Inspection on 07/11/07 for Homeleigh

This inspection was carried out on 7th November 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

Homeleigh 21/09/09

Homeleigh 04/11/08

Homeleigh 10/01/07

Homeleigh 25/01/06

Homeleigh 18/10/05

Homeleigh 17/03/05

Homeleigh 27/04/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Homeleigh Avenue Road Erith Kent DA8 3AU Lead Inspector Lorraine Pumford Unannounced Inspection 7th November 2007 09:30 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 DS0000006793.V341039.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. DS0000006793.V341039.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Homeleigh Address Avenue Road Erith Kent DA8 3AU 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) 01322 339691 01322 350291 allison.pettican@kcht.org.uk www.kcht.org Kent Community Housing Trust vacant post Care Home 48 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (32) of places DS0000006793.V341039.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2007 Brief Description of the Service: Homeleigh is a large detached building situated in a pleasant residential area of Erith. It is near to local shops and facilities, and has bus routes and train stations within easy travelling distance. It is owned and managed by Kent Community Housing Trust (KCHT), which is a charitable (not for profit) Trust, and who have other care homes for older people within the region. The home is set into a hillside, and has four floors, of which three form the care home. The home is also registered to accommodate up to sixteen people who have been diagnosed as having dementia. KCHT’s Bexley Regional Office is also based here. There are bedrooms, bathrooms and toilets on each floor. There are a number of lounges, a dinning room and activity room on the ground floor. All levels can be reached via a passenger lift. As the home is on a hillside, the gardens are accessed from the first floor at the rear of the building, and there is a spacious patio area, walkways, a lawn and mature shrubs. The home provides day care for up to five people each day. This service is not inspected by CSCI, However the impact on other people living in the home is taken into consideration. DS0000006793.V341039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by two inspectors who spent the day in the home. During that time the person in charge was spoken with and a number of staff and residents were also spoken with. Prior to the inspection a number of residents and their relatives were invited to complete CSCI surveys and their comments have also been included in this report. In addition a number of policies and procedures were examined and parts of the premises inspected. Since the last key inspection the home has received an additional inspection carried out using the Short Observational Framework inspection, (SOFI). This system is used to assess the quality of life for people who have limited ability to express their views. This SOFI inspection took place on the unit specifically designed to care for people who have dementia, therefore this unit was not inspected again on this occasion. The finding and subsequent requirements are detailed in a separate report and are available from the provider or upon request from the CSCI. Since the last inspection a new manager has been appointed to run the home on a day-to-day basis. The overall feedback from residents and their relatives is they are happy with the care and service provided. Fees range from £425.67 to £498.72 What the service does well: An assessment is undertaken in relation to all prospective residents prior to their admission. Prospective residents are able to visit the home prior to admission. Staff respect residents privacy and dignity. Staff ensure residents have access to appropriate community health care. Residents have a varied nutritious diet. The provider monitors the care and service provided by people working in the home. Residents are provided with a range of appropriate activities. DS0000006793.V341039.R01.S.doc Version 5.2 Page 6 There is a complaints procedure to enable the provider to investigate any issues or concern brought to their attention. The majority of staff working in the home have attained an NVQ in care. What has improved since the last inspection? What they could do better: The Statement of Purpose must be updated to insure that prospective residents have all available information regarding the service including the fact the home provides day care. Staff must ensure that residents care plans provide accurate information so their needs can be met and residents or their advocates are involved in the process. Medication practises need to be improved to safeguard residents and staff. The home needs to ensure that people attending the home for day care do not adversely affect the quality of live for the residents living there. Remedial work is required to make good the seal and woodwork around wash hand basins. The provider must be able to evidence that sound recruitment procedures are in place. The provider needs to ensure that action is taken to mend the emergency lighting. The home must have a satisfactory telephone system. A record must be kept of all items of value held on residents behalf. DS0000006793.V341039.R01.S.doc Version 5.2 Page 7 All staff must undergo an appropriate induction before providing care to residents. 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. DS0000006793.V341039.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 DS0000006793.V341039.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): 1,3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be assured that a comprehensive assessment of their needs will be undertaken prior to admission. The Statement of Purpose must be updated to ensure that prospective residents have all available information regarding the day care service provided by the home. EVIDENCE: The home provides day care for up to five people during the course of the week. The homes Statement of Purpose must be updated to ensure that prospective residents have all available information regarding the day care service provided by the home. Documentation was examined for four people in relation to the homes prospective residents assessment process, two of whom had been admitted in DS0000006793.V341039.R01.S.doc Version 5.2 Page 10 the last few weeks. All of these people had been assessed either by a local authority care manager or a representative of the provider. There was evidence seen that letters had been sent to residents stating that following the assessment the home was able to meet their needs at the time of admission. Some residents spoken with said they had visited the home prior to admission and during the inspection a prospective resident was seen viewing the home with their family. DS0000006793.V341039.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. Residents care plans must reflect their assessed needs to ensure staff can meet these needs. Medication procedures must be developed further to safeguard residents and staff. EVIDENCE: A requirement was made at the time of the last inspection that residents care plans must be complete and contain up-to-date information. Action is still required to address this issue. Four care plans were examined. The care plans formulated lacked basic information. A number of entries said ‘staff to monitor’ or ‘staff to monitor and help when needed’. None of the care plans seen provided adequate detail as to how staff should meet the resident’s needs. A night care plan was seen for two resident and provided adequate information regarding night care. DS0000006793.V341039.R01.S.doc Version 5.2 Page 12 One of the residents has a visual impairment and there was no information in this care plan as to how staff were to assist the person to move about the home or to participate in appropriate social or life activities. The records showed and the resident said that they got frustrated and worried as they felt ignored but there was no care plan to show how these needs were addressed. The current care plan format covers nutritional needs however there was no evidence to show that two residents had been weighed at the time of admission or monitored there after, even though records for one resident indicated there were concerns around this issue. The care plan for another resident stated the person was independent in relation to continence management however under additional information it stated staff need to empty catheter-bags. Another care plan highlighted that a resident could become aggressive however there was no information for staff on how to manage the situation. Risk assessments were also poorly completed and did not clearly show what area of need was being assessed. The moving and handling assessment for one person was blank. From reading entries in one residents care plan it was apparent the resident is prone to falls, however this information was not included on the residents moving and handling assessment. There was no written evidence to indicate that residents had been involved in the development of their care plan. The manager stated that the care plan format had been under review and a new system would be introduced when staff had received training. Residents spoken with did not express any concerns in relation to their care needs. Staff were seen to respected residents privacy and dignity when assisting them with personal care. Residents stated staff were very kind. One resident stated she was worried about moving into the home but was now very happy. An issue arose in relation to a person who attends the home for day care. The person felt unwell at lunchtime and staff assisted her back to the lounge, which was still occupied by other people. The day care person was clearly unwell and became very distressed, which affected the residents in the room. Discussion took place with the manager regarding this issue, if the home is to provide day care it must also provide a room suitably furnished and kept available for day care people, so that in the event they become unwell it is available for their comfort and to maintain the quality of life for people living in the home. DS0000006793.V341039.R01.S.doc Version 5.2 Page 13 A medicine storage/medical room is provided. A recommendation was made at the time of the last inspection that the temperature of the room be regularly monitored. On this occasion the room was quite warm and although a thermometer was provided the temperature was not being monitored. A medicine storage fridge was provided but the temperature had not been recorded since May 2007. A medicine trolley is provided to administer medicines. Medicines were provided in blister packs and individual containers and on a four weekly cycle. Pre-printed administration charts were also provided. Records were kept for receipt storage and disposal of medicines. The medicine records and supplies for four residents were viewed. Inaccuracies were noted in relation to three residents. For example medicines were not administered and there was no reason given. The supply of medicines remaining did not tally with the amount prescribed and administered. Not all had written entries made by staff on administration charts had been countersigned. Staff had added residents names in large print on the top of individual boxed and bottled containers. This is not considered safe practice as staff may look at the name and not check the medicine details. None of the current residents managed their own medicines and the service did not supply homely remedies. Other issues discussed with manger were the need to have a medicine profile for each resident with evidence of regular medicine reviews. The need to have protocols in place for administration of ‘as required’ medicines such as pain relief for residents with poor or no communication skills. The need to evidence that staff responsible for medicine management are assessed annually as being competent to do so. Where possible residents are able to retain the GP they had whilst living in the community. A number of district nurses also attend residents in the home. One district nurse was spoken with and said that she was a regular visitor to the home to see residents regarding wound care, diabetic care and to provide advice on specific areas such as pressure area care. The nurse said that staff used the service appropriately and followed advice given regarding residents care. Staff had access to information on medicines. Staff said they arranged for residents to see the dentist, optician and chiropodist on a regular basis. Other health care needs were addressed through GP referral. DS0000006793.V341039.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a wide range of activities and are provided with a varied nutritious diet. EVIDENCE: Residents benefit from the home having a full time activity co-ordinator and a well equipped designated activity room. During the course of the day residents who are able came down and choose from a range of games and craft activities. In addition the activity co-ordinator provided activities for small groups of people in lounges around the home. The provider has its own transport which can be booked for outings. Records seen indicated that residents have been out to church coffee mornings and visited the cafeteria of the local supermarket. Residents also have access to the providers activities bus brighter days. One resident spoken with stated the mobile library attends the home on a regular basis and she is able to choose which books she likes for herself. On the day of the visit the activitys organiser had arranged a handbag sale and this was a great hit with staff, DS0000006793.V341039.R01.S.doc Version 5.2 Page 15 residents and visitors to the home. All profits made went into the residents amenity fund. The majority of residents spoken with presented as relaxed and comfortable in the home. They said staff listened to them and encouraged them to make decisions about their day. For example staff asked them what they wanted to wear, to make a meal choice and whether they wanted to join in with organised activities. One resident was laying the tables for lunch and took time to ensure that every table had a vase of flowers. Residents said that they enjoyed family visits and outings and that visitors were welcome at any time. One relative expressed concern that it was not possible to contact staff on the office phone outside office hours and when a message had been left no one had returned the call. This matter was discussed with the manager who stated that generally staff were working with residents in other areas of the home. The manager was asked to take action to ensure that the telephone system is suitable for the needs of the home. One resident recently admitted to the home was having a cup of tea in the lounge when another resident asked them to move as they were in their seat. The resident changed seats but before sitting down asked the other residents which chair they could use. Dialogue regarding the new resident continued between residents in the corridor on the way to lunch. Staff need to be more vigilant and provide support and reassure new residents to ensure they do not feel embarrassed or uncomfortable during their first days in the home. The home provides day care to a varying number of people each day. This group sat in one lounge with some of the permanent residents and stayed together for their lunch. There are no additional staff designated to provide care and support to the day care people and there was no evidence to show that this part of the service was discussed with permanent residents. The manager was asked to seek the views of permanent residents in relation to sharing their home with non-residents. The majority of residents have lunch in the ground floor main dining room. The room was clean and tidy and the tables nicely laid for the meal. In addition staff were assisting two residents to eat in one of the lounges. Staff were attentive to residents during lunch and provided assistance where needed. Staff wore hats when serving meals, which seemed a little unnecessary and made the process seem clinical and institutional. The daily menu was displayed on a notice board in the dinning room however residents are asked the day before to make a meal choice from the menu. A member of staff was seen to ask residents what they wanted for lunch the next day while they were still eating. This confused some residents and is not considered good practice. DS0000006793.V341039.R01.S.doc Version 5.2 Page 16 The meal serving was well organised and a number of residents said they enjoyed the meal. A choice of two meals was provided and an alternative for residents who did not want what was on the menu. Some residents had requested the alternative dish, which was a cheese salad. However no salad dressing was offered until staff were asked by an inspector to offer this to the residents. DS0000006793.V341039.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider has a complaints procedure in place to investigate any concerns brought to their attention. The homes safeguarding adults policy and procedures helps protect residents in the home. EVIDENCE: A complaints policy and procedure was provided. Residents spoken with said they would talk to staff if they had any concerns. Records were kept for complaints made about the service. Since the last inspection four complaints were recorded. Records seen showed these were appropriately managed however the written response to one complainant was not available to view. The majority of relatives who completed surveys stated they were aware of the providers complaints procedure. A number of residents spoken with presented as having a feeling of belonging and empowered and seemed capable of raising concerns they may have with staff and management. The home has a safeguarding adults policy, however it was not viewed on this occasion. Staff spoken with displayed a good understanding of safeguarding adults and the action they would take if they had any concerns. Staff stated they undertaken training in relation to Safeguarding adults as part of their NVQ training and this issue was also addressed as part of the DS0000006793.V341039.R01.S.doc Version 5.2 Page 18 providers induction. The manager stated that staff also attend routine training updates. DS0000006793.V341039.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a clean comfortable environment. EVIDENCE: Areas of the home seen such as lounges, the dining room bathrooms and bedrooms were clean and tidy. A requirement was made at the time of the last inspection regarding the need to take action to eradicate the smell of urine on the top floor and it was apparent that this issue has been addressed. Although some relatives who completed CSCI surveys thought the home would benefit from some redecoration, residents spoken with did not raise any DS0000006793.V341039.R01.S.doc Version 5.2 Page 20 concerns regarding their environment. Two residents sitting in there bedroom reading stated they were comfortable and had everything they needed. Bedrooms seen were individually personalised. The units under the washbasins in the toilets were in need or attention. The seal under the basins was dirty and needed to be replaced and the woodwork needed to be repainted. One relative raised an issue in relation to the front doors and reception area of the home stating its unsuitability for people in wheelchairs. The provider needs to look at this area with a view to making it more welcoming and wheelchair friendly. A requirement was made at the time of the last inspection regarding the need for the laundry to be updated to ensure that soiled and clean laundry could be kept separate. Following the last inspection the provider wrote to the CSCI stating that it was not possible to structurally chance the building to accommodate a new laundry, however the procedures for processing laundry had been reviewed. Staff responsible for undertaking this task were clear about the process required in relation to managing soiled linen and this was found to be satisfactory. A requirement was made at the time of the last inspection in relation to the need to ensure hazardous substances were kept secure at all times. It was apparent that action has been taken to address this issue. Hand washing facilities and protective clothing are provided. DS0000006793.V341039.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider must ensure that sound recruitment procedures are followed to protect residents and staff in the home. Staff must be provided with appropriate training to protect residents and themselves. EVIDENCE: A sample of five staff files were examined in relation to recruitment and training. Some of the staff were employed specifically to work in Homeleigh, others have transferred from another home and one person had been recruited to work as a relief member of staff. There was evidence that CRB and POVA checks had been completed for all staff. Records seen indicated that staff completed application forms, provided proof of identity and references had been followed up for staff that had not previously worked for the provider. Discussion took place with the manager regarding the fact that staff had transferred over from another home and references had not been taken up in these instances. This should still be undertaken to ensure that any employment issues are not overlooked and to ensure that the staff concerned DS0000006793.V341039.R01.S.doc Version 5.2 Page 22 have the appropriate skills to meet the needs of residents accommodated in Homeleigh. Not all of the applicants had completed a detailed employment history and the files for two employees did not contain their photograph. An issue arose in relation to the member of relief staff employed. This person has not previously worked in the care profession or any other related occupation, however has commenced working shifts in the home prior to any training being given including moving and handling training. Action is required to address this issue to protect the health and safety of both residents and staff. Also there was no evidence that this person was receiving formal supervision, which should be provided on a regular basis for all staff, but particularly in light of this persons lack of experience. Staff who had completed application forms stated they had successfully completed various courses however there were no documents attached to the application to evidence this. The Manager was advised to obtain copies or keep a record of certificates seen as part of the recruitment process. A recommendation was made at the time of the last inspection regarding the need to review staffing levels in the home. This issue was raised by staff, they were concerned there were insufficient staff to meet the additional needs of residents attending the home for periods of respite care. The manager stated that the provider no longer provided routine respite care and so had relieved the pressure staff were experiencing. The manager stated that the majority of care staff working in home now hold an NVQ 2 or 3 in care. From records seen it was difficult to gain an overall view of staff training. The Manager stated she is currently working on implementing a system of recording this. However staff spoken with stated that they feel they are offered appropriate training opportunities. Documents seen indicate that a local college is arranging comprehensive training in relation to dementia. Residents spoken with stated that staff are kind and helpful. One resident said staff were nice and nothing was too much trouble. The majority of relatives who completed CSCI surveys stated they thought that care staff had the right skills and experience to look after people properly. DS0000006793.V341039.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider has comprehensive quality assurance mechanisms in place to protect residents. Health and safety issues must be addressed promptly to protect residents and staff working in the home. EVIDENCE: A requirement was made at the time of the last inspection that the manager must submit an application to be registered by the CSCI. This person no longer works for the provider, however a new manager commenced work in the home in June of this year and has submitted an application to be registered. DS0000006793.V341039.R01.S.doc Version 5.2 Page 24 The atmosphere of the home feels relaxed and comfortable and staff were seen to work well together. The home provides assistance to residents to manage personal allowances. All money is held in a ‘Resident’s Homeleigh’ account. Relatives, solicitors and other relevant parties provide personal allowance money on behalf of individual residents. Computer records are kept for money received and spent and receipts obtained and numbered for all expenditures on resident behalf. The administrator manages this aspect of the service and she and the home manager are the only people with access to the safe. Financial records were checked for two residents and found to be correct. Staff said that all residents had access to personal money and could have their hair done and buy items from the in-house trolley shop as well as go on outings. The safe is used to store other items such as wills, resident’s chequebooks and jewellery. A record of the safe contents was not kept and action must be taken to address this. At the time the last inspection a recommendation was made that two members of staff witnessed the signing of cheques for residents and action has been taken to address this. Staff record maintenance and health and safety issues they identify in a designated book and the maintenance technician crosses these off when completed. The date of the repair was not recorded so it was not possible to assess how long it took to get repairs attended too. The maintenance record showed that on the 19th October two residents reported that the radiators in their bedrooms did not get hot and to date there is no evidence to indicate this has been addressed. Other safety records viewed included electricity, gas, lift service, service of moving & handling and bathing equipment. The kitchen received an inspection by Environmental Health in October 2007 and received an excellent report. Fire safety records showed the system was last serviced in July 2007; however, the emergency lights on the dementia unit had been out of order since the 10th August 2007. Urgent action is required to address this. Since the last inspection one fire drill was held in May 2007. Satisfactory accident records are maintained. Staff complete two forms following any accident involving residents. The manager completes a monthly accident reports for head office. From discussion with staff and records seen it is apparent that the provider arranges training for staff in relation to health and safety, food hygiene and first aid. Discussion took place with the manager in relation to moving and handling training for staff. This needs to be undertaken by a suitably qualified DS0000006793.V341039.R01.S.doc Version 5.2 Page 25 person who can assess and sign staff of as being competent to perform the task. Video training in relation to this issue is not acceptable. From discussion with the manager and records seen it is apparent that the provider is establishing a comprehensive system of monitoring and reviewing the quality of the care and service provided in this establishment. The manager stated that regular audits take place. In addition the provider arranges for senior personnel to visit the home on a monthly basis. Copies of their findings are forwarded to the CSCI on a regular basis. DS0000006793.V341039.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 DS0000006793.V341039.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The registered person must update the homes Statement of Purpose to indicate that they also provide day care for people in areas of the home used by residents. The registered person must ensure a care plan is prepared to show how all assessed needs will be met. A system must be in place to monitor all resident’s weight, for the purpose of monitoring residents’ nutritional needs. The registered person must ensure residents care plans are complete with up-to-date information. Timescale 30/04/07 not met. The registered person must ensure that all medication is stored, recorded and administered in line with the Royal Pharmaceutical Society in this instance countersign hand written entries, state reason for non-administration of medication, keep an accurate record of room and fridge DS0000006793.V341039.R01.S.doc Timescale for action 30/04/08 2 OP7 15 30/11/07 3 OP7 15(b) 03/03/08 4 OP9 13 30/11/07 Version 5.2 Page 28 5 OP14 12 6 OP24 23 7 OP24 23 8 OP24 23 9 10 OP29 OP30 sch 2 18 11 12 OP35 sch 4 9(a) 16 OP13 temperatures, to show medication is being safely stored. Timescale 30/03/07 not met. The registered person must ascertain residents’ views in relation to sharing their home with people attending the home for day care. The registered person must make sure that the premises are fit for the purpose in this instance ensure a room is available for people who attend the home for day care in the event they become unwell for their comfort and to maintain the quality of life for people living in the home. The registered person must ensure that all parts of the home are kept in good repair, in this instance take action to remove the dirty seals under wash hand basins and repaint the woodwork. The registered person must ensure that action is taken to repair the broken emergency lighting on the unit accommodating residents with dementia. The provider must ensure there is evidence of sound recruitment procedures in place. The provider must ensure that staff receive appropriate training before they commence care duties with residents. The provider must ensure that a record is kept of any valuables held by them for safekeeping. The registered person must ensure that the home has a satisfactory telephone system. 31/01/08 01/04/08 01/04/08 03/12/07 01/02/08 01/12/07 01/01/08 01/03/08 DS0000006793.V341039.R01.S.doc Version 5.2 Page 29 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 OP9 Good Practice Recommendations The registered person should ensure a medicine profile is prepared for each resident, that there is evidence to show that residents medicines are regularly reviewed, that a protocol is prepared for the administration of ‘as required’ such as pain relief to residents with poor communication skills and evidence that staff responsible for medicine management have their competency assessed annually. It is recommended that staff do not wear protective hats and gloves when serving food. It is recommended that whilst serving lunch residents are not asked what they want for their meal the following day. The provider needs to explore ways to make the front entrance to the home more wheelchair friendly. 2 3 4 OP15 OP15 OP24 DS0000006793.V341039.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000006793.V341039.R01.S.doc Version 5.2 Page 31 - 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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