Inspection on 21/10/06 for Heatherbrook Nursing Home

This inspection was carried out on 21st October 2006.

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

Heatherbrook Nursing Home 22/08/07

Heatherbrook Nursing Home 25/02/06

Heatherbrook Nursing Home 23/08/05

Heatherbrook Nursing Home 23/03/05

Heatherbrook Nursing Home 06/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heatherbrook Nursing Home 80 Como Street Romford Essex RM7 7DT Lead Inspector Diane Roberts Key Unannounced Inspection 21st October 2006 10:00 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 DS0000015594.V314920.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. DS0000015594.V314920.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heatherbrook Nursing Home Address 80 Como Street Romford Essex RM7 7DT 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) 01708 737 961 01708 737 962 manager.heatherbrook@careuk.com www.careuk.com Care UK Community Partnerships Limited Care Home 45 Category(ies) of Dementia - over 65 years of age (45) registration, with number of places DS0000015594.V314920.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Minimum Staffing Notice To include one named person under 65 years of age. Date of last inspection 25th February 2006 Brief Description of the Service: Heatherbrook is a purpose built home in a residential area of Romford. It is in walking distance of local shops and public transport links. The home provides 24 hour nursing care for 45 older people with dementia. Service users are accommodated on two floors, Bluebell on the ground floor and Hylands on the first floor. A passenger lift is available. All rooms are single occupancy and have en-suite facilities. The current scale of charges is from £520.00 to £650.00 per week. There are additional costs for items such as hairdressing, toiletries, chiropody and newspapers. Information is made available to prospective service users via a Service Users Guide, which is available prior to admission. DS0000015594.V314920.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over eight hours and was carried out as part of the annual inspection programme for this home. Alison Graham, the new manager was in charge and had been in post six weeks. Both the manager and her deputy were available throughout the inspection. The home was full. It has 30 contracted beds to a local Primary Care Trust and 15 private beds. There is currently a waiting list for private beds. The home takes residents with differing levels of dementia, which includes end of life care. The majority of the current residents have a high dependency in relation to dementia. The inspection focused upon all of the key standards and the homes response to the last agenda for action. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. Three residents and five staff were spoken to during the inspection. Due to the care needs of the majority of residents at the home it was not possible to fully obtain their views but residents appeared happy, relaxed, comfortable and interacted well with both staff and the inspecting officer. Comment cards were received from 16 relatives/representatives. These comments were taken into account when writing the report. What the service does well: Residents are happy living at the home; they interact well with staff and visitors and where possible comment positively in satisfaction surveys. Relatives are satisfied with the standards of care at the home and feel that the staff team are responsive and communicate well with them on any issues. The staff team are happy working at the home and feel that the management team are always reviewing and aiming to improve things. They also feel that the training provided is good. Recruitment procedures at the home are good and the training programme is generally sound. Healthcare provision at the home is good and the medication systems are sound. The food provide at the home is good. DS0000015594.V314920.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000015594.V314920.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 DS0000015594.V314920.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Relatives feel that they have enough information about the home prior to admission but this could be developed further so that it can be used with residents in mind. Prospective residents are assessed prior to admission to the home but the assessment tool could be developed further to identify the needs of this specialist resident group. EVIDENCE: The home has a Statement of Purpose and Service Users Guide in place. The Statement of Purpose meets the required standard. The Service Users Guide is currently undergoing a review and the company are using some computerised pictures to illustrate each section and make the format more accessible for the resident group. Some of these pictures are limited and do not really relate to the subject matter and are of questionable value. Actual pictures that relate to the home may be of more useful to this resident group. DS0000015594.V314920.R01.S.doc Version 5.2 Page 9 Information was seen to be helpful, although the guide did not contain the complaints procedure or the summary from the last CSCI report or residents’/relatives’ views. Whilst the majority of the residents may be unable to use the guide, the home should look at this guide as a document that relatives can use with their relatives. Service User Guides were seen in residents’ bedrooms, on a tour of the home. Relatives who commented said that they felt that they had received enough information prior to their relatives coming into the home. Relatives said that they had been shown around the home and that all their questions had been answered. They also felt that staff were very helpful at the time of the visit. Two recent pre-admission assessments were inspected. The manager undertakes the assessments and usually takes another member of the care staff with her, such as a Senior Carer. Assessments were seen to have been completed well giving detailed information on the individual. Whilst the assessment tool is generally sound, it needs to be developed to include comments on the persons weight/appearance, nutritional status and their abilities and strengths, moving towards a more person centred approach. Records showed that, where possible, the home has liaised with previous carers, prior to admission, to ensure that they receive a full picture of the care and management of a new resident, especially when there are care needs relating to behaviour. DS0000015594.V314920.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a care planning system in place that could be developed further in order to ensure that all the residents’ needs are addressed. Residents’ health care needs are satisfactorily met. The medication systems are in good order. Residents’ privacy and dignity is compromised at times. EVIDENCE: The majority of the care records held in the home are computerised, with stations on each floor for staff access. Nursing and care staff have differing levels of access to these records and were able to demonstrate their input to the inspecting officer. Three care plans were inspected at random from a range of residents. The home has a standard care planning system in place that is nursing orientated. The company has sent through documentation to the team at the home on person centred care planning. The manager and the deputy have discussed DS0000015594.V314920.R01.S.doc Version 5.2 Page 11 this with a view to moving their recording and approach forward. Some aspects of the current system are person centred but this needs to be developed further with this resident group in mind. At the current time the home does not assess residents for signs of well being or ill being and also does not identify their strengths and skills which could be worked with to promote self worth. The care planning system does have a section to record abilities. Although completed in many cases they did not always reflect any actual abilities. The care plans and a wide range of risk assessments were seen to be up to date but did not always contain all the information or needs identified in the assessment documentation. The home needs to ensure that all the identified information is used in the plan of care. Some of the care plans seen were very good and detailed whilst others could be improved upon. Some care plans in relation to behaviour management and identification of mood were good and gave detailed guidance to staff whilst others needed more information on behaviour triggers and how they may be reduced. Individual preferences are listed but on comparing past information and assessments documents, not all preferences are listed/utilised and life plans/histories are not in place for all residents. At the time of the inspection the home has limited evidence of relative involvement in the care planning process. Care staff complete daily notes and these were seen to vary in quality. Some care staff record well and comment on the care provided and the residents’ mood, interaction etc. whilst others just state ‘care as planned’. From records, GP input was seen to be appropriate and timely. Records also show that other healthcare professionals visit the home regularly such as Community Psychiatric Nurses, Chiropodists etc. From feedback, relatives are happy with the level of GP input into the home. Records show that residents’ weights are being monitored regularly and that nutritional risk assessments are in place. Referrals are being made to the dietician as appropriate. The nursing staff in the home provide wound care. At the time of the inspection they were only managing one wound. Records pertaining to this were inspected and found to be generally sound but required more detailed information on measurements and descriptions of the appearance of the wound to enable a more informed evaluation. At the time of the inspection none of the residents had a pressure sore and records showed that risk assessments had been completed and reviewed in relation to this. On a tour of the home it was evident that the home has pressure relieving equipment available and in use. Manual handling and falls risk assessments had been completed and reviewed as appropriate. It was possible to observe measures that had been put in place to reduce the risk of residents falling when touring the home. DS0000015594.V314920.R01.S.doc Version 5.2 Page 12 The majority of relatives felt that the care and support provided by staff in the home was good and appropriate. Relatives who commented said that staff always listened to them and acted upon what they said. They also felt that staff were available to them if needed and comments included: ‘You never feel like you are bothering the staff if you need them’ and ‘ most, if not all the staff are very receptive’. ‘My relative’s nurses are wonderful and contact me if required’. ‘When my relative went into hospital, both the manager and the deputy went to visit her’. Medication systems in the home were inspected and found to be in good order with clear MAR sheets, a disposal system and satisfactory management of controlled drugs. Records show that nursing staff have attended training on specific drug groups but have not attended updates on the overall safe handling and administration of medications/current practices. The home may wish to review this. Records showed that staff monitor the temperature of the drugs fridge and medication room. Records show that the new manager has recently audited the medication system and this is good practice. From records and discussion with staff, it is clear that residents are having regular medication reviews and that staff are seeking advice from other professionals on medication matters and the management of residents. From review of the MAR sheets and associated records, quite a few residents were on antibiotics all for urinary tract infections. This should be reviewed in relation to the drink availability in the home. Records and discussion with staff showed a respectful and understanding approach to the needs, rights and choices of residents. Relatives felt that staff had a caring approach to their relatives. Whilst the majority of residents were seen to be well groomed and cared for, it was noted that some attention was needed. For example, residents were noted to be wearing clothes with large obvious name labels on or wearing ill-fitting pop socks which could be affecting a person’s circulation. It was also noted that there were lots of hand written signs around in residents’ rooms relating to care and manual handling. This is a dignity/privacy issue and also makes it look like staff do not know residents well. The home has a key worker system in place and upon inspection it was noted that residents’ wardrobes and clothes were not well kept. These matters need to be addressed. DS0000015594.V314920.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities in the home have improved and are developing positively. Residents have good contact with family and friends. As far as possible, residents are helped to exercise choice and control over their lives but this could be developed and evidenced further. The food provided is good and enjoyed by residents but the actual mealtime experience could improve. EVIDENCE: The home has an activities officer who has attended a 3 day training course on therapeutic activities for people with dementia. She works 40 hrs per week and maintains records on the computer/care planning system. Whilst an outline programme is in place, activities are flexible and the activities officer recognises the needs of these residents with regard to this. Outside entertainers do come to the home but records show that the majority of the work is on a one to one basis and she ensures that this is provided regardless of the ability of the resident. Residents identified that they liked one to one activities in the last satisfaction questionnaire completed by the home. DS0000015594.V314920.R01.S.doc Version 5.2 Page 14 From discussion, care staff do take part in activities but do identify the activities officer as the lead person for this aspect of care. Some person-centred care is taking place and, where possible, residents are taken out of the home to go shopping and participate in the process and take part in household tasks. Under the abilities section of the care plan the record should show at what level people can participate and if they are able to finish activities, but records show that these need to develop further to give a full picture of the resident’s abilities. Objectives should also be in place to ensure that staff know what they are trying to achieve with a person, and life histories may help to identify activities that an individual may find interesting. From discussion with the activities officer and staff, there is possibly more person-centred work being done than is evidenced in the care planning system. A third of relatives who responded stated that activities only sometimes take place and were unsure as to whether the residents in the home could take part at all. The development of person-centred care in the home, with relatives where possible, may help to address this issue. Discussion with staff reflects daily routines that are generally resident-led and staff acknowledge choices and preferences, as they describe how both residents and staff spend the day. As the care plans have limited information on personal preferences and routines, life histories etc, it is difficult to fully assess that residents are spending the day in the way they would wish and in relation to their previous lifestyle. Records did not, for example, identify preferred rising times/bed times. Records did evidence that residents are up when the night staff come on duty and go to bed at differing times after that, so choice is available. Residents were observed sitting around the home in different areas and some were in their rooms, further indicating respect for their preferences. Improvement in the care planning process may develop and evidence this aspect of care further. It was noted that residents being cared for in bed and around the home did not have drinks available to them. Staff say that drinks are not left in rooms, as other residents will interfere with them. This does not allow for impromptu drinks and sips when staff pop into the room and is not resident led. The team should think of ways to over come this, to ensure residents do not become dehydrated. The home has an open visiting policy and relatives who commented felt that they were welcome and had a good relationship with staff. The menu provided for the resident group is appropriate and discussion with the kitchen staff and records demonstrates that there is a level of flexibility and that personal preferences are taken into account. For example, some residents like crust rolls and these are supplied and often gentlemen like a shandy and this is also supplied. From discussion, the kitchen staff know the residents’ needs well. A hot meal choice is provided 3 times a week in the DS0000015594.V314920.R01.S.doc Version 5.2 Page 15 evening and two choices are available at lunchtime. Cooked breakfast is provided 3 times a week. Lunch was observed and it was noted that residents appeared to be enjoying the food and the portion sizes were good. However the setting looked institutional, as there were no tablecloths etc. and residents were being fed next to people waiting to be fed. The lunchtime routine and service could be better and new manager is already aware of this. Relatives who felt able to comment on the meal service at the home felt that it was satisfactory and that the food always looked good although they had not tasted it. One relative said that ‘the vegetarian options were good and varied’. Relatives also commented that the there was ‘plenty of food and that it was of a good quality’. They said that liquid supplements were offered and that staff monitored how much people ate and drank. DS0000015594.V314920.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has systems in place to help ensure that concerns and complaints will be listened to and acted upon. The home has systems in place, which help to ensure the protection of vulnerable adults from abuse. EVIDENCE: The home has a satisfactory complaints procedure in place, which meets the required standard. This is displayed in reception but is not in the Service Users Guide. Records of recent complaints were reviewed and these were seen to have been investigated by staff at the home and sound records maintained, which evidenced the work undertaken. Records show that complaints have been dealt with promptly and objectively. Relatives, who commented, knew about the homes complaints procedure and who they would raise any concerns with, although many stated that they had not had cause to complain. Relatives also confirmed that regular meetings were held where they could raise any concerns or queries and that the manager was nearly always available. This was also confirmed by inspection of the most recent relatives meeting with the new manager. The home has a satisfactory adult protection procedure in place, which is up to date and contains local guidance from Social Services. Training is carried out for staff in house and the content was seen to be sound and is accompanied by a comprehensive handout. Training records show that nearly all of the staff have received up to date adult protection training. DS0000015594.V314920.R01.S.doc Version 5.2 Page 17 DS0000015594.V314920.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The home is adequately decorated and safe. The home is generally clean and hygienic. EVIDENCE: A partial tour of the home was undertaken. The home is now five years old. It was noted that communal areas are starting to look tired and this included some toilets. Bedrooms were in a better state of decoration as these do get painted when they become vacant. Chairs, both in the lounge and dining areas need replacement. Relatives also commented that this was a concern. An odour was noted in Bluebell lounge and the carpets in this area are poor and require possible replacement. One small lounge upstairs was seen to be particularly poor with regard to décor and cleaning. The new manager plans to decorate this room in the near future. DS0000015594.V314920.R01.S.doc Version 5.2 Page 19 The home has two gardens, which are secure and were seen to be well maintained. Lighting in some parts of the home was seen to be dim and this requires a review/risk assessment to ensure that the lux is sufficient for this resident group. Heating throughout the home was found to be satisfactory at the time of the inspection and low surface temperature radiators are in place. Appropriate signage was seen around the home for the resident group to help them identify their own rooms and toilets etc. This was more apparent on the ground floor and ideally this should be consistent throughout the home. Fire safety records were inspected and found to be in order, including maintenance of equipment and staff fire drills. The home has an up to date fire risk assessment in place, which has been completed with the input from the local fire officer. The home was seen to be generally clean apart from issues noted above. Relatives who commented felt that the home was generally clean and fresh. DS0000015594.V314920.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff currently meet the services users’ needs. The number of care staff with an NVQ qualification is steadily increasing. The home has sound recruitment policies and procedures, which it follows. Staff are trained and competent to meet the needs of residents but this still could be improved further. EVIDENCE: The new manager has reviewed dependency levels in the home and has increased these recently as dependency levels are high. The home is on two floors and 2 nurses and 9 care staff are provided during the day and 2 nurses and 4 care staff during the night until 8a.m. In addition to this the deputy manager and manager are also on duty, with some supernumerary time for the deputy. There has been no agency staff use for over one year and the staff team is stable with a good bank of relief staff if required. The home also provides sufficient ancillary staff although there were vacancies within the domestic team at the time of the inspection. Relatives who commented felt that the staff were generally very good or great and that the staffing levels were good and should remain at the current level to maintain standards. Staff spoken to are happy working at the home and feel that the management support and training provided is good. DS0000015594.V314920.R01.S.doc Version 5.2 Page 21 The manager encourages NVQ training at the home. Records show that 36.6 of the care staff have attained an NVQ level 2 or above. The manager has 15 more staff signed up to undertake this training and should therefore achieve the 50 standard during 2007. Some staff have signed up to undertake the NVQ level 3 but the manager is finding an assessor for this level hard to find locally. The company has recruitment policies and procedures in place. Staff files were inspected at random and found to be in good order with a checklist system in place. Interview records are held and gaps in employment discussed. These were available for inspection. All the required documentation was seen to be in place along with CRB /POVA checks. The home has a staff-training programme in place and a training matrix, which provides records pertaining to the majority of the training provided at the home. The manager should consider extending this to record the numbers of staff attending additional training, so a full picture of the programme can be provided to the CSCI, which can reflect positively on the home. Records show that there is a good level of compliance with statutory training, with the majority of staff being up to date with manual handling, health and safety, COSHH, first aid and fire safety. In addition to this, the majority of staff have attended training on challenging behaviour (2004/5) and infection control (2005). It is disappointing to note that compliance levels with dementia training, from the records submitted, show significant gaps and this should be addressed in relation to the registration of the home. Some staff have attended nutrition in dementia training but the records do not identify how many. The home has an induction programme in place, which is a TOPPS induction combined with a local home induction. From records and discussion with staff new staff undertake this. At the current time the home are yet to move over to the Skills for Care induction. DS0000015594.V314920.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new manager is suitably qualified and experienced. As she has only been in post a few weeks it was not possible to assess this standard fully and this should be reassessed at the next inspection. The home has a quality assurance programme in place, which could be developed further. Residents’ financial interests are safeguarded. The health and safety of residents and staff is promoted. EVIDENCE: Since the new manager has been in post, records show that she has been holding both staff and relatives meetings in order to introduce herself and DS0000015594.V314920.R01.S.doc Version 5.2 Page 23 answer any queries people may have. Minutes of meetings show that she has an open approach and welcomes comments. The home sends out an annual quality assurance satisfaction questionnaire to relatives and wherever possible comments from service users have been incorporated. The activities officer takes opportunities to gain reactions from residents whenever possible. This was last completed in March 2006 and the new manager plans to continue and develop this aspect of the home. The results of the residents’ survey are available in the reception area and were seen to be generally positive and the team at the home analysed the results and put action points in place. A range of key subjects areas are covered such as food, activities etc. The manager undertakes other internal audits such as medication, health and safety and care plans. The system could be developed to seek the view of healthcare and other professionals visiting the home. The home does hold personal monies on behalf of residents. The systems for this were checked at random and found to be in good order with receipts and account balances available. An internal audit system is in place, although it is recommended that 2 people undertake the audit and sign as appropriate. The home has a health and safety policy and associated procedures in place. No health and safety or COSHH issues were noted on a partial tour of the home apart from the lighting levels as discussed under section 5 – Environment. Records show that the hot water temperatures are checked regularly and the thermostatic valves are adjusted as appropriate. Safety and maintenance certificates were checked at random and were found to be in good order apart from an out of date electrical wiring certificate for the home. This needs to be addressed and records show that the manager has already been trying to action this matter with the company. Accident records were inspected in relation to case tracking and these were seen to be in good order with evidence that matters had been followed up by the management team at the home. DS0000015594.V314920.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 2 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 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 DS0000015594.V314920.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 Requirement The registered person must ensure that the Service Users Guide contains a summary of the home’s complaints procedure and most recent CSCI report. The registered person must ensure that care plans outline all the care needs of the resident and where possible has input from the residents and/or their relative/representative. The registered person must ensure that residents’ privacy and dignity are upheld at all times. The registered person must ensure residents have easy access to fluids and review the incidence of urinary tract infections in the home. The registered person must ensure that meals are taken in a congenial setting. The registered person must undertake a risk assessment for the lighting of the home to ensure that there is adequate lux. The registered person must DS0000015594.V314920.R01.S.doc Timescale for action 31/12/06 2 OP7 12 and 15 31/12/06 3 OP10 12 30/11/06 4 OP14 OP8 12 and 15 30/11/06 5 6 OP15 OP19 12 13 (4) 31/12/06 14/12/06 7 OP19 16 31/01/07 Page 26 Version 5.2 8 9 OP26 OP30 16 (K) 18 10 OP38 13 maintain all parts of the home in a reasonable decorative order. With reference to the upstairs small lounge, general communal areas, carpets and lounge and dining chairs. The registered person must keep all parts of the home free from odours. The registered person must ensure that staff are trained to ensure that they can fully meet the care needs of the residents. The registered person must ensure that the home has an up to date electrical safety certificate. 30/11/06 31/01/07 31/12/06 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 The registered person should review the format of the service users guide with the specialist resident group in mind. The registered person should develop the pre-admission assessment tool to cover weight/appearance, nutritional status and strengths and abilities. The registered person should continue to develop a person centred care planning system for people with dementia, to include life histories etc. The registered person should ensure that wound care records are detailed enough to enable a full evaluation. The registered person should continue to develop the signage system in the home with the resident group in mind. The registered person should continue to develop the NVQ training programme in the home. 2 3 4 5 6 OP3 OP7 OP8 OP19 OP28 DS0000015594.V314920.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: 0845 015 0120 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 DS0000015594.V314920.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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