Inspection on 25/10/06 for Inglewood Residential Rest Home

This inspection was carried out on 25th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Inglewood Residential Rest Home 03/03/08

Inglewood Residential Rest Home 04/01/06

Inglewood Residential Rest Home 23/06/05

Inglewood Residential Rest Home 23/02/05

Inglewood Residential Rest Home 15/10/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Inglewood Residential Rest Home 330 Chester Road Streetly Sutton Coldfield West Midlands B74 3ED Lead Inspector Maggie Bennett Key Unannounced Inspection 25th October 2006 08:20 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 Inglewood Residential Rest Home DS0000020855.V316555.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. Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inglewood Residential Rest Home Address 330 Chester Road Streetly Sutton Coldfield West Midlands B74 3ED 0121 352 1113 0121 353 9005 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) Mrs Janet Beecroft Mr Craig Chance Mrs Janet Beecroft Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: Inglewood is a detached two storey mock-Tudor house, which has recently been extended and refurbished to provide accommodation for 31service users for reason of old age. There have been considerable improvements to the physical environment and Inglewood now provides 25 single rooms, 20 of which have an en suite toilet and 3 double rooms, 2 of which have an en suite toilet. Communal space now consists of 2 lounges, a conservatory, a visitors’ room and a large dining room. There is a car park to the rear of the property and a pretty, landscaped garden with a patio area. The building is situated on the main Chester Road and is within walking distance of local amenities such as shops, places of worship and public transport, enabling easy access to Birmingham and Sutton Coldfield. The fees charged at Inglewood range from £362.00 to £410.00 per week. Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday between 8.20 a.m. and 7.30 p.m. All the Key Standards of the National Minimum Standards were assessed. Prior to the inspection a Pre Inspection Questionnaire was completed by the home and service users and their relatives were asked to complete surveys. 15 surveys were completed and returned to the Commission. During the course of the inspection 7 service users were spoken to and 2 visiting relatives were seen. The midday meal was taken with the service users. Discussion took place with the Registered Manager throughout the day and 2 members of staff were also spoken to. The assessment information of newly arrived service users was seen and the care plans of 8 service users were seen in order to inspect care planning processes and practice. A number of staff files were seen in order to assess recruitment procedures and staff training. A tour took place of the building and this included a random selection of service users’ rooms. Various documents were seen in order to assess the home’s compliance with health and safety legislation. What the service does well: The majority of prospective service users have the opportunity to spend a day at Inglewood and spend time with other service users before making up their mind as to whether they wish to live at the home. There is evidence of good liaison between the home and visiting healthcare professionals and the Registered Manager is proactive in seeking medical advice when needed. Service users spoken to confirmed that their privacy was respected at Inglewood and that they were able to make choices. The meals provided at Inglewood are of excellent quality and clearly much enjoyed. There are robust systems in place to protect service users and staff are aware of their responsibilities with regard to the Protection of Vulnerable Adults. The environmental standards at Inglewood are excellent and very attractive accommodation is provided. There are good standards of hygiene and cleanliness. Staff are enthusiastic and display an excellent rapport with the service users. There are robust staff recruitment procedures in place. The home is well managed by an experienced and well qualified person, who is respected by both service users and their representatives. In their returned surveys, several service users and relatives praised the home. Here are some of their comments: “I’ve been here for .. years and have never had an unhappy moment.” Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 6 “I cannot praise the standard of care given to my mother highly enough and feel very lucky to have the knowledge that she is looked after well in every way.” “I have always found Inglewood’s staff to be kind, caring and very helpful.” “I am more than happy living here.” “Inglewood is a very good home where both management and staff are dedicated to the well-being of the residents.” What has improved since the last inspection? What they could do better: Although it is clear that the Registered Manager always meets prospective service users, she must ensure that a written assessment covering all those areas detailed in Standard 3.3 of the National Minimum Standards is completed for those people who are self-funding. There is not enough opportunity for stimulation through leisure and recreational activities at the home at present. This is not only the conclusion of the assessment on the day of the inspection, but is also the view of a number of service users and their relatives. It was apparent at the inspection that there were insufficient staff on duty on the morning shift to fully meet the needs of the service users. An immediate requirement was made that this be addressed that day. It is acknowledged that the Registered Manager is actively seeking to increase the staff group. Staff were observed to be moving a service user in a wheelchair without using footrests. They were also seen to be moving a service user with the wrong technique. The Registered Manager was asked to speak with the staff concerned about this and to arrange updated moving and handling training. Please contact the provider for advice of actions taken in response to this Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 7 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. Inglewood Residential Rest Home DS0000020855.V316555.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 Inglewood Residential Rest Home DS0000020855.V316555.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): Standard 3. Standard 6 is not applicable, as Inglewood does not offer Intermediate Care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users who are referred by Social Services are properly assessed before they move to Inglewood. Where service users are self-funding, the Registered Manager must complete a written assessment. No one is admitted to Inglewood unless the home are sure that they can meet the needs of the individual. EVIDENCE: The assessment information for 5 recently admitted service users was seen during the inspection. 3 of the service users were funded by their Local Authority and in these cases a full assessment had been forwarded to the Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 10 Registered Manager prior to the person moving in. 2 service users were privately funded and they had been visited by the Registered Manager in Hospital. The Manager stated that she had taken notes at the time, but these were not available on file. Where service users are self-funded, the Registered Manager must carry out a written needs assessment covering all those areas detailed in Standard 3.3 of the National Minimum Standards. In all 5 cases, following assessment, the Registered Manager had written to the individual confirming that the home would be able to meet their needs. In their returned surveys all service users said that they had received sufficient information about the home prior to moving in. The majority had had the opportunity to spend a day at the home. During the day of the inspection a prospective service user was spending a day at the home, having lunch with the service users. In all of the files seen there was a copy of the statement of terms or conditions or contract. Inglewood Residential Rest Home DS0000020855.V316555.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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are comprehensive care plans in place to ensure that the personal, health and social care needs of service users are met. The Registered Manager is proactive in seeking medical advice when needed and there is good liaison with healthcare services. Medication is stored, administered and recorded appropriately and service users are protected by the home’s policies and procedures for dealing with medication. Service users’ right to privacy is respected. EVIDENCE: In addition to the 5 recently arrived service users, the care plans for a further 5 service users were seen. All had care plans in place and all included a risk Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 12 assessment. The risk assessment includes a falls risk assessment. All aspects of the care plan are evaluated on a monthly basis and the evaluations provide an up to date picture of the person’s needs. It is recommended that the home produce an overall up to date picture from this evaluation material along the lines of their “Care Plan on Admission” document. This document should reflect any changing needs (see Standard 7.4). In some cases it was clear that the care needs of individuals had changed and although this was reflected in the evaluation, the original care plan had not been updated. Where possible, service users are involved in drawing up their care plans and sign their agreement of the plan. The current healthcare needs of service users are clearly documented within the care plans in the Evaluation documents. These documents are broken down to include current mental health needs, current physical health needs, pressure sore evaluation and oral hygiene. There is evidence that when needed service users receive regular visits from Community Psychiatric Nurses, District Nurses and Continence Advice Nurses. Pressure relieving equipment is provided where needed. All files seen contained evidence of nutritional screening and of the fact that service users are regularly weighed. Where service users had been seen by a healthcare professional, this information had been recorded, including the outcome of the visit and any treatment prescribed. Service users have access to visiting dentists, opticians and chiropodists. Some service users choose to pay privately for a chiropodist. Light exercise sessions are held. A visiting Doctor was spoken to during the visit, who confirmed that the home were proactive in appropriately seeking medical advice and gave an example of this by describing a recent event. In their returned surveys, 12 of the 15 service users who responded said that medical support was “always” available when they needed it, 2 said “usually” and 1 person said that this had not been needed for them yet. The home have clear policies in place with regard to medication administration. It is recommended that this should include a policy on homely remedies and that where service users wish to take a homely remedy, such as a complementary therapy, their G.P. is contacted by the home and his or her written agreement requested that the homely remedy can be taken. All service users have a lockable facility in which to keep their medication if they wish to self-administer, although none choose to do so at present. Correct records are kept of all medicines received, administered and leaving the home. The Registered Manager carries out a weekly audit of the medication and administration records. The home are now using a medicines’ trolley, which is a great improvement on the previous practice. A monitored dosage system is used. A random sample of the medicine cassettes and administration record sheets were checked at the inspection and there were no discrepancies. All the medicines in the trolley were kept in good order. Controlled drugs are stored, administered and recorded correctly. The majority of staff have successfully completed the Safe Handling of Medicines training. A further 6 staff are undertaking this training at present. Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 13 The majority of service users at Inglewood have their own single rooms and therefore all personal care-giving takes place in private. Screens are provided in double rooms. It was noted during the inspection that staff always knock before entering bedrooms. Service users are asked at their assessment how they wish to be addressed. All new staff take part in induction training, during which they are instructed in how to treat service users with respect. Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users confirm that they are able to exercise their choices at Inglewood. Some criticism was voiced about the provision of social care activities and there is room for improvement in this area. The meals provided at the home are of excellent quality and are much enjoyed. EVIDENCE: Service users spoken to during the inspection confirmed that they were able to choose whether or not to join in social activities at Inglewood. Service users interests are recorded in their care plans, but in one of the plans seen this information had not been updated since 2001. In the care plans seen there was no evidence of the service users taking part in social care activities. The home keeps a record of activities provided, but none had been recorded since 18th October 2006, which, if correct, means that no activities had been provided for a week. The activities that had been recorded consisted of T.V., Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 15 visits (presumably visits from friends and relatives), gentle exercise, chats and dominoes. An exercise session organised by “Progressive Mobility” had taken place on 13th October 2006. On one day a visit from the chiropodist had been recorded as a leisure activity. There is, however, evidence that birthdays and Festivals are celebrated and that various entertainers will visit over the Christmas period. The provision of suitable activities is an area which was criticised in some of the returned surveys from service users, several of whom were assisted to complete them by their relatives. Of the 15 surveys returned, 6 said that suitable activities were “always” provided, 3 said “usually”, 3 said “sometimes” and 2 said “never”. One person didn’t know. Relatives also made a specific comments in the returned survey that perhaps more could be done to provide stimulating activities. It was also suggested that proposed activities should be posted on a notice board so that service users and relatives were aware of future plans. The provision of activities is the only area which received any criticism from service users and their relatives. Whilst it is acknowledged that not all service users want to take part in activities, the home now has sufficient space to provide an activity on a daily basis and those who do not wish to join in have other quieter areas available. This is an area which needs improvement. The majority of service users have single rooms and are able to see their visitors in private. A new visitors’ room has been added, which provides a quiet and pleasant area. There are no restrictions on visits and relatives and friends are encouraged to maintain involvement once the service user has moved to the home. Where possible, service users are encouraged to handle their own financial affairs. Information on the local Age Concern Advocacy Service is available in the home if needed. All service users have been informed in writing of their right to access their personal records. The majority of service users spoken to during the inspection and in their returned surveys made very positive comments about the quality of the food provided at Inglewood. Menus seen show that a variety of nutritious foods are offered and that a choice is available for every meal. One service user who had been explaining how good the food was, exclaimed “Now look at that!” when his appetising meal was placed in front of him. In addition to the 3 main meals, regular drinks and snacks are offered during the day. Supper is served at 8.00 p.m. One service user described how staff had served her a cup of tea and sandwich during the evening at her request. Special therapeutic diets are provided as needed and at the time of the inspection some service users were receiving a diabetic diet. The mealtime was a pleasurable occasion, some service users enjoying a glass of their own wine with their lunch, stored on their behalf in the kitchen. Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 16 Inglewood Residential Rest Home DS0000020855.V316555.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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints procedure and service users feel that any complaints they may have will be listened to and acted upon. There are robust Adult Protection Procedures in place to protect service users. EVIDENCE: There is a clear Complaints Procedure in place, a copy of which is given to all service users and is also available on the notice board. Service users spoken to during the inspection said that they would know who to speak to if they wished to make a complaint. In their returned surveys, all of those who responded also confirmed that they would know how to make a complaint. The home does have a system for recording complaints and their outcome, but no complaints have been received by the home or by the Commission for Social Care Inspection. The home has a robust Adult Protection Procedure in place. They now also have a copy of the updated Walsall Social Services Adult Protection Procedure. There have been no allegations of abuse at Inglewood. Several staff have Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 18 taken part in Adult Protection Training. The home has a policy in place for dealing with any physical and/or verbal aggression by service users. Staff spoken to during the inspection were clear of their responsibilities with regard to Whistleblowing and the Protection of Vulnerable Adults. Inglewood Residential Rest Home DS0000020855.V316555.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): Standards 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A full inspection was also made of the environment when the home was registered for additional numbers in July 2006. Ingelwood provides very attractive accommodation in a safe and wellmaintained environment. There are good standards of hygiene and cleanliness at the home. EVIDENCE: Inglewood has recently been extended and refurbished to a high standard and provides very comfortable and attractive accommodation. The home is now registered to care for 31 people. There are 25 single rooms, 18 of which have Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 20 an en suite toilet and 3 double bedrooms, 2 of which have an en suite toilet. 3 additional bathrooms, 2 showers and 4 additional toilets have been provided. The dining room has been extended and there is an additional large lounge and small quiet room or visitors’ room. There are a number of parking places to the rear of the property and there is a pleasant, south facing landscaped garden. The building has been visited by the Fire Officer and meets his requirements. The Registered Persons are aware that there are some fire doors, which are not yet closing firmly into the rebates and remedial work is in progress. Furnishings throughout the home are of a high quality and in addition to the new rooms, existing rooms have been decorated and provided with new furniture. The laundry has also been refurbished and a new washing machine, with a sluice facility, has been provided. There are policies and procedures in place for the control of infection. Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been occasions when the home have not employed sufficient care staff to meet the needs of the service users. This can, at least, cause an inconvenience to service users and at worst, a risk. Staff are well trained and enthusiastic. There are robust recruitment procedures in place to protect service users. EVIDENCE: When the inspection commenced, at 8.20 a.m., there were 3 members of staff in the home, 2 were providing personal care to the service users and helping them to breakfast, whilst the third was preparing breakfast. These staffing levels are not sufficient to meet the needs of the current group of service users (21 at the time of the inspection), at least 2 of whom need assistance from 2 carers. This shortage of staff impacted directly on one service user, who was waiting for her breakfast for over an hour (until 9.30 a.m.) because she needed 2 carers to assist her to the dining room. From observation of the rotas it could also be seen that there were not enough staff rota’d on weekend Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 22 afternoons, with 2 providing care and 1 preparing the tea-time meal. The home were issued with an Immediate Requirement Notice to rectify this shortfall and the Registered Manager undertook to ensure that during day-time shifts there would always be at least 3 staff on care duties plus an additional person to prepare any meals. Staff rotas also show that on some occasions staff work extremely long hours, in some cases coming in on an afternoon shift and then working the night shift. The Registered Manager explained that she was aware that she needed to increase the staff group and had already advertised for 4 additional carers, 2 assistant cooks and 2 cleaners. Interviews were to take place the following week. Overnight there are 2 waking night staff and a senior member of staff is On Call in the event of any emergencies. There are no staff employed who are under the age of 18 and the home is never left in the charge of anyone under 21. 60 of the staff have achieved the NVQ level 2 and 1 member of staff has commenced NVQ3 training. There are robust recruitment procedures in place. Staff files seen showed that no new member of staff is employed until the home have received 2 satisfactory written references and satisfactory Criminal Records Bureau and Protection of Vulnerable Adults checks. Where staff had been employed on the basis of a POVA First, a risk assessment had taken place and the member of staff had worked under supervision. On the files seen at the inspection there was evidence that staff have an individual training plan in place. Newly recruited staff take part in induction training to Skills for Care specifications and evidence of this was seen on their files. In addition to the mandatory health and safety training (see Standard 38), evidence was seen of staff training in a number of other relevant areas, including safe handling of medicines, Adult Protection, communication skills and dementia care (1 day only). All staff receive at least 3 paid days’ training a year. Service users and their relatives spoke highly of the staff, both at the inspection and in their returned surveys. Some of the things they said are as follows: “They see you’re safe”. “The staff are always very helpful.” “I have always found Inglewood staff to be kind, caring and very helpful….” “The staff are always ready to receive any suggestions and listen with interest.” Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an experienced and well qualified Registered Manager, who displays good leadership skills and is well respected. There are systems in place for obtaining the views of service users and other stakeholders, although these have not been sought recently. Service users’ finances are safeguarded by the home’s policies and procedures. The health and safety of service users and staff are protected by the home’s policies and procedures. Care must be taken, however, to ensure that proper moving and handling techniques are employed. Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 24 EVIDENCE: There is an experienced and well qualified Manager at Inglewood. Comments were made during the inspection of the excellent leadership skills of the Manager and of the example she displayed to younger staff. The Manager updates her skills by taking part in relevant training. Some of the relatives, in their returned surveys, made the following comments: “The owner/manager is very approachable.” “They (the carers) show affection and care which gives us peace of mind. This ethos is generated by Mrs. Beecroft who leads by example.” The home sends out questionnaires seeking the views of service users, their relatives and visiting social and healthcare professionals. A six month Quality Assessment Audit has been produced in the past, but this has not been carried out recently. This is probably because the Registered Manager has been extremely busy with the refurbishment and extension of the home. It is recommended that this practice be resumed as soon as possible. The home should also produce an annual development plan, which reflects the aims and desired outcomes for the service users. Service users’ meetings are held, although none have been held recently and it is recommended that these be re-commenced as soon as possible. The home takes charge of some personal allowance money on behalf of service users. A random sample of the monies and accompanying records were seen at the inspection and all were in order. All monies are kept securely. Records show that staff take part in regular training in moving and handling, fire safety, first aid, food hygiene and infection control. It was noted during the inspection that staff were moving a service user in a wheelchair without using footrests. Footrests must be used at all times. It was also noticed that staff were using inappropriate techniques to move one service user. Further moving and handling training has been arranged for November 2006. Records show that fire safety checks take place at the required intervals. There is a Fire Risk Assessment in place, which was reviewed in August 2006, and the fire alarm system and fire fighting equipment are regularly serviced. The home carry out a regular Health and Safety assessment of the premises. In addition fire safety is discussed with each member of staff at their supervision sessions. All hazardous substances are kept securely. Evidence was seen of the regular servicing of boilers, the hoists, electrical system and of the testing of electrical equipment. The home are aware of its responsibilities with regard to Legionella. Water temperatures at outlets accessible to service users must be regularly checked and recorded. Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 25 Risk assessments have been carried out for all safe working practice topics. The CSCI are notified of any incidents, accidents or illnesses under Regulation 37 of the Care Homes Regulations. Inglewood Residential Rest Home DS0000020855.V316555.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) Requirement For service users who are selffunding and without a Care Management assessment/Care Plan, the Registered Manager must carry out a needs assessment covering all those areas detailed in Standard 3.3. The home must provide more opportunities for stimulation through leisure and recreational activities in and outside the home, which suit the needs, preferences and capacities of the service users. The Registered Manager must ensure that there are sufficient care staff on duty to meet the assessed needs of the service users. Footrests must be used on wheelchairs at all times. Staff must ensure that appropriate moving and handling techniques are employed. Water temperatures at outlets accessible to service users must be regularly checked and recorded. DS0000020855.V316555.R01.S.doc Timescale for action 10/11/06 2. OP12 16(2)(m)( n) 30/11/06 3. OP27 18(1)(1) 25/10/06 4. OP38 13(5) 25/10/06 5. OP38 13(4)(a) 10/11/06 Inglewood Residential Rest Home Version 5.2 Page 28 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 OP7 OP9 Good Practice Recommendations It is recommended that the home produce an overall up to date care plan from the monthly evaluation. It is recommended that the home produce a “homely” remedies policy and procedure. Where service users wish to take a “homely” remedy, such as a complementary therapy, their G.P. should be contacted and his or her written agreement requested that the “homely” remedy can be taken. It is recommended that an up to date Quality Assessment Audit be produced. It is further recommended that Service Users’ Meetings be re-commenced as soon as possible. 3. OP33 Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Inglewood Residential Rest Home DS0000020855.V316555.R01.S.doc Version 5.2 Page 30 - 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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