Inspection on 30/10/07 for Life Care Home

This inspection was carried out on 30th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Life Care Home 27/04/06

Life Care Home 15/11/05

Life Care Home 25/07/05

Life Care Home 25/05/05

Life Care Home 19/01/05

Life Care Home 13/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Life Care Home 31 Cressingham Road Reading Berks RG2 7RU Lead Inspector Delia Styles Unannounced Inspection 30th October 2007 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lifecare Home DS0000011253.V346743.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. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Life Care Home Address 31 Cressingham Road Reading Berks RG2 7RU 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) 0118 9866371 0118 9346872 lifecarehm@hotmail.com Mr S S Ahluwalia Miss Sevinj Hashimova Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That provision is made for one service user aged under 65 years of age, identified in the application form dated 21.2.05, to be resident in the home. 27th April 2006 Date of last inspection Brief Description of the Service: Life Care is a residential home providing accommodation and personal care for sixteen older people, of both sexes. The home is situated in a residential area approximately 2 miles from Reading town centre. There are local shops including a post office, hairdresser, general store and off licence. The home is on a local bus route. There are five ground floor and nine first floor bedrooms, accessed by a lift. One ground floor bedroom has en-suite facilities and one of the first floor bedrooms is a double room. All bedrooms have washbasins. The current fees range from £356 to £600 per week. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’ during which we assessed a number of the standards considered most important (‘key’) by the Commission, out of the 38 standards set by the government for care homes for older people. The inspector arrived at the service at 11:20 am and was in the service for 5½ hours. This inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s managers in the form of the Annual Quality Assurance Assessment (AQAA) - a selfassessment and summary of services questionnaire that all registered homes and agencies must submit to the Commission each year; and any information that the Commission had received about Life Care since the last inspection. The inspector saw all areas of the home and looked at records and documents relating to the care of the residents. The inspector spoke to a number of residents and staff during the visit. The inspector also asked the views of the residents, relatives and health and social care professionals about the home, through questionnaires (comment cards) that the Commission had sent out and some of their comments are included in the report. A total of 8 residents, 1 relative and 1 health care professional completed comment cards. The home’s registered manager, Ms Sevinj Hashimova was available during the inspection visit. The registered provider, Mr Sats Ahluwali joined us during the afternoon. The inspector fed back to the managers at the end of the day’s visit. We would like to thank all the residents, manager and staff for their welcome and assistance both on the day and in taking time to complete questionnaires. What the service does well: This home provides a safe, comfortable, clean and homely environment for residents. Staff are kind, patient and attentative towards residents. Some of the written comments from residents included: ‘I would like to say all [the staff] are perfect and helpful’; ‘The staff are good’; ‘the staff are very good at keeping me contented’. The home works hard to put into practice its stated aims and objectives of care for the people who live here. The residents are encouraged to give their opinions about how the home is run, including the meals and activities provided, and the manager and staff act on peoples suggestions. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 6 The home has a good training and development plan for staff and staff are encouraged to learn and share their experiences with others, to improve the quality of care for the people who live here. The provider and manager are enthusiastic and committed about improving the home’s environment and the facilities for residents. The home has good links with local NHS and social services so that residents’ health care needs are met. Comments made by a healthcare professional indicated that Life Care Residential Home is good at ‘joint working with other professionals and agencies. [Residents’] care records are readily available. [There is a] generally caring and welcoming atmosphere’. What has improved since the last inspection? What they could do better: We found that the home meets the needs of the people who live here well. The manager and homes owner are committed to maintaining and improving the standards further and have identified and planned how they will do this. We have made just three good practice recommendations on this occasion. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 7 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. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply, as the home does not provide intermediate care. Quality in this outcome area is good. Prospective resients and their representatives have the information they need to decide whether the home is likely to meet their needs. The personalised needs assessment mean that peoples diverse needs are identified and are planned for before they move into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has updated the written information about the home contained in the Statement of Purpose and Service User Guide. This is made available to current and prospective residents. In addition, a clearly written and illustrated Information Guide has been produced and is given to each person. This is available in large print for people with visual impairment. The manager confirmed that she assesses all prospective residents before offering them admission. She has developed a ‘pre-information’ form that includes other professional carers who may be involved in prospective resident’s care, for example community nursing staff. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 10 Prospective residents and their families are invited to visit the home and have tea or lunch so that they can meet other residents and staff and discuss their views and experiences. A sample of residents’ admission assessment information looked at included the manager’s assessment and that of care managers and social workers currently involved in the residents’ care Only one of the 8 residents who completed the questionnaires sent by the Commission said they had received a contract; 5 people ‘could not remember’ having seen a contract, but three were aware that their relative had signed on their behalf. Four of the 8 residents felt they had enough information about the home before deciding to move in; four people stated they ‘could not remember’. However, 12 of the 16 residents have lived here for more than 12 months and it is likely that the sample of people surveyed could not remember the details of their contracts and information they received over time. We checked a sample of residents’ records and found that they had signed contracts setting out the terms and conditions of the fees, facilities and accommodation for the home. Each resident has a key worker allocated who has the responsibility of discussing and explaining their contract of care. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The staff have a good understanding of residents care needs and care is offered in a way that promotes and protects residents privacy, dignity and independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at a sample of residents’ care records and plans of care. The home has just invested in a new system of commercially produced documents to record all the assessments and care needs of residents. The manager said that the staff have had some training in how to complete these written records, but acknowledged that some further work is needed to improve the written detail of what care staff need to do to in practice to meet residents’ assessed care needs. More information should be included in the evaluation of care records i.e. to what extent has staff interventions met the person’s assessed care and support needs and if not, what changes in their care have been made. For example, one resident had been having increased episodes of aggressive behaviour; their care plans did not show what actions staff should take to help Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 12 the resident to communicate the reasons for their anger and how to reduce the risk of injury or distress to other residents and staff. The manager explained that a community nurse and the doctor had been involved in assessing and reviewing this person’s care with good outcomes - the individual was now settled and joining in with other residents and the life of the home as much or as little as they wished. Each resident has a key worker – a suitably experienced carer who is allocated to coordinate the care and update the written care records for a number of residents. Key workers are responsible attending review meetings with the resident, and their family or representatives, to make sure that the home continues to meet the needs and the life style preferences of the resident. Five out of the 8 residents who completed comment cards feel they ‘always’ receive the care and support they need and 3 residents that this is ‘usually’ the case. Seven out of 8 residents feel they ‘always’ receive the medical support they need; and one that this is ‘usually’ so. The manager has undertaken approved training to assess residents who have continence problems; this has improved the speed of the process needed to make sure that residents are supplied with the correct continence aids. The home has accessed training and information from services such as the falls prevention specialist to advise residents and staff about how to avoid falls. A dietician was commissioned to recommend improvements to the menus to add to the nutritional content and balance of meals. It is evident from the homes AQAA and discussion with the manager and homes owner that a great deal of thought and consideration is given to how the home can meet residents’ needs in a ‘person-centred’ way and the commitment for promoting equality and diversity for all the people who live and work here. From the evidence seen and comments received, we consider that this home would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. The practices and procedures for the storage, management and administration of medication are good. Residents’ prescribed medicines are dispensed from a local large high street chemist chain in individual cassette boxes with compartments filled with the medications for each time of day. All care staff who are responsible for administering medicines complete an accredited training course and are routinely assessed in their practice by the manager and her deputy to ensure that they maintain their competence. We felt it was commendable practice that the manager had written a brief description of each resident’s medication and its purpose, to help staff to explain to residents about their medicines when questioned by them. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 13 The manager said that she hopes to encourage the GPs to review residents’ medication more frequently: this will ensure the effectiveness of residents’ treatment is checked and should keep the number of prescribed medicines to a minimum. The homes stated philosophy of care emphasises the aim for people who live here to do so ‘with dignity, have the respect of those who support them and be entitled to live a full and active life, given the fundamental right to selfdetermination and individuality’. In discussion with residents and from information provided by residents’ surveys in was evident that residents do feel respected and that their right to privacy is safeguarded. All 8 of the residents who completed comment cards answered ‘yes’ to the question ‘Do the staff listen and act on what you say?’ The managers are considering the impact of the Mental Capacity Act on their practice, for example, how they will need to uphold residents’ rights to self determination and to access independent mental capacity advocates in relation to admission procedures and care reviews. We observed that staff knocked on residents’ room doors before entering and were polite and kind in their conversation with individuals. We noted that most of the bathroom and lavatory doors did not have ‘engaged/vacant’ indicators, so that if residents or staff forget to lock doors when residents are receiving personal care, there is a potential risk that others may open the doors, compromising the user’s privacy and dignity. The home should add signs or engaged/vacant signs to the doors of shared facilities and consider fitting privacy curtain screens where bath and shower rooms open directly onto corridors. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. There are a variety of activities organised within the home and wider community so that residents have a range of opportunities to take part in stimulating and motivating activities to suit their abilities and interests. Mealtimes are flexible to meet individuals different needs and preferences. The meals are good and offer choice and variety and cater for residents special dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The range and focus of activities provided in the home have continued to improve. Of the 6 residents who answered a survey question about their satisfaction with the activities arranged by the home, 3 felt there is ‘always’ something that they can take part in, and 3 that this is ‘usually ‘ so. Two people added that they prefer to watch TV in their room or go out. It was evident that the manager and staff support residents to be involved in hobbies and practical activities around the home that interests them. One person wrote of their enjoyment of gardening, and tidying up and setting the tables. Another person appeared to be content with their own company and pastimes, commenting ‘Who wants the activities at 90 ?’ Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 15 Several residents mentioned their enjoyment of the church services held in the home. The home has the use of a car and driver who can take a few residents for trips out into the local community and to shops. The home’s AQAA document states that they plan to improve the activities and social life for residents by the appointment of a full time activities manager who will plan and organise individual and group activities. The activities manager will support and train staff to provide activities at different times of the day. It is hoped that community groups will become more involved with projects for the home, for example, garden design. There are plans to include a sensory room in the new extension planned for summer 2008, and develop more activities suitable for residents who have dementia. The home is considering providing a computer with Internet access for residents’ use; this will encourage residents to learn and develop new skills, and to access information about local activities, global news and to receive and send e-mails. The homes owner recently commissioned a dietician to review and advise the home about the menu choices and nutritional needs of residents. This has led to the manager and cook changing the menus, in consultation with the residents. An illustrated Menu Booklet about the meals on offer and showing the various nutritional values had been produced by the homeowner for each resident to have in their room. The cook confirmed that fresh fruit and vegetables are delivered to the home and form an integral part of every meal. The cook makes a point of sitting with each service user on a regular basis to ascertain their views about the food provided. We noted that residents’ individual preferences about where they eat – in their own room, dining room or sitting room – are respected, and timing of meals is flexible. There was evidence that the nutritional needs of residents who are assessed as being ‘at risk’ of malnutrition are monitored carefully; diet supplements and the staff attention to helping people eat a balanced diet has improved their health and wellbeing. The Commissions survey responses completed by 8 residents showed that 3 people ‘always’ like the meals; 4 people ‘usually’ and 1 person ‘sometimes’. Lifecare Home DS0000011253.V346743.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good The home has a satisfactory complaints system and the practices and procedures in place ensure that residents feel their views are listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes complaints policy is clearly written and provides clear stages and timescales for investigation by the home and responses to complainants. A central log is maintained which indicates the outcome for all complaints. Residents and their representatives are made aware of the complaints procedure. All 8 of the residents’ survey answers indicated that they are confident about whom to speak to if they are not happy (the manager, senior carers or ‘boss’ were mentioned) and all know how to make a complaint. Feedback on all aspects of the service are encouraged and actively sought through regular review meetings with individual residents, family member or representative, their key worker and the manager. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The homes own records showed that they have had 2 complaints in the last 12 months (the last being in April 2007) and these had been satisfactorily resolved. All the homes staff have had training about how to identify and report suspected abuse (Safeguarding of Vulnerable Adults). We spoke to 2 staff Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 17 members who confirmed this; they have a sound understanding of the principles and potential for abuse, but were less confident about the practical process for reporting suspicions other than directly to the manager or proprietor. We suggest that staff training should include discussion of scenarios where managers might not be immediately available, and the contacts and procedures for staff to follow in the event of an incident of alleged abuse in the home. Training and information is provided through East Berkshire Social Services. New care staff have training as part of their induction through Skills for Care. All staff receive copies of the General Social Care Council (GSCC) Codes of Conduct that set out the standards expected of employers and employees involved in social care. Lifecare Home DS0000011253.V346743.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The standard of the environment within this home is good providing residents with an attractive and homely place in which to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided by the home in the AQAA document confirmed that equipment in the home is serviced and maintained appropriately. We found that the home was clean and tidy throughout. In the last 12 months the home has been redecorated and new carpets fitted in the sitting rooms and corridor areas. Residents’ bedrooms were attractively decorated and personalised with their own possessions, ornaments and small pieces of furniture. Residents spoken with confirmed their satisfaction with their rooms and how they are kept clean and comfortable. Seven of the 8 resident’s stated in the surveys sent by the Commission that the home is ‘always’ fresh and clean and one that this is ‘usually’ so. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 19 The home is planning a purpose built 19- bedroom extension to be built during 2008. The new building work programme will include an extension to the lounge, bedrooms and office areas and renovation in the existing home. The laundry room is clean, tidy and well organised. The washing machine was out of order at the time of the inspection, but an engineer was booked to repair it. In the meantime, laundry work was being done at Mulberry House (another residential home owned by the proprietor nearby). All staff receive infection control training and there were plentiful supplies of disposable gloves and aprons and separate hand washing facilities for staff use. Fabric towels for hand drying are provided in shared bathrooms and lavatories. Ideally, disposable paper towels should be provided to reduce the risk of cross-infection from shared fabric towels. However, the manager said that the hand towels are changed very frequently to maintain a high standard of hygiene. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. There is a good match of well-qualified staff offering consistency of care to residents. The recruitment and training practices of the home are good, so that residents are safeguarded from potential risk from unsuitable or poorly trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is fully staffed and staff turnover is very low so that residents benefit from having continuity of care from a familiar and well-trained staff team. The home does not use agency staff. The recruitment records showed that the home’s policies and procedures are rigorous and the home follows up references and obtains confirmation of satisfactory Criminal Records Bureau (CRB) and PoVA checks before employing people to work at the home. The homes AQAA information shows that the appointment of a deputy manager has improved the supervision of residents’ care and staff members. The interview policy and procedures have been reviewed and strengthened. The home is looking at ways of involving residents in the recruitment of new staff in future. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 21 The home uses a commercial consultancy to provide up to date Human Resources and employment advice and has achieved the Investors in People award. There are regular staff meetings and key worker meetings where issues affecting individual residents’ care can be discussed. All staff receive regular supervision and a programme of annual appraisals for staff is in place. Seven of the 13 permanent care staff employed have achieved National Vocational Qualification at Level 2 and one person is working towards Level 3. These means that home exceeds the 50 target for NVQ trained staff. The deputy manager is also attending NVQ Level 4 in Care and the Registered Manager’s Award course. Staff attend regular training both in-house and external sessions that cover a range of topics including safe moving and handling, First Aid, fire safety, infection control and safe food handling and food hygiene. Additional training has been provided for staff in caring for people with dementia. Staff are expected to do a short presentation to their colleagues about what they have learned at any external training sessions they have attended. This encourages better communication of good practice and ideas to others in the team. There are plans to install e-mail and access to the Internet for staff use in the next 12 months, to further improve learning and information sharing between staff and external training organisations, for the benefit of residents’ care. Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 22 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 and 38 Quality in this outcome area is good. The manager is supported well by the provider and senior staff in providing clear leadership to staff. Residents views about how the home is run are actively sought and are acted upon so that the home operates in the best interests of the people who live here. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was substantial evidence that the registered manager, Ms Sevinj Hashimova, is very well qualified for her role and has made a positive impact on the running of the home. She has achieved NVQ Level 4 in Care and the Registered Manager Award (with distinction) and completed a course in Leadership Skills. Both staff and residents complemented her, and her qualities and contribution are clearly recognised by the proprietor. She recognises the need to consolidate the improvements and to continue to strive for even better practices. The assessment of the homes current standards, and plans for Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 23 future developments set out in the detailed AQAA document submitted to the Commission. There was ample evidence that this manager is dedicated to running the home with the best interests of the residents as the central focus. She spends time talking to residents and encourages all staff to do so. The proprietor acknowledged that he has not been completing the monthly unannounced ‘provider visits’ to the home and making reports of his findings to the manager, as required under Regulation 26 of the Care Standards Act 2001 but confirmed he will comply with this future. All proprietors (Registered Providers) who are not in day-to-day charge of registered establishment must carry out these visits as part of their own quality assurance approach to hearing residents and staff members’ opinions about the standards of care and facilities. The home has updated its quality questionnaire that is sent out to residents and their relatives to improve the information about how it is meeting the needs of the residents and the aims and objectives set out in the Statement of Purpose for the home. There are regular meetings with staff, residents and their relatives to discuss the way the home is run and to hear any suggestions and concerns. There is a clear policy in relation to managing residents’ monies. The manager holds the personal allowances for 4 service users. Comprehensive records are maintained including receipts. The home has made no notifications to the Commission (as required under the terms of Regulation 37) since the last inspection. The manager was asked to check that there had been no reportable occurrences and that the home continues to comply with this requirement Health and safety records are comprehensive. All the homes’ policies and procedures have been reviewed and updated in the past 12 months. The AQAA information provided by the proprietor confirmed that all maintenance checks are undertaken at appropriate intervals and records seen were up to date. The home employs a consultancy firm to act as Health and Safety Consultants and they carry out regular independent checks on a regular basis. A wide range of risk assessments is in place which are reviewed at least annually or when changes occur. The rolling programme of staff training includes health and safety issues. Staff demonstrated a good understanding of the need for clear procedures to ensure that risks to residents and themselves are minimised. Lifecare Home DS0000011253.V346743.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 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 4 X 3 X 3 X X 3 Lifecare Home DS0000011253.V346743.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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations * Continue to improve and develop the system of care plans to ensure that care plans provide sufficient written instruction for staff about the actions that they need to take to ensure that all aspects of the health, personal and social care needs of residents are met. * Care plans should be drawn up with the involvement of the resident as far as possible and should include evaluation comments to show to what extent the person’s care needs have been met by the planned staff support and interventions. Improve the privacy signs in bathrooms and lavatories. Ensure that all staff are familiar with the practical procedures that should be followed by them (in the absence of senior managers) to report allegations and incidents of abuse to the appropriate social services and/or police in line with the published local safeguarding protocols. 2. 3. OP10 OP18 Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Lifecare Home DS0000011253.V346743.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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