Inspection on 06/06/06 for Laburnums

This inspection was carried out on 6th June 2006.

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

Laburnums 29/06/07

Laburnums 14/11/05

Laburnums 25/04/05

Laburnums 13/12/04

Laburnums 27/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Laburnums 20 Chalkwell Avenue Westcliff On Sea Essex SS0 8NA Lead Inspector Mr Trevor Davey Key Unannounced Inspection 6th June 2006 11:00 X10029.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 Laburnums DS0000015444.V298692.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 and Care Homes for Adults 18 – 65*. 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. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Laburnums Address 20 Chalkwell Avenue Westcliff On Sea Essex SS0 8NA 01702 477898 01702 480679 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) East Homes Limited Manager post vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care and accommodation to be provided to persons between the age of 18 and 65 with a learning disability. 14th November 2005 Date of last inspection Brief Description of the Service: Laburnums is registered to provide personal care and accommodation to nine residents whose primary need of care is learning disability. Residents Currently living at Laburnums are in the older age range, with the majority being over 65 years of age. It has been considered appropriate, therefore, to focus the inspection on the Older People’s Standards. Accommodation is provided in a larger style three-storey house in a residential area. A shaft lift has been provided. The type and style of property provides plenty of space for service users and has a large garden area. It is close to local shops and main bus routes. A variety of social recreational activities/events are available. All service users have their own bedrooms, which are decorated and personalised to individual preference and choice. The monthly range of fees was not stated on the pre-inspection questionnaire and it is understood that these are based on individual assessed need. Extra charges are made for hairdressing, chiropody and newspapers/magazines. A copy of the previous inspection report is on display on the notice board in the home and the findings & outcomes are made known to residents at their meetings. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit took place over a period of 6.50 hours. The visit mainly focused on the progress the home had made since the last inspection and covered all Key standards. A tour of the home took place. Staff and residents were spoken with during the site visit who were helpful in their contributions and the assistance they gave to the Inspector. In addition, case tracking took place using some of the personal care records and other official records within the home were also assessed. Letters have been sent out to health care professionals and funding authorities requesting feedback of the service provided by the home. From the limited responses received, these showed that improvements in the home & staffing had taken place during the past year. Information was also taken from the pre-inspection questionnaire submitted by the acting manager and additional information was obtained from the deputy manager on the day of the site visit. The home does not currently have an ‘E’ mail address. What the service does well: What has improved since the last inspection? Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 6 Following requirements from the previous inspection report, a controlled drugs register has been introduced as well as updating the medication and administrative procedures. Although there are still some issues to be resolved, improved arrangements have been made to ensure residents have access to local doctors and treatment when this is required. The acting manager has also submitted updated versions of the Statement of Purpose, Service User Guide and Complaints Procedure. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 6 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide omits specific information which residents and prospective users of the service require to enable them to make an informed choice about living in the home. Pre-admission assessment details for care/health needs had not always been recorded to give staff suitable information to determine whether the needs of potential residents could be met by the home. EVIDENCE: Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 9 Updated copies of the Statement of Purpose and Service User Guide have been sent to the Commission for Social Care Inspection. Relevant qualifications and experience of the manager had not been included in the Statement of Purpose and details of the size of rooms in the care home had also been omitted. Although the Service User Guide has a section for fees payable by individual residents, it is understood that this information had not been included. The acting manager is now arranging for this to be rectified. Information about the fees payable and extra items which residents are responsible for must be clearly documented and also included in contracts/terms of conditions. From the sample check made, pre-admission assessment information was not available for one of the residents who was admitted to the home in 2001. Although not in place, there was evidence of good holistic information, which had been included since admission as part of the personal care records. This included a carer support plan covering details of history, family and cultural background as well as physical and emotional needs. The home does not provide intermediate care. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, & 10 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to this service. Assessed and identified care/health needs were being met appropriately which included the added support of other healthcare professionals as required. The format of personal care records had been updated which showed detailed relevant information. Review reports were thorough and had been made available to other interested agencies prior to review meetings. EVIDENCE: Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 11 Case tracking took place in respect of two residents and other personal care records were also looked at. The format of care records had been updated which clearly showed personal and background information as well as an overview of mobility, personal care, feelings and emotions. Other areas covered included personal and family information as well as daily living skills and routines. The management are currently developing a key worker task list for each month. This is intended to ensure that the agreed routines are followed through with individual residents and are appropriately recorded. The management are planning to introduce Person centred planning training as part of this development. Details of health care intervention by doctors, speech and language therapists as well as a record of visits from occupational therapists were clearly documented. The support of local doctors has generally improved since last inspection and the management of the home are continuing to seek to improve still further, liaison and lines of communication with all GPs. The deputy manager stated that the home had received good support from occupational therapists who had been instrumental in assessing suitable wheelchairs as well as a shower chair for one of the residents. There was evidence of good professional co-operation with district nurses and local doctors where specific medical needs had been identified and protocols had been agreed. This had been supported by recorded contact with on-call managers. In this context, the home has regularly kept the C.S.C.I. up-todate with events in the home as required under Regulation 37 of the Care Homes Regulations. Risk assessments had been updated and reviews had taken place. Information in advance of the review had been well prepared which included an overview as well as action taken since the last review. Other headings included health and medication, daily living skills, levels of support and action plan. This format is being adopted by the home for all residents and has been approved by the Area Manager as well as being welcomed by other outside agencies. A sample check was made of the medication procedures and these were being followed based on agreed procedures with protocols in place which included advice from the local doctor. Entries were up-to-date and the controlled drugs register completed as required. At the time of the inspection, none of the residents were selfmedicating. It was not always possible to have detailed conversations with residents because of communication difficulties . However,there were positive gestures and recorded evidence of where residents had been involved in decision making regarding the care and support, which had been sensitively provided by the staff team. Hoist and lifting equipment was was being used according to agreed care plans and risk assessments. Residents were seen to be clean, well dressed and properly supported by the staff team. The staff have a good rapport and interact well with residents. It is recommended that training be provided to include non-verbal communication to assist in further promoting communication for the benefit of residents. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home provides an activities/recreational programme to meet individuals’ needs. Meals take account of residents choice. Relatives and friends are encouraged to have regular contact with the home. EVIDENCE: Opportunity activity sheets were available for inspection, which gave details of the activity attended, date and who was involved as well as the skills and support required. Based on their choice, the residents attend training centres Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 13 and other community facilities on various days during the week. This includes college where music sessions are provided as well as flower arranging classes. An art therapist attends the home once a week and all residents are involved. Local musicians also provide in-house music sessions. Some of the residents spoke to the inspector after having returned home after attending gardening projects and were positive in the experience gained from this activity. Annual holidays are arranged based on resident choice which includes visits to holiday camps and other venues. Photographs were displayed throughout the home of these occasions as well as other in-house activities. Special transport is arranged for wheelchair dependent residents to enable them to attend the cinema, restaurants and other places of their choice. Some of the residents have regular family support and the advocacy services are also used successfully. Records of resident meetings were available for inspection and this had generated ideas from the residents to rearrange the use of some of the home’s communal facilities as well as raising other issues regarding services provided. The deputy manager advised the Inspector that the Registered Provider provides annual clothing and holiday allowances of £100 respectively. A record of meals was available which reflected residents’ choice and staff spoken to, stated that they were involved in assisting residents to prepare and cook meals on a daily basis. The outcomes of the inspection showed that values of privacy, dignity, choice and fulfilment were being met but no record was available showing when the Registered Provider had last reviewed or updated their policy on these core values. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area was good. This judgment has been made using available evidence including a visit to this service. There is an established complaints procedure in place. Staff had an adequate understanding of the reporting procedure for the prevention of harm of vulnerable adults, ensuring that the safety of residents in the home is of paramount importance. EVIDENCE: The home had updated its complaints procedure which included picture symbols and copies had been given to all the residents.There were no recorded complaints since the last inspection. Staff spoken with had an adequate understanding and knowledge of P.O.V.A. reporting procedures. The homes training records identified those who had attended training but other staff are still waiting to complete the course. Although the Registered Provider has recently updated its policy on P.O.V.A. reporting procedures, which has been agreed with the Commission for Social Care Inspection, this was not available in the home on the day of inspection. This document should be made known to all staff to ensure that they are Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 15 aware of the measures in place to safeguard and protect vulnerable adults who are being cared for in the home. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Areas of the home were clean and hygiene. Bedrooms were suitably furnished and the layout reflected residents individual preferences . Ongoing maintenance and improvements to the building are taking place, but not all maintenance safety certificates were current and up to date. EVIDENCE: Kitchen, laundry and utility areas were clean and hygienic with staff observing regulations with regard to the control of substances hazardous to health. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 17 Safety precautions were displayed in the kitchen and substances used were securely locked in a cupboard. Liquid soap and paper towels were made available in bathrooms and toilets as well as the kitchen area.According to the homes training record, four of the staff have attended infection control courses. During a tour of the building, the bedrooms, which were inspected, had personal items and furniture, which was laid out in accordance with the individual preference of residents. Some of the residents spoken to were able to express that they were satisfied with their rooms. Communal areas were spacious and alternative sitting areas were available for residents use. Work to rectify the dampness in the conservatory has begun although there was plaster flaking off the walls showing that work still has to be completed to resolve the problem . It is understood that the boiler for the hot water and central heating system has been replaced. The electrical safety wiring certificate was dated 18 July 2000, which should have been renewed in July 2005. This is to ensure that any risks to residents and staff are minimised and to support this, up-to-date maintenance/servicing must take place together with the issuing of a current safety certificate.(This has also been referred to under Standard O.P.38.) Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 & 30 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The number of staff on duty, with supporting supervision, was able to meet the needs of residents. Not all staff had received up to date training related to current policies, procedures and care practices operating in the home. Staff recruitment records were not available for inspection. EVIDENCE: At the time of inspection, the acting manager was on holiday and the deputy manager together with two other support workers (for the early and late shift respectively), were on duty. Staff rotas had been submitted which included permanent, relief, agency and bank staff. Staff spoken with said that they received good and positive support from management and regular supervision takes place. Agency staff confirmed that recruitment checks had been carried out including the completion of the Criminal Records Bureau procedures. It Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 19 was not possible to inspect the recruitment records on this occasion as the acting manager was on holiday. These will be assessed at the next inspection. Staff gave information as to some of the courses of training completed, which included food hygiene, moving & handling, prevention of vulnerable adult procedures, first aid and medication. Positive comments were made about the home but it was mentioned that it would be good to have more permanent staff even though there is consistency with relief and agency cover being provided by the same people. It is of some concern to the Inspector that the Registered Provider has not given approval to the appointment of permanent staff and that great reliance is placed on relief and agency personnel. Staff commented that on some occasions, relief staff have been left to look after residents in the home whilst permanent staff have attended training. It is understood that although relief, bank and agency staff are used in the home on a regular basis, they are not included or given priority by the Registered Provider so far as regular training is concerned as this is generally made available for permanent staff only. This could lead to inconsistency in practice without sufficient permanent staff always being available to provide support and supervision. The deputy manager stated that further training is being arranged for infection control and P.O.V.A. It is understood that part of the supervision process with staff is intended to identify training needs and these should be planned and scheduled more consistently into the training programme . Five staff attended a medication administration course with the Registered Provider but it is understood that they were unable to be assessed for the practical examination as there was nobody available. Courses of training should be followed through to completion with certificates issued to staff confirming they have completed the course to the standard required. It was noted from the training record provided by the home that only two staff had attended a course on diversity and cultural awareness, in October 2000 and May 2004 respectively. This topic is seen as one of importance given the diversity of need and different cultural backgrounds from which residents may have come. The deputy manager stated that arrangements were in place to improve and update training for staff and to include specific topics, which are relevant to the resident group. All staff must have an awareness of how to respond and deal appropriatley with diagnosed health needs/medical conditions (e.g. autism) of existing and prospective residents who are to be cared for. Staff felt the acting manager was approachable and there was an openness within the home to enable issues to be discussed, which gave reassurance to staff. Other staff had worked in the home for many years and sometimes found it difficult to adapt to changes, which had occurred. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 & 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Management systems have improved and the home is run in the best interests of residents. The management respond robustly and rectify matters of health and safety when identified. Not all maintenance safety certificates were up to date. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 21 EVIDENCE: The acting manager has been in the home for approximately nine months and was given a permanent position in April 2006. An application to be the Registered Manager is still awaited from the Commission for Social Care Inspection. There is evidence to show that the acting manager has brought stability into the home and has worked together with the staff team to develop the service and improve the standard of care in the interests of residents. Responses from some of the health care professionals surveyed, stated that organisation & staffing of the home appears to be much better since a permanent manager has been in place. Many of the policies, procedures and care practices within the home have been updated and the daily operation of the home reviewed which has had positive outcomes for both residents and staff. This process is continuing. The C.S.C.I. have been kept informed of issues relating to the home as required under Regulation 37 of the Care Homes Regulations. The staff team feel valued and welcome the openness and clear communication, which exists. It was noted from the home’s training record, that the acting manager has attended various courses of training but these must be updated to include medication administration and other relevant topics in relation to the needs of the residents being cared for, including health and safety awareness. From sample checks made, financial transactions of residents’ personal allowances had been properly recorded and documented. Risk assessments were in place for a safe working enviroment including access to larder & kitchen, use of knives and outside grounds/security. Reference has already been made in the report under Standard O.P.19 regarding the electrical safety certificate, which expired in July 2005. This must be updated in the interests of safety for both residents & staff. It is over twelve months since the last recorded fire drill took place.There should be evidence that staff (and where possible residents), are aware of fire procedures & fire drills have taken place on a recommended three monthly basis. This is to ensure the safety of people in the building & safe evacuating procedures are in place. The management are currently developing a questionnaire for residents to obtain their views on what it is like to live in the home as part of the quality assurance programme. Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 22 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 Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 23 CHOICE OF HOME Standard No Score 1 2 2 x 3 2 4 x 5 x 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 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 2 ENVIRONMENT Standard No Score 19 2 20 x 21 x 22 x 23 x 24 x 25 x 26 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 3 33 3 34 x 35 3 36 x 37 x 38 2 Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulati on 4&5 Timescale for action The Registered Person must include 31/08/06 in the Statement of Purpose for the home the relevant qualifications & experience of the manager,as well as bedroom sizes. (Sched. 1).The Service User’s Guide must include the amount & method of payment of fees. The Registered Person shall not 01/08/06 provide accommodation to a service user unless their needs have been assessed by a suitably qualified or trained person & a copy of the assessment has been made available. The Registered Person shall make 01/08/06 arrangements for completing the training of staff to prevent residents being harmed or suffering abuse or being placed at risk. This includes making available to staff the latest policy & guidance for reporting issues of this nature. The Registered Person must ensure 01/08/06 that evidence is available in the home for inspection of recruitment Records, including C. R. B. checks. (Previous timescale of 31/12/05 not met). DS0000015444.V298692.R01.S.doc Version 5.2 Page 25 Requirement 2. OP3 14 3. OP18 13(6) 4. OP29 19 Sched. 2 Laburnums 5. OP30 18 6. OP31 8 7 OP38 13(4) 23(2) 8 OP38 23(4) The Registered Person shall, having 31/12/06 regard to the size of the care home, the Statement of Purpose & the number & needs of residents, ensure that at all times, suitably qualified, competent & experienced persons are working at the care home in such numbers as to meet the needs of residents. All staff must receive training appropriate to the work they are to perform. The Registered Person must 14/08/06 arrange for a completed application form for registration to be submitted to the C.S.C.I. in respect of the newly appointed manager. (previous timescales of 7/02/05, 31/07/5 & 31/01/06 not met). The Registered Person must ensure 30/09/06 that all parts of the home to which residents have access are so far as practicable, free from hazards to their safety.Electrical & other safety/servicing certificates must be maintained up-to-date.The premises must be of sound construction & kept in a good state of repair,including completion of damp proofing in the conservatory.(OP 19 also refers). The Registered Person shall ensure 31/07/06 that fire procedures are up-to-date & adequate arrangements are in place for evacuation & that fire drills take place at regular intervals. 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 OP10 Good Practice Recommendations The Registered Person should arrange for staff to receive DS0000015444.V298692.R01.S.doc Version 5.2 Page 26 Laburnums 2 OP33 training in non-verbal communication. The Registered Person should, as good practice, continue the process of updating policies & procedures in the home which are relavant to resident’ needs & following reviews of the service provided.(O.P. 14 also refers). Laburnums DS0000015444.V298692.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. 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