisation specification within the first six weeks of appointments to their posts, including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group, and the influences and particular requirements of the service setting. Confidentiality Policy must be 15/07/07 drawn up and implemented. 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 OP22 OP22 Good Practice Recommendations An Occupational Therapist to assess the building and facilities and provide a report. (This is a repeated recommendation.) The registered managers should consider utilising some of the home’s garden behind the office to provide additional storage area. DS0000007232.V337210.R01.S.doc Version 5.2 Page 27 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 DS0000007232.V337210.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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