Inspection on 25/11/08 for Ivonbrook Care Home

This inspection was carried out on 25th November 2008.

CSCI found this care home to be providing an Adequate service.

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

Ivonbrook Care Home 13/09/07

Ivonbrook Care Home 13/09/06

Ivonbrook Care Home 24/10/05

Ivonbrook Care Home 07/06/05

Ivonbrook Care Home 03/08/04

Ivonbrook Care Home 28/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOMES FOR OLDER PEOPLE Ivonbrook Care Home Eversleigh Rise Darley Bridge Matlock Derbyshire DE4 2JW Lead Inspector Bridgette Hill Unannounced Inspection 25th November 2008 09:20a 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 Ivonbrook Care Home DS0000002061.V373209.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. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivonbrook Care Home Address Eversleigh Rise Darley Bridge Matlock Derbyshire DE4 2JW 01629 735306 01629 735441 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) David Treasure Mr A Wright, Mrs Glenys Pamela Wright, Alison Treasure Manager post vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit the person named in variation V38675 in the category DE(E) dated 8 February 2007 Date of last inspection Brief Description of the Service: Ivonbrook care home is situated in its own grounds in Darley Bridge village, near Matlock, and provides nursing and personal care for up to 40 persons aged 65 years and over. The home is purpose built and the facilities are on 2 floors; stairs and a passenger lift access the floors. All bedrooms are single rooms; 12 rooms have en-suite facilities. There are 2 lounges, dining rooms and a small quiet lounge area. Residents have access to a garden. At the time of this inspection the Home’s fees ranged from £300 to £550. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means the people who use this service experience Adequate quality outcomes. This inspection was an unannounced one. The purpose of this inspection was to assess all key standards and compliance to previously listed requirements. Various records including care planning records were examined the findings are recorded in the body of this report. Discussions were held with residents, staff and a visiting professional during the visit. An Annual Quality Assurance Assessment was completed by the Acting Manager of the home prior to the visit and where relevant the content has been included in the body of this report. Surveys were also sent to service users. Relatives and staff. Where these were returned these have also been considered. The Acting Manager Anne Poole was on duty during the inspection and one of the owners David Treasure was available for the majority of the day. What the service does well: What has improved since the last inspection? What they could do better: Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 6 The care plans we looked at were not always consistent or descriptive with the actual identified needs of the resident as the system to update them did not ensure that all information recorded was relevant. There was some poor practice evident in the recording of medication records which may potentially lead to the wrong medication dosage being given. The recruitment procedures were not being robustly followed and all required documentation was not being obtained for staff and volunteers prior to them starting work at the home. There was poor recording of staff training and the records kept indicated that some training such as Moving and handling and fire safety was out of date. Some staff had no recorded training at all. Staff told us they had received a range of training but this could not be verified by the records available to us. The induction checklist in place was not a skill based induction and did not meet required standards. The owner is not completing required monthly quality assurance checks on the home although the owner does have an almost daily presence in the home and was well regarded by all we spoke to. 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. Ivonbrook Care Home DS0000002061.V373209.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 Ivonbrook Care Home DS0000002061.V373209.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was varying but sufficient assessment information available on residents to ensure their needs can be met by the home. EVIDENCE: Some information on the home was available in the entrance hallway including a copy of the most recent inspection report. The care files we looked at contained varying information regarding the assessment of residents needs prior to admission. The home had their own forms to use which if fully completed should give an excellent overview of needs. In two files this form had been completed but in a third had not been. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 9 The Annual Quality Assurance Assessment told us that pre admission assessments were carried out by the manager. We discussed with the acting manager and owner that one had not been completed. This admission appears to have taken place during the absence of the acting manager however a Free Nursing Care assessment was on file to give assessment information. For two files the home had completed their own assessments. For all residents had been seen by the Free Nursing Care team or care managers it was found that copies of their assessments were on file. One resident told us they liked staying at the home and used it as a respite placement on a regular basis. Residents told us that it was mostly their families who had visited and chosen the home for them. The home does not offer intermediate care as defined by National Minimum Standard 6. Ivonbrook Care Home DS0000002061.V373209.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. 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. There are not robust systems in place to ensure that residents care plans are updated, therefore residents needs may not be met. EVIDENCE: We looked at 3 care files to assess how staff were recording peoples care needs. There did not appear to a system in place to ensure that the information in care plans was always kept under review and up to date. There was typically a range of information on one page some spanning two years and where needs had changed it was not clear on the plan. In one file it appeared from the information that the resident had a pressure sore. When we talked to the acting manager about this it had actually healed and not been updated. Information had been added on different dates and some information was crossed through and generally it was confusing as to what the residents actual Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 11 needs were. Whilst some needs were identified for example constipation it was not recorded fully in the plan of how this should be treated should the problem occur. Positively there was an index of needs for each resident kept and some aspects of the care plans informed staff about the abilities and wishes of the residents such as their ability to choose their own clothing or what aspects of self care the resident was able to complete. For one resident, a very recent admission staff had not yet developed a plan of care however the log notes that were kept indicated that information on the residents preferences was being recorded and information had been sought from the residents family. Parts of the social history and daily preferences forms were completed, as were the risk assessment forms. Staff completed log notes for each shift that they worked. Staff also told us they completed some additional information on residents where needed such as turn charts and fluid/food charts. Staff told us they received handovers and could access files to get the information they needed to care for residents. In each care file were a range of risk assessments including nutrition, tissue viability, falls and Moving and handling. Each resident also had a fire risk assessment on file which informed staff of their needs should there be a fire at the home. There were clearly documented systems for recording medication received in and staff told us that medications no longer needed were returned to pharmacy and recorded in a book which was at the pharmacy. The medication administration records indicated that residents generally received their medication regularly however for one medication round there were no signatures recorded but the medication was missing from the blister packs. Specimen signatures for staff were available and balances for controlled drugs correlated with the records. One medication administration records was somewhat confusing as staff had changed the dosage according to the GP’s instructions. As a result differing dosages of the same medication were due at two different times on the same box on the medication administration record however the actual dosage given was not recorded and the dosage on the packaging remained as it was prior to the reduction in one dosage. This could be potentially confusing to staff and the wrong dosage may be administered. Generally however where variable dosages were prescribed the actual dosage given was recorded. Good protocols and instructions were in place for ‘as required’ medicines on each residents file. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 12 The medication administration records had photographs of residents on them and the fridge temperature was checked albeit infrequently. The care records we looked at told us that residents healthcare needs were met by visiting chiropodists, optician and dentist. We spoke to a visiting professional during our visit. They told us that staff were always knowledgeable about the residents when they visited and keen to learn from the professionals input. They told us that when care instructions were left that these were carried through and whilst there were some difficulties in aspects of continence management for some residents with complex needs there had also been some notable improvements for some residents. Residents told us they knew staff by name and they were like ‘old friends’. We were told staff were friendly and helpful. Some care files we looked at had information recorded where people had made decisions about their post death wishes and informed staff if relatives wished to be contacted at any time should emergencies/concerns occur. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home have varied lifestyles according to their abilities and regular activities are offered to residents therefore choice and variety are offered. EVIDENCE: There are two volunteers who visit the home on a regular basis who get involved with providing activities for the residents. They told us about the work they did which included dominoes, board games, jigsaws, cards and helping out at meal times. Photographs of some of the events held at the home were seen this included birthday and valentine celebrations. There were some arts and crafts around the home which residents had completed. A local organisation called ‘First Taste’ also visited the home to offer activities to residents. This included some crafts and photography sessions. Some slide shows and poetry sessions had also been held. Residents told us that a church service was held in the home each week if residents wished to attend. One resident also told us about going out to a local club with transport being provided by the home. Residents told us their families were made welcome by staff at the home. We were told that one Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 14 resident regularly accessed talking books as their eyesight affected their ability to read. The home booked and use community transport to arrange some visits out. The schedule on display indicated that usually two trips per month were organised. A Christmas shopping trip was planned for the coming week. A hairdresser visits the home on a regular basis and uses a designated room, the residents pay extra for this service a dedicated room was available for the hairdresser to use.. The Acting Manager told us that weekly church services were also held in the home. The residents we spoke to told us they enjoyed the services. Residents told us enthusiastically about a herd of deer who lived in the grounds of the home which were clearly very popular with residents and visitors alike. Some residents got involved in feeding the deer and photographs of residents with the deer were seen in the home. Different dining rooms were available for residents to use on each floor. The menu was displayed on the wall to tell residents what was being served. Generally one main meal was offered but residents told us that they could order alternatives if they didn’t want the main meal. One resident had a special diet who we spoke to and they told us they were happy with the food. During the meal residents were observed using plate guards to maintain their independence and different residents had been served different portion sizes. We were told by a number of residents that the food was good and most plates were empty after the meal. A choice of three desserts were offered including a fresh fruit option. Residents told us a choice of drinks was offered with each meal. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to safeguard resident’s welfare and ensure that their concerns are listened to and acted upon. EVIDENCE: The Annual Quality Assurance Assessment told us that there had been three complaints received at the home, however when we looked at the complaints records in the home only one was recorded since our last visit. This was regarding a bought in food item in which a foreign object had been found. The home had appropriately contacted the environmental health department about this. The Owners told us that if anyone did tell them about any concerns they were dealt with quickly and depending what it was if it was a minor verbal concern it may not always be recorded. The complaints procedure was in the entrance hallway for residents and visitors to see. Residents told us the manger, owner and staff were approachable. A whistle blowing policy was also in place to tell staff they could raise concerns if they had any however in our discussions with staff they were vague on their knowledge of this and did not know if there was a policy in place. There had not been any Safeguarding Adults allegations or referrals made in the past according to the Annual Quality Assurance Assessment completed by Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 16 the home and the acting manager told us at the visit there had not been any since the Annual Quality Assurance Assessment was completed. There was a Safeguarding Adults procedure in the home which was clear in the reporting procedure to be followed which was any allegation should e reported through to Social Services and the locally agreed procedures which are in place. We talked to staff about what they would do if they had any concerns regarding abuse of residents. All told us that they would speak to the nurse in charge or the owner who was said to be very approachable. Staff told us they had received training in Safeguarding Adults however the poor staff records did not reflect this. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally clean and well maintained environment for residents to live in however there are areas where odours remain evident. EVIDENCE: The home is an extended property which offers facilities on two floors. There are lounges and dining areas on both floors with a passenger lift being available to help residents with mobility problems access both floors. Generally the home appeared to be in reasonable decorative order with a record of maintenance jobs being recorded and signed of as completed regularly. There had been some new tables and chairs purchased for the lounges. Some parts of the lounge areas appeared a little untidy with items being stored inappropriately in wheelchair storage areas and furniture units Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 18 being a little clouted. There was however a general homeliness feeling about the home. The fire records told us that there was regular checking and of the fire system doors and lighting to ensure it was functioning. At the Fire Officers last visit on 1.2.08 all matters regarding fire safety were found to be satisfactory. Since our last visit there has been some replacement of floors with non slip laminates in some bedrooms to promote ease of cleaning. Despite this there were some areas where odour management remained a problem. The owner told us that new air filtration machines were in place and a carpet shampooer was available which was used regularly. Our discussions with a visiting professional told us that there were issues with the management of continence where residents had complex needs. One resident told us their room was kept ‘reasonably clean’. It was observed that one toilet did not a privacy lock fitted on to ensure residents privacy when using the toilet. We talked to residents about their bedrooms and some were proud to let us look at their rooms and how they had personalised them. Some residents had personal telephones lines installed in rooms and satellite television. The owner told us there had been some investment in providing variable height adjustable beds, particularly for residents who needed help with mobility or who were cared for in bed for the majority of the time. The laundry area was tidy with all equipment functioning. Residents told us the laundry service was ‘superb, a good service with clothes beautifully ironed on their return’. The excellent laundry service was also remarked on in a survey the home had completed however occasional mix ups in the clothing returned was recorded in the residents meeting in July. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recording and planning of staff training and induction is not ensuring that staff receive updates and required training in a timely way to ensure they can deliver care to residents. There were not systems in place to ensure staff were robustly being recruited possibly placing residents at risk EVIDENCE: There were 31 people in the home on the day we visited. The usual staffing levels on the current rota were one nurse for each shift 4 care staff each morning, 4 each afternoon and 2 at night. The acting manager told us that due to there being a nurse vacancy they were currently working as the nurse on duty and had limited time to ensure management tasks were completed. A sample of four staff and volunteer recruitment files were examined to assess if robust procedures were being implemented. Whilst a recruitment procedure was in place some files we looked at had significant deficits as there was not completed application forms for some volunteers and staff. On some application forms there was only one person identified as a referee and Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 20 subsequently there was insufficient references on file to assess staff suitability for the job they were applying for. The deficits appeared to be largely in files where staff had been recruited through agencies and where volunteers were used. We looked at the staff training records available at the home. These were found to be poorly kept with no training at all recorded for some staff. For others the extent of training recorded over the past 18 months appeared to be Moving and handling and fire safety both of which were now out of date. We spoke with staff about the training they had received or that which was planned and all staff we spoke to said they had received training in a range of areas including Safeguarding Adults, Moving and handling, fire safety, and had nearly finished health and hygiene courses. Staff also told us a range of training was planned although he manager did not appear aware of this as it had been arranged by a sister home of the same owner. It is apparent therefore that there is inconsistencies evident in the evidence relating to the level of training staff have received. The owner told us that the kitchen staff are in the process of completing a higher level of food hygiene training. The Annual Quality Assurance Assessment told us that there was 4 out 17 staff had achieved National Vocational Qualification level 2 or above in care the acting manager told us this had not changed since the Annual Quality Assurance Assessment was completed. A skill-based induction checklist was available at the visit however the full workbook was not available in the home and the only induction in place was an in house checklist. We talked to the manager about the induction process and they were not familiar with the full skill based induction packages. Residents told us that staff ‘very good and helpful, you can have a laugh and joke with some staff’. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are a range of areas where the management of the home could be improved to ensure the home is always run in the best interests of residents. Systems to protect the Health and Safety of residents appear to be established. EVIDENCE: Since that last inspection there has been a change of Manager and an Acting Manager is now in post. The Acting Manager is an experienced care home manager and has previously been the registered manager for Ivonbrook. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 22 Following our last inspection of the home on 13th September 2007 an improvement plan was requested but none was forwarded to us to tell us how the home was going to address the requirements listed. At this visit there are managerially a number of areas where requirements have been made, this includes safe recruitment of staff and evidence that staff are suitably trained. We talked to the owner about recorded monthly quality assurance checks but were told that there was nothing recorded. The owner is well known to the residents and is present at the home most days but they told us recorded visits hadn’t been completed for around six months. There had been one residents meeting since our last visit where a range of topics were discussed including, cleanliness of tables and chairs, variety of sandwiches, communication with staff, laundry and activities. There were also minutes of a trained staff meeting. Topics discussed at this meeting included new medication policies, reviews of care plans and use of phones. Some surveys had been given out to residents in August 2008. The surveys were long and detailed and as such may be difficult for some residents to complete however they were comprehensive in asking residents about their views on most aspects of the home. It was noted however that some had not been fully completed, 14 had been returned. Generally the feedback given was good with excellent care of clothing recorded. Three comments did record however that staff did not always knock on doors before entering. We talked to staff about supervision and were told that they were ‘not really’ receiving any individual supervision to ensure they were supported to fulfil their role. For some residents small amounts of money was held safely by the manager. This was typically used for hairdressing and chiropody. The records appeared well kept with double signatures to record and witness the transactions taking place. Where valuables were kept safely on residents behalf there was also a record of these kept. The office where residents records were kept on an open shelving unit was not lockable, this meant that records could be potentially accessed by unauthorised persons when the office was not occupied by staff. Regular health and safety checks were being done. This included testing water temperatures and the fire alarm. The radiators in the home were low surface temperature type to protect residents against burns. Staff told us that first floor windows were fitted with restrictors to ensure residents would not accidentally fall out. There was a fishpond in the grounds of the home which was also fitted with wire over it to prevent anyone falling in. The owner told us thermostatic mixers were fitted on sinks and bathing outlets to limit the risk of residents being scalded. Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 23 Where accidents had occurred these were documented and it was recorded what actions, if any had been taken. The Annual Quality Assurance Assessment completed by the home indicated that all service checks were up to date at the time the form was completed. Since then the gas appliances were due for servicing. The owner told us a new boiler had been fitted and a certificate of testing was seen to confirm this was in date. Ivonbrook Care Home DS0000002061.V373209.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 x x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 2 x 3 Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 25 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 2 Standard OP7 OP7 Regulation 15 15 Requirement Care plans must be in place to describe to staff how all assessed needs are to be met A system of care plan reviews must be introduced to ensure the care plans in place are up to date and reflective of residents needs. Where medications are prescribed on a regular basis these must be administered or a record maintained of the reason for omissions. All staff must receive training on the protection of vulnerable adults. Privacy locks must be fitted on all toilets to protect service users privacy and dignity A review of cleaning must to be undertaken to establish if there is alternative approaches which can be taken to eliminate odours in the home Staff must only be confirmed in post following all preemployment checks described by Schedule 2. There must be a comprehensive DS0000002061.V373209.R01.S.doc Timescale for action 30/01/09 30/01/09 3 OP9 13,17 30/12/08 4 5 6 OP18 OP21 OP26 18 12 13 28/02/09 30/01/09 30/01/09 7 OP29 19 30/12/08 8 OP30 18 30/01/09 Page 26 Ivonbrook Care Home Version 5.2 9 OP30 18 10 OP31 8 11 OP33 26 12 OP37 17 skill based induction programme in place for new staff. An audit must be completed of staff training and a planned programme of training introduced to ensure all staff hare suitably trained and receive mandatory training in order to meet residents needs. An application must be made to allow the Commission for Social Care Inspection to register and approve the manager of the home as a ‘fit person’. To ensure service provision is effectively monitored Regulation 26 visit must be performed on a monthly basis together with the necessary paperwork, to satisfy Regulation 26. All of the records relating to residents must be held securely in line with data protection guidance to ensure residents confidentiality is protected. 30/01/09 30/01/09 30/01/09 31/12/08 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 OP28 Good Practice Recommendations Staff should be offered and encouraged to undertake National Vocational Qualification training in care to enable the home to achieve at least 50 of care staff who are suitably trained. The manager and staff should complete Mental Capacity training. A plan should be implemented to ensure all staff must receive supervision. 2 3 OP30 OP36 Ivonbrook Care Home DS0000002061.V373209.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Ivonbrook Care Home DS0000002061.V373209.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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