Inspection on 21/06/06 for Kallar Lodge

This inspection was carried out on 21st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Kallar Lodge 31/10/05

Kallar Lodge 09/08/05

Kallar Lodge 15/02/05

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

CARE HOMES FOR OLDER PEOPLE Lake Rise 75 Gregory Road Chadwell Heath Romford Essex RM6 5RU Lead Inspector Mrs Sandra Parnell-Hopkinson Unannounced Inspection 19th June 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lake Rise DS0000040415.V300781.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. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lake Rise Address 75 Gregory Road Chadwell Heath Romford Essex RM6 5RU 020 8270 6750 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) London Borough of Barking & Dagenham Ms Carol Ann Darkins Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2005 Brief Description of the Service: Lake Rise Residential home is operated by the London Borough of Barking & Dagenham and is located in a residential area within the Padnall Estate. Care is available to 37 older people over the age of 65 years. The accommodation is split between 3 floors and has a passenger lift. The first and second floor each have their own communal lounge and kitchen area, all bedrooms are single with an en suite and are used by permanent residents. The third floor is dedicated for use as an intermediate care unit for those older people requiring a degree of rehabilitation following discharge from hospital but prior to returning home. The accommodation on this unit is provided in bed sits each with a small kitchen and an en suite. In addition there is a large lounge on the ground floor which is used for social events for all residents and as a private visitors room. All rooms are spacious and have TV points and a call system in place. The rear garden is with disabled access to the grounds and there are car parking facilities at the front of the property. The home is situated close to local services and facilities which are easily accessible by car and public transport as is the M25 and A12. The care home is linked to a sheltered housing complex which is separately operated by the local authority’s housing department. At the time of the inspection the fees were £545. per person per week, and the statement of purpose, service user guide and latest inspection report can be obtained on request from the home. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 21st June, 2006 over 6.5 hours and commenced at 10.00 hours. The visit included discussions with the registered manager, the deputy manager, staff, relatives, residents and visiting health professionals. A tour of the premises was also undertaken. Questionnaires were sent out to both a random selection of residents, staff, social care professionals and health professionals. Generally the service provided at Lake Rise is good and it was evident from observation, discussions and case tracking that service users’ interests are of the prime importance to the manager and her staff. The home generally conveyed an impression of calm and staff were constantly smiling and interacting with service users. Feedback from both residents and relatives was that the home provides an excellent service. It is important that the registered manager becomes more involved in the service being provided on the intermediate care unit, since she is the registered manager for the whole of Lake Rise and is responsible under the Care Homes Regulations. What the service does well: What has improved since the last inspection? A different format for care plans has been introduced for all permanent residents, and these are now much more detailed and are used by staff as a working document. It was evident that residents are now actively involved in the development of their care plans. Reviews are being done monthly or sooner if necessary. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 6 Medication administration, policies and procedures on both Willow Walk and Mallard Way have improved following the recent visit by the Pharmacy Inspector. 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. Lake Rise DS0000040415.V300781.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 Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although each resident has an assessment of need prior to admission, and is given a copy of the current statement of purpose, service user guide and statement of terms and conditions, work is still in progress on developing the information given to residents to ensure that they have a very clear understanding of what they can expect if deciding to live at Lake Rise. EVIDENCE: The statement of purpose and service user guide has been revised but still needs more work to ensure compliance with the Care Home Regulations. A copy of the Commission’s guidance on The Statement of Purpose has been sent to the manager to enable her to develop a comprehensive document. It was evident from case tracking that residents are given a copy of the statement of terms and conditions, and a welcome pack is put into each Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 9 bedroom. Information on the services and facilities provided by the home are produced in large print formats. A full assessment of needs is undertaken by the manager or her deputy prior to admission to the home to ensure that the services offered can meet the needs of the prospective resident. During discussions with residents and relatives it was apparent that the opportunity to spend time in the home prior to admission is given and one resident said “the visit made up my mind that I wanted to live at Lake Rise, everybody was so pleasant.” However, it was not evident that the manager can always ensure that the home can meet the needs of residents admitted to the Intermediate Care Unit. Often the decision is made by health care professionals or senior officers within the local authority. The registered manager is ultimately responsible for the residents at Lake Rise, and she must ensure that staff have the skills and experience to meet the assessed needs of the prospective resident. It is essential that the manager or her deputy are fully involved in the decision making process for admissions to the Intermediate Care Unit, and that information is shared, views, opinions and comments are listened to and fully debated before agreement is given for the admission. The Care Home Regulations 2001 have been amended with effect from the 1st September, 2006 for new residents, and for existing resident with effect from the 1st October, 2006 so that more comprehensive information is to be included in the service users’ guide. Details of information to be included are contained within the amended regulations. Therefore, the service users’ guide must be reviewed and amended by the stated timescales. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. On Willow Walk and Mallard Way units the residents’ health, personal and social care needs are set out in individual care plans and health care needs are fully met. These residents are also protected by the home’s policies and procedures for dealing with medicines. However this is compromised by the current practices operated on the Intermediate Care Unit where the home’s management team appear to have little control. This is to the detriment of residents and staff on this unit. EVIDENCE: The manager and her deputy have worked extremely hard to ensure that the new care plan format has been put into operation and is now being implemented on both Willow Walk and Mallard Way. Care plans are now a working tool and used by care staff to ensure that the assessed needs of residents are better met. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 11 It was evident from case tracking and from discussions with several residents that they were very involved in developing their own care plans with the deputy manager. Risk assessments were in evidence and both risk assessments and care plans are reviewed on a monthly basis or sooner if needs change. During discussions with the deputy manager it was agreed that she would include ethnic and cultural needs as well as religious needs, and would also include communication as a separate area of need. Also from case tracking it was evident that residents have access to health professionals when necessary, and there was evidence of routine visits by an optician, dentist, chiropodist and GP. The inspector also had the opportunity to talk with a visiting GP and district nurse, both of whom said that they had no problems at the home, residents always appeared well dressed and cared for, and had good working relationships with the management and staff. One resident said that the staff “were absolutely wonderful, nothing was too much trouble and they always knock on my bedroom door before coming in.” Another said that “they always treat me with respect and are always gentle when helping me to get washed and dressed.” Staff talked about and were observed to treat residents in a respectful and sensitive manner. They understood the need to respect an individual’s dignity through practices such as in the way they addressed residents and when entering bedrooms, bathrooms and toilets. The home operates a key worker system and talking to residents they found this really helpful. Residents’ personal aids such as spectacles and hearing aids are well maintained as is other necessary equipment to support staff and residents in daily living activities. Following a recent visit by the Pharmacy Inspector the home now works to an efficient medication policy supported by procedures and practice guidance. Medication is administered by senior staff and Medication Administration Records (MAR) charts inspected were found generally to be in good order. However, it is essential that handwritten entries on MAR charts must be signed and dated by the person making the entry, and the entry must also include the source of the information e.g. GP, relative. There is a policy and procedure to ensure that care and comfort are given to service users at the end of their life, and the issue of an end of life care plan was discussed with the manager and her deputy. The inspector is satisfied that this matter is treated with sensitivity when residents enter the care home, and the manager and deputy would be able to judge the right time to discuss Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 12 end of life matters with each individual. The right time may not necessarily be on pre-admission or immediately following admission to the care home. On the Intermediate Care Unit, from case tracking it was evident that residents did not have care plans which covered health and social needs. In fact there were no care plans and no risk assessments in evidence. A visiting occupational therapist said that all of the information was contained in the daily records, on the original assessment and sometimes on the white marker board in the office. One file contained an assessment and care plan relevant to when the resident was discharged from hospital to her own home. This matter was fully discussed with the manager who must ensure that each resident accommodated on the Intermediate Care Unit has a detailed and comprehensive care plan covering both health and social needs, together with the necessary risk assessments emanating from the care plan. The inspector was told by the occupational therapist that each resident on the unit had an allocated care manager, and it may be that that person is responsible for ensuring that residents are admitted with a comprehensive care plan and risk assessments. At the present time therapists are visiting the unit almost daily and have regular contact with both care workers and residents, but in the very near future this practice will cease and therapists may only visit once or twice a week which will make it even more necessary to have comprehensive care plans in place which are regularly reviewed and updated for the benefit of both residents and care workers. Medication administration on this unit is not in accordance with the policy and procedures of the care home, and current practices put both staff and residents at risk. During the inspection the inspector informed the manager and her deputy that no member of staff was able to administer medication unless they had received adequate and appropriate training, and were deemed to be competent. Any resident who had been risk assessed as able to selfadminister medication must only be able to do so within the boundaries of the home’s policy and procedures on self-medication. Relatives could not fill dosset boxes and then expect members of staff to assist with the administration of the medication. From the date of this inspection the inspector was assured that the administration of medication on this unit would be undertaken by either the manager, deputy manager or another senior member of staff who had been appropriately trained. However, from discussions with staff and some residents the inspector was satisfied that the health needs of residents on this unit are being met. It is essential that the manager ensures that this unit operates in accordance with the Care Home Regulations, and that she is fully aware of the practices being undertaken on this unit since she is the registered manager and is ultimately responsible for the health and safety of both staff and residents. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle experienced in the home generally matches their expectations and preferences and satisfies their social, cultural and religious needs. However, although some general activities are organised for all residents, activities should be more individually based to the benefit of all residents, especially those with a cognitive impairment. Whilst the menus appeared wholesome and nutritious, more could be done to meet the preferences of residents. EVIDENCE: It was evident from observation and discussions with residents and staff that activities are organised for all residents at Lake Rise. The previous day to the inspection there had been an entertainer at the home, and from the programme advertised at various points throughout the home it was evident that there were activities organised for later in the year. On Saturday, 24th June 2006 the home was holding a summer fete to which both residents and relatives had been invited. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 14 However, although some small group activities do seem to happen it is essential that care workers endeavour to involve all residents in social activities. Some of these have been identified in care plans and these now need to be put into practice. Some residents have a cognitive impairment and activities for these people need to be of a short time span because of lack of concentration. The Alzheimer’s Society is a very useful resource for information on the provision of appropriate activities for those with short term memory loss or a cognitive impairment. Residents spoken to did say that often it was “boring” because they just say in chairs. The inspector was advised that several members of staff have been on a training course around activities, and the manager must ensure that this training is cascaded to all care workers so that activities in the home can be more motivating and meaningful for residents. The inspector was able to talk with the locum chef and it was evident that there was a programme in place of four weekly menus. He was aware of the likes and dislikes of certain residents and of special dietary needs. However, on the day of the inspection it was not possible to provide the meal as per the menu since “sausages” had not been ordered. An alternative was prepared and offered to residents. The contracts for the provision of food are undertaken by a central purchasing department within the local authority, and the home is not able to make local arrangements with, perhaps, more appropriate suppliers or for emergency provisions. Since there is a four weekly menu programme, there should be no need for supplies not to be in stock. The inspector also understands that the average allocation for meals per day per resident is in the region of £1.77 - £1.80 per day. However, the inspector was satisfied that often the food budget for the home is overspent but there is little flexibility within the budget. The registered persons’ attentions are drawn to the Commission’s report Highlight of the day? Improving meals to older people in care homes. A copy of the checklist attached to this report was given to the manager during the inspection. The tables were nicely laid for lunch and the dining areas are congenial and residents were not hurried to finish the meal. However, some residents told the inspector that “the lunch was not very nice to-day and they didn’t like either of the choices.” Two residents had asked for an egg which was not provided and, therefore, they only had chips. One resident said that she liked a salad but that these were not often on offer. It is important to offer people a real choice because many residents don’t want to make a fuss or don’t know they have a choice or can’t express a choice. Often the alternative is the same, perhaps an egg or a sandwich. It was evident that drinks were freely available. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 15 Nutritional and dietary monitoring is undertaken on admission and then on a monthly basis with records being maintained of a person’s weight. Any changes are monitored and necessary referrals made to a health professional. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The 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 policy and procedure for addressing complaints and concerns and residents are confident that they will be listened to. Residents are also protected from abuse by the policies and procedures of the home, and through staff training and supervision. EVIDENCE: Because it is part of a local authority, the home currently uses the form provided with regard to the main local authority’s complaints procedure. However, in accordance with the Care Home Regulations it is a requirement that the complaints procedure initially operated by a care home must be in line with regulation 22. This is a requirement which has previously been made and will be reiterated in this report. If, following investigation through the home’s complaints procedure a complainant is not satisfied then he/she will have recourse through the local authority’s social services complaints procedure and/or through the Commission for Social Care Inspection if appropriate. However, from talking with relatives and service users, and from viewing the complaints record, the inspector was confident that all concerns are dealt with Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 17 in an effective and positive manner by the manager. One relative said that “I really haven’t found anything to complain about, but the manager’s door is always open.” From discussions with staff and from viewing training records, it was evident that adult protection training is being delivered to staff and they were very aware of the need to ensure that service users are safeguarded from physical, financial/material, sexual abuse, neglect, inhuman or degrading treatment. Service users and relatives spoken to said that staff were always kind and caring and treated them with respect. From discussions with the manager it was evident that any allegation would be followed up promptly and necessary action taken. From viewing financial records and discussions with the administrator, the inspector was satisfied that the home’s policies and practices regarding service users’ money and financial affairs ensure that the interests of service users are safeguarded at all times. Where items are purchased on behalf of service users receipts are obtained and retained on file with appropriate records being kept. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24 25 and 26 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a warm, clean and homely environment with individually personalised bedrooms which are spacious and have en suites. However, some health and safety issues are compromised due to current access arrangements for the adjoining sheltered housing unit. EVIDENCE: Many areas at Lake Rise have been redecorated, and these include the corridors, all of the bed sits on the Intermediate Care Unit and the communal bathrooms. On the day of the inspection the home was clean, airy and free from any offensive odours. All of the bedrooms are large with their own en suite of toilet and hand basin. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 19 The inspector was able to talk to several residents in their bedrooms, and they all said “they had lovely rooms” and these had been individually personalised. Visiting relatives also said that “they thought the home was really nice and clean and there were never any awful smells.” The communal bathrooms were in the process of being redecorated, and all of the toilets were equipped with soap, paper towels and toilet rolls. Bath taps have now been fitted with temperature control valves. The call alarms were in situ in all of the bedrooms visited by the inspector and were within easy reach of the beds and armchairs. The communal lounges and dining areas on both Willow Walk and Mallard Way were nicely furnished and decorated, as was the Lake Lounge on the ground floor. Lake Lounge is used for entertainment activities which involve the three units and is also used as a quiet lounge by visitors. This lounge can also be booked for family occasions by arrangement with the manager. The accommodation on the Intermediate Care Unit is in bed sits each with a small kitchen and en suite. All of these bed sits have been re-decorated and furnished to a good standard. The unit is also equipped with areas designated for rehabilitation work undertaken by occupational and physio therapists. There is also a communal area where residents can sit and socialise if they so wish. The kitchen was visited and was clean and well maintained. Frozen, chilled and dry goods were appropriately stored and labelled. The locum chef was fully aware of food hygiene requirements. The laundry area was clean and well maintained and the laundress was aware of COSSH regulations and when to use protective clothing and goggles. There remains an issue with the adjoining sheltered housing unit and the need of some of the tenants in that unit to access the lift in Lake Rise in order that they can reach their flats. Those tenants have key fobs which they and their visitors can use to enter and exit the care home. However, the staff in the care home have no knowledge of whether these tenants are in or out of the care home since they do not have to sign in, whereas any other visitor to the care home enters through the front main door where there is a staff and visitor signing in book. This is essential in the event of an emergency such as a fire. It is, therefore, not acceptable that key fobs are held by people with no connection to the registered care home and alternative arrangements must be made by the registered persons with the tenants and the local authority housing department. One solution is that a doorbell is sighted between the sheltered housing unit and Willow Walk and between the sheltered housing unit and Mallard Way, and tenants from the sheltered housing unit are then Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 20 accompanied by a member of staff to/from the lift and then to the entrance to/exit from the care home. Arrangements also need to be reviewed around the joint fire alarm. Because the fire brigade view the whole complex as one building the alarm when triggered by someone in the sheltered housing unit rings throughout both buildings, and the indicator panel is situated in the residential care home. From discussions with the manager and deputy, it is obvious that the fire alarm is often triggered by people in the sheltered housing unit, and because the warden only works limited hours this is impacting on the care home. It is also causing distress to some residents who become very anxious in case it is a fire. Again the registered persons must review this arrangement and arrive at a solution which will not cause distress to the residents of the care home. Lake Rise DS0000040415.V300781.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff, together with a robust recruitment policy and practices, and the provision of ongoing training ensures that residents are protected and in safe hands at all times. EVIDENCE: On the day of the inspection the staffing numbers and skill mix were appropriate to meet the assessed needs of residents and had regard to the size and layout of the care home. In addition to care staff ancillary staff were in evidence in the kitchen, laundry and in other parts of the care home. 95 of staff now have the NVQ level 2 and several are undertaking the NVQ level 3. In discussions with staff it was apparent that this training had positively changed the way in which they viewed the service and residents, and it was evident that they understand and fully support the main aims and values of the home. There was evidence from training records that this is now a priority for the staff who have attended adult protection, violence and aggression, food hygiene, medical emergencies, dementia awareness and manual handling. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 22 Personnel records were viewed and the inspector was satisfied that the recruitment processes are robust with application forms being completed, interviews being undertaken with notes being maintained, appropriate references being obtained together with enhanced criminal records bureau disclosures. There are occasions when agency staff are used and the manager tries to ensure that consistent staff are engaged and that the necessary robust recruitment procedures have been implemented by the employment agency. Lake Rise DS0000040415.V300781.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a committed staff team who have the skills and training to meet their needs. Monitoring visits are undertaken regularly by a person, delegated by the responsible individual, to monitor and report on the quality of the service provided. However, these visits need to include the intermediate care unit to ensure the quality of service to residents accommodated on that unit. EVIDENCE: The management approach of the home creates an open, positive and inclusive atmosphere and it was obvious that “an open door” policy applies. However, with the long term sickness of a senior member of staff, the manager and her Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 24 deputy have had to work hard to ensure that the service to residents has not been affected. The inspector was told by some residents and relatives that “the office door is always open and any problems are always dealt with immediately.” It was evident from viewing staff records that permanent staff are now receiving regular supervision, but this must be extended to agency staff employed at the care home because whilst working at the home they are also subject to the requirements of the Care Home Regulations. Regulation 26 visits are undertaken on a regular basis to check the quality of care being provided but these need to be extended to include the intermediate care unit which is also a part of the registered premises. These visits also include asking residents and their relatives and staff what they think about the service offered at Lake Rise. In addition to these visits the manager also undertakes quality monitoring through residents’ meetings and surveys to residents and relatives. To comply with health and safety requirements, magnetic door closures activated by the fire alarm have been ordered for bedroom doors and these should be fitted in the very near future. In the meantime fire doors are not to be wedged open. Residents’ finances are managed either by the local authority as the appointee, or by relatives. Some small amounts of money are held but receipts are obtained for any expenditure and accurate records maintained by the administrator. Maintenance records such as fire alarm testing, gas, electrics, lift maintenance and water supply were viewed and found to be in good order. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 3 2 3 STAFFING Standard No Score 27 3 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 2 3 3 Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 &5 Requirement The registered manager must ensure that the statement of purpose and the service user guide complies with the regulations. The registered manager must ensure that care plans are in place for all residents accommodated on the intermediate care unit The registered manager must ensure that the home’s policies and procedures on medication administration are extended to the residents accommodated on the intermediate care unit The registered manager must ensure that there is a varied programme of activities having regard to the individual needs of residents. The registered manager must ensure that the meals provided meet the preferences of residents. The registered persons must ensure residents are protected by the introduction of alternative arrangements for those tenants DS0000040415.V300781.R01.S.doc Timescale for action 31/08/06 2. OP7 15(2) 31/07/06 3. OP9 13(2) 30/06/06 4. OP12 16 (m)(n) 31/08/06 5 OP15 16(i) 30/06/06 6 OP25 23 31/08/06 Lake Rise Version 5.2 Page 27 7 OP36 18(2) in the sheltered housing unit needing to access the lift in the care home. (This requirement is restated from previous inspection reports) The registered manager must ensure that all persons working at the care home are appropriately supervised. 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP7 OP7 OP12 OP15 OP30 Good Practice Recommendations It is recommended that the care plan document be used as one live working document. It is recommended that the food intake of all residents is recorded to monitor nutritional intake. It is recommended that more hours are designated to social activities and day trips and the weekly rota of activities is available to residents throughout the home. It is recommended daily menus are readily available for residents and relatives to view within the home. All staff training records are kept up to date. Lake Rise DS0000040415.V300781.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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