Inspection on 25/04/06 for Lime Trees, The

This inspection was carried out on 25th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lime Trees, The 09/11/07

Lime Trees, The 28/06/07

Lime Trees, The 07/11/06

Lime Trees, The 15/11/05

Lime Trees, The 12/04/05

Lime Trees, The 02/11/04

Lime Trees, The 19/05/04

Lime Trees, The 23/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Lime Trees, The 2 The Limes Avenue London N11 1RG Lead Inspector Brian Bowie Unannounced Inspection 25th April 2006 11:00 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 Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 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. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lime Trees, The Address 2 The Limes Avenue London N11 1RG 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) 020 8361 5840 020 8361 8020 Mr Aloysius Onyerindu Ms Nnenna Ekeoma Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Room 11 must not be used for a service user needing a wheel chair Room 12 must not be used for a service user needing two people to transfer as the bed is against the wall. Room 17 to be used as a shared room for a couple of either sex who were previously living together prior to admission. The small quiet room adjacent to be used for the sole use of the couple in that room. The top floor rooms, ie staff sleeping in room; owner’s bedroom; staff room and bath and toilet facilities must be used only by staff. These are not registered for the use of service users. The owner confirmed this address as his permanent address. The home must not admit a service user with a diagnosis of dementia, learning or physical disability or suffering from a mental health illness. Staffing levels must at all times comply with the regulations and that there must be a minimum of two waking staff in the night. 15th November 2005 4. 5. 6. Date of last inspection Brief Description of the Service: The Lime Trees is a privately run care home for up to 16 older people. It is situated in a residential road in New Southgate close to local amenities, shops and public transport. Residents bedrooms are on the ground and first floors. The laundry, office and staff accommodation are on the second floor. A lift serves all floors of the home. There are twelve single bedrooms, some with en-suite facilities, and two double rooms. Communal space consists of a ground floor lounge/dining area with two smaller rooms on the first floor, with a garden at the rear of the building. There are enough bathrooms and toilets in the home for the number of residents. There are some aids and adaptations in the home to help people with physical disabilities get around more easily. However the narrow corridors and sloping floor surfaces means that there are limitations for wheelchair users who wish to be as independent as possible. In April 2006 Mr Onyerindu, the owner of The Lime Trees, said that the fees charged by the home ranged from £377/week up to £ 400/week. The brochure detailing the service provided by The Lime Tress and inspection reports on the home are made available to residents, families and prospective residents. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3 days and lasted 15.5 hours. Brian Bowie, the allocated inspector for The Lime Trees, carried out the inspection. The owner was present throughout and assisted with the inspection. The inspector looked round all areas of the home and spoke to all of the 10 people resident in the home at the time of the inspection. 4 of the residents said what they thought about the home in the privacy of their own bedroom. Relatives and friends of 4 of the residents were spoken to in confidence to get their views and comments on the home. Staff on duty were also interviewed. A variety of records, including care plans, staff files and health & safety documents were looked at. The overall impression is that The Lime Trees is continuing to provide a reasonable standard of care to residents and has a relaxed family-like atmosphere. However a number of important areas relating to the running of the home must be improved urgently. These areas for improving the service were discussed and agreed with Mr Onyerindu. What the service does well: What has improved since the last inspection? The home has improved its policies and records in relation to medication and complaints and tidied up the rear garden. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 6 The owner, Mr Onyerindu, has achieved the NVQ Level 4 award in managing a care home. He is also doing a MSc in Dementia and Ageing in order to increase his knowledge of this area so that the needs of people with dementia can be better met by The Lime Trees. What they could do better: At the previous inspection there had been 12 areas the home had to improve. 4 of these areas have been sorted out. Requirements made to improve the other 8 areas have not yet been dealt with and have been restated in this report, with a new timescale for compliance. In the ‘Timescale for Action’ column, the date in ordinary type relates to the timescale given at the last inspection. The date in bold type relates to the new timescale. Further information about unmet requirements can be found in the relevant section. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. In addition 7 new areas to be improved are identified. In order that residents are supported by suitably qualified and skilled staff the home needs to ensure staff receive training in adult protection, dementia, and have regular training opportunities, including undertaking NVQ Level 2 in caring for older people. In order that the needs of residents are properly met at all times the home needs to achieve the following: • • • Residents’ care plans and risk assessments are reviewed regularly and are kept up to date The programme of daily activities is sufficiently varied and stimulating An occupational therapist assesses the living environment at The Lime Trees so that it is as accessible as possible for residents In order that residents are provided with a good quality service at all times the day to day management of the The Lime Trees must achieve the following: • • The staff rota is accurate and up to date at all times Residents and staff have regular meetings and other opportunities when they can contribute their ideas and comments on the running of the home and suggest improvements Staff are supported regularly and these supervision meetings are properly recorded All record keeping in the home is accurate and up to date DS0000010636.V288164.R01.S.doc Version 5.1 Page 7 • • Lime Trees, The • • Significant events are reported to CSCI without delay Fire safety arrangements in the home are approved by the London Fire & Emergency Planning Authority (LFEPA ) Without these improvements the good care practice that is in place at the The Lime Trees will be weakened and residents will end up with a poorer and less reliable service. 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. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 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 Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 does not apply to this home) Quality in this outcome area is adequate. As a result people moving into the home can be confident that their needs will be assessed and an appropriate plan for meeting these needs will be drawn up. EVIDENCE: The files for 4 of the residents were looked at and indicated that before they moved in a full assessment had been received from Social Services. The Lime Trees had then carried out its own assessment in order to decide if the home could meet the individual’s needs. A care plan had then been drawn up by the home showing how these needs were to be met. The majority of the residents spoken to said that they enjoyed living at the home and thought that their needs were being met. Observation throughout the inspection showed that none of the existing group of residents is inappropriately placed at The Lime Trees. This indicates that The Lime Trees is careful to ensure that it is able to meet the needs of new residents, and does not admit people whose needs it is unable to meet. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. The home is good at meeting the health needs of residents. Residents are protected by the effective and safe arrangements in place in relation to the administration of medication. Staff treat residents with respect and residents can be sure that staff will respect their privacy. The home does not review and update its care plans and risk assessments regularly enough. As a result residents do not get the full benefit of having their needs consistently met at all times. EVIDENCE: The records for 4 residents were looked at and indicated that for each one there was a current plan of care. These set out the needs of the resident and how they were to be met by the home together with relevant risk assessments. However there was insufficient evidence that these care plans and risk assessments are being regularly revised to reflect changes in the resident’s needs. For example care plans had not been updated following annual review meetings where new needs had been identified needs, such as a resident needing to be checked half hourly instead of hourly at night. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 11 In some cases risk assessments had also not been updated, for example to reflect how the home was trying to ensure the safety of a resident who falls over regularly. The manager must ensure that both care plans and risk assessments are updated regularly so that they reflect changes over time and are accurate. ‘I feel I’m cared for beautifully, especially medically- I’m very impressed.’ ‘People are cared for here.’ These were the comments of 2 of the residents. These findings were supported by the views of relatives and visitors, with one relative saying: ‘He’s cared for- his health needs are being looked after.’ The records showed that residents are being weighed regularly and are being seen by dentists, opticians, chiropodists and doctors. Interviews with staff and the owner confirmed that the staff are responding well to the health needs of residents and liaise with other health professionals where appropriate. Medication arrangements were observed and relevant records looked at. Medication is given out appropriately and records relating to the administration of medication were accurate and up-to-date. In one case a relative gave information to staff about a change in medication following a hospital appointment which staff then recorded and followed up correctly when giving out the medication. The medication is stored appropriately with each resident’s medication having a separate shelf within the medicines cupboard. Staff have had training in the administration of medication. One resident commented: ‘I find the staff are very reliable about giving me my medication.’ One of the relatives commented: ‘The medication is always punctual.’ Throughout the 3 days of the inspection staff were observed treating the residents with respect. Staff were seen to provide support discretely at mealtimes if a resident needed some help. Staff were also seen knocking before entering residents’ bedrooms. Interviews with both residents and relatives took place in private areas. One resident prefers to stay in her bedroom and this wish has been respected by staff. As a result residents at The Lime Trees benefit from being treated respectfully and have the opportunity to be private when they wish to be. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 12 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): 12,13,14,15 Quality in this outcome area is adequate. Residents do not have the benefit of a sufficiently organised and stimulating range of social activities. Residents are getting what they expect from the home in terms of the friendly and caring atmosphere. Staff are good at welcoming relatives and friends so that they also feel part of the home. Residents make their own decisions wherever possible about what they do when. Mealtimes are enjoyed by the residents who have a choice about what they eat. EVIDENCE: Feedback from both residents and relatives indicated that both groups particularly appreciated the friendly family-like atmosphere in the home. The home is good at responding to the religious needs of residents. One resident goes regularly to church. For residents who find it difficult to get out a minister comes in from the local church. A former resident had specific cultural needs in relation to his diet and these were provided for by the home. As a result residents feel their religious and cultural wishes are acknowledged and supported. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 13 ‘The Lime Trees does not appear to have many organised activities for its residents.’ This was the comment of one of the resident’s social workers about the home. One resident commented: ‘I’d like to see more activities especially for those residents who need more help and encouragement.’ One resident said that they go out when they want, sometimes with a friend, sometimes to the local church or for a walk. Other residents like to read and benefit from having a library visiting service to the home. The owner made the point that some residents do not wish to take part in activities provided. However the home must ensure that a more imaginative and varied programme of activities is available to residents which takes account of their different needs and interests and which is recorded properly so that progress in this area can be reviewed. This is particularly important for those residents who are not able to go out on their own and have particular needs because of difficulties in communicating or because since moving into the home have developed dementia. During the inspection several relatives and friends visited residents and were seen to be relaxed in the home and had good relationships with staff and the owner. One resident said: ‘‘Visitors are welcomed and can come any time they want.’ Relatives are encouraged to be as involved as they wish in the running of the home and the care of their relative. One family member was seen bringing the resident back to the home from a hospital appointment. ‘It’s alright here. I can go out first and have my breakfast later. I go down the shops when I want, and buy what I want with my own money.’ This was the comment of one resident who valued the opportunity he had at The Lime Trees to live as independent a lifestyle as possible. Another resident commented: ‘ People are free to come and go- there’s no bossiness in the place.’ As a result residents are able to choose how they lead their life at the home. Residents were positive about the food in the home. Comments included: ‘The food is quite adequate, and is varied.’ ‘The food is very good, good portions and there’s plenty of variety.’ The lunchtime and teatime arrangements were observed and seen to be relaxed. Discussion with residents and relatives confirmed that individual preferences are catered for and that culturally appropriate food is available to residents who wish this. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 14 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): 16,18 Quality in this outcome area is adequate. Residents and relatives are able to sort out their concerns and complaints as they arise. Residents are not fully protected since staff have not had training in the current procedures and policies applying to the protection of vulnerable adults. EVIDENCE: ‘Anytime I’m in trouble I can look to staff.’ This was the comment of one resident. The owner deals with complaints and concerns as they arise so that residents and relatives feel confident their complaints and concerns will be listened to and acted on. The complaints book was seen and indicated that no complaints had been received since the previous inspection in November 2005. One relative who visited the home regularly said: ‘ If I have any worries or concerns I get them sorted out with staff at the home.’ In the past the owner had provided training for care staff at the home in adult protection. The home also had copies of the relevant local authority guidelines on dealing with abuse and had copies of the appropriate form available to be used when reporting an incident, or alleged incident. There had been no incidents in relation to adult protection in the home in the last year. However staff need to have up to date training in adult protection so that they are fully aware of current policies and procedures. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 15 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): 19,22,26 Quality in this outcome area is adequate. The living environment is homely, comfortable and clean. Residents who are wheelchair users have restricted access around the home. EVIDENCE: One resident commented: ‘The home is always well kept.’ Throughout the 3 days of the inspection the home had a homely and comfortable appearance. The residents’ bedrooms reflected their individual tastes and preferences. One relative said: ‘The resident’s bedroom is always tidy.’ On the final day of the inspection the grass in the rear garden was cut with 2 of the residents helping to tidy up the garden. Residents feel safe and looked after at the home, with one resident saying: ‘Whenever I need to pull the alarm cord the staff come quickly.’ Another one said: ‘If I’m cold they cover me up.’ Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 16 The Lime Trees is a converted building with restrictions for wheelchair users, including narrow corridors and some sloping floors. An up-to-date assessment of the premises by an occupational therapist is needed so that the home can be confident that it is doing everything possible to make sure the home is as accessible as possible. This is particularly important if the owner proceeds with his plan to expand the home further so that people with dementia can be admitted into the home. Throughout the inspection the home was found to be clean and hygienic. Comments from residents and staff indicated that they considered a good standard was being achieved in this area. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 17 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): 27,28,29,30 Quality in this outcome area is adequate. Residents benefit from the support of a committed and experienced team of staff at the home and from staff who have been recruited using the procedures and checks designed to safeguard residents. The home is good at ensuring staff get the basic and essential training to do the job but not so good at ensuring staff have ongoing and varied training opportunities so that they keep up with good practice in the care of older people and achieve suitable qualifications. EVIDENCE: Staff on duty were observed and spoken to. Most staff at the home have worked there for a number of years and have built up a good knowledge and understanding of the needs of each resident. Positive feedback was received from the residents about the care they receive from staff. One resident said about the staff: ‘ Any time I’m in trouble I can look to them.’ Staff are positive about the residents with comments such as: ‘They’re a lovely group to work with.’ The staff rota was looked at and had not been corrected to show a change on a recent shift. The amended rota was then still found to be incorrect. The rota was also difficult to follow in term of which staff were working at what times. The manager must ensure the staff rota is accurate, with changes noted, and is clear so that it can be readily understood as to who is working when. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 18 At the time of the inspection all of the residents came from a White British background, whereas most of the staff have an ethnic minority origin. It is recommended that the owner identifies ways in which the ethnic make up of the staff team can more closely reflect the ethnic make up of the residents. The owner and the manager have relevant qualifications in relation to the care of older people. Some care staff are undertaking NVQ Level 2 training in the care of older people to improve their caring skills further. Most care staff have not yet achieved NVQ Level 2 in care. The manager must ensure that at least half of the staff team achieve this qualification so that residents can be assured there are suitably qualified staff on at all times in the home. Staff files were looked at and contained the information needed to make sure that all new staff in the home had been recruited appropriately using the appropriate checks, including CRB disclosures and written references. No new staff had been recruited since the previous inspection in November 2005. Staff files were looked at and showed that staff had done training in essential areas, such as food hygiene, manual handling, health and safety, administering medication, first aid. Each member of staff has a training profile which lists the training they have done. However there was little evidence of a planned and ongoing training programme in response to the identified needs of staff and residents. In-house training sessions had not taken place since Summer 2005. The owner needs to ensure that there is an ongoing programme of training which responds to the developing needs of both residents and staff. All staff need to have training in working with people with dementia in order to improve practice at the home. This is particularly important since the owner of the home is considering applying to CSCI for a major variation to The Lime Trees’ current certificate of registration to enable the home to admit people with a diagnosis of dementia. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 19 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): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. Residents benefit from having the home run by an owner who is experienced and qualified to operate a care home and where there are appropriate procedures in place to look after residents’ monies. The Lime Trees needs to be better at reviewing and improving the quality of care provided to residents, using systems which draw on the residents’ own experiences of living at the home. Staff benefit from having supervision meetings, but these need to be more frequent and recorded. The home keeps residents safe and secure but needs to improve further fire safety measures to ensure the home is as safe as possible. Key aspects of the day to day management of the home, in particular in relation to the keeping of a wide variety of records, are inadequate. EVIDENCE: Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 20 Mr Onyerindu has run The Lime Trees for a number of years and has recently achieved the registered managers’ award for running a care home. He is also undertaking further training in the area of the mental health, including dementia, of older people. He is actively involved in the daily running of the home. The manager of the home although not present at the inspection has been assessed and registered as a suitable person to manage the home. The day to day management of the home is weak in a number of areas. Feedback from residents and relatives indicated that the registered manager is not a strong presence within the home. The unreliability of the rota meant it was difficult to determine the manager’s level of input into the home. However areas of responsibility, including the rota, in-house training, care plans and risk assessments, staff supervision records were not being kept reliably and consistently. In addition both residents’ meetings and staff meetings were being held infrequently and therefore reducing the opportunities residents and staff have to contribute to the running of the home. As a result many aspects of the management and administration of the home are poor. The owner acknowledged this area of weakness. The owner must ensure that the home is managed at all times effectively and in a way that encourages good practice and improvement so that residents benefit from a home which is trying hard to raise the standard of care provided. The home has a policy on how it reviews the quality of care provided. As previously required the home has now produced reports that include the views and comments of residents, relatives and professionals involved with the home about the care provided. However an ongoing system of evaluation and improvement is not yet in place. The owner needs to ensure that this is put in place and draws on the views and comments of residents. Arrangements regarding residents’ finances were checked. In most cases relatives look after the resident’s monies and financial affairs. Some residents look after their own monies. One resident said: ‘I go down the shops when I want, and buy what I want with my own money.’ No concerns were raised or identified in this area. Currently the home is not looking after valuables belonging to any of the residents. As highlighted earlier record keeping is a weak area within the home. Individual residents’ files are not in good order so that key information, such as a risk assessment, may not be readily available. The owner acknowledged that CSCI had not been notified, as is required, following the deaths of 2 of the residents. The registered manager must ensure that CSCI is notified of any serious event in the home, including the death of a resident. Health and safety and fire safety records were looked at. These records were up-to-date and accurate and confirmed that essential checks are being made and acted on. Fire drills are held four times a year. In line with guidance from Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 21 the LFEPA the home must have an up to date fire safety risk assessment of the premises and an emergency plan. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 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 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X x 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 2 X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 2 X 3 2 2 2 Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 (2) (b) Timescale for action The registered persons must 30/06/06 ensure that care plans and risk assessments are updated regularly. (Timescale of 31/12/05 not met. Requirement restated) The registered persons must 30/06/06 ensure that a more imaginative and varied programme of activities is available with take up of activities offered recorded. (Timescale of 31/12/05 not met. Requirement restated) The registered persons must 31/07/06 ensure that staff have training in adult protection. The registered persons must 31/07/06 ensure that an up-to-date assessment of the premises by an occupational therapist is made. The registered persons must 30/06/06 ensure that the staff rota is accurate and clear. (Timescale of 31/12/05 not met. Requirement restated) Requirement 2. OP12 16 (2) (m) 3. 4. OP18 OP22 18 (1) (c) 23 (2) 5. OP27 17 (2) Sch 4 (7) Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 24 6. OP28 18 (1) (a) 7. OP28 18 (1) (c) The registered persons must 31/07/06 ensure that over half of the care staff achieve an NVQ Level 2 in caring for older people, or equivalent qualification. The registered persons must 30/06/06 ensure that there is an ongoing programme of training which responds to the developing needs of both residents and staff. (Timescale of 31/12/05 not met. Requirement restated) 8. OP30 9. OP32 10. OP33 18 (1) (c ) The registered persons must 31/07/06 ensure that all staff have training in the care of people with dementia. 9 92) (b) The registered persons must 30/06/06 ensure that the home is managed effectively at all times and in a way that encourages good practice and improvement 24 (1)24 The registered persons must 30/06/06 (3) ensure that the quality of service is regularly reviewed and evaluated. (Timescale of 31/01/06 not met. Requirement restated) 18 (2) The registered persons must 30/06/06 ensure that all staff supervision meetings are recorded. (Timescale of 31/12/05 not met. Requirement restated) The registered persons must 30/06/06 ensure that records to protect residents and to ensure the home is run effectively and efficiently are maintained, up to date and accurate. The registered persons must 27/04/06 ensure that CSCI is notified without delay of any serious event in the home, including the death of a resident. DS0000010636.V288164.R01.S.doc Version 5.1 Page 25 11. OP36 12. OP37 17 (3) (a) (b) 13 OP37 37 Lime Trees, The 14. OP38 23 (4) (a) The registered persons must 30/06/06 ensure that the home has an up to date fire safety risk assessment of the premises which has been approved by the LFEPA. (Timescale of 31/12/05 not met. Requirement restated) 15. OP38 23 (4) (c) (iii) The registered persons must 30/06/06 ensure that the home has an emergency plan that has been approved by the LFEPA. (Timescale of 31/12/05 not met. Requirement restated) 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 OP27 Good Practice Recommendations The registered persons should implement a plan to ensure the ethnic make up of the staff team more closely reflects the ethnic make up of the residents. Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Lime Trees, The DS0000010636.V288164.R01.S.doc Version 5.1 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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