Inspection on 28/06/07 for Lisnaveane Ltd

This inspection was carried out on 28th June 2007.

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 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

Lisnaveane Ltd 07/08/06

Lisnaveane Ltd 12/05/06

Lisnaveane Ltd 17/01/06

Lisnaveane Ltd 19/09/05

Lisnaveane Ltd 12/01/05

Lisnaveane Ltd 14/06/04

Lisnaveane Ltd 16/01/04

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 Lisnaveane Ltd 790 Longbridge Road Dagenham Essex RM8 2AA Lead Inspector Mrs Sandra Parnell-Hopkinson Key Unannounced Inspection 28th June 2007 08:15 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 DS0000027906.V343725.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. DS0000027906.V343725.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lisnaveane Ltd Address 790 Longbridge Road Dagenham Essex RM8 2AA 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) 0208 592 0022 0208 491 8424 Lisnaveane Ltd Vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places DS0000027906.V343725.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2006 Brief Description of the Service: Lisnaveane is a residential care home situated within the London Borough of Barking & Dagenham. The building has been converted and extended over time to provide a care home for 19 older people. The home is situated on the corner of a busy road with good transport links. There is on street parking to the side of the property, and very limited parking to the side/rear of the home. Bedrooms are single with a few double rooms, and bedrooms do not have an en suite but all do have a washbasin. There is a lift to the upper level. There are two lounges and a dining room, which all over look a well-maintained rear garden, which is accessible to residents. Currently the home is operated as a ‘homely’ environment where residents and staff know each other very well. A copy of the statement of purpose and service user guide was available during the inspection, and a copy of this can be obtained upon request to the home. At the time of this inspection the fees ranged from £431 to £450 per week. DS0000027906.V343725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place on the 28th June 2007 by Mrs. Sandra Parnell-Hopkinson. The inspection site visit took place over 6.5 hours and included discussions with residents, relatives, staff, the responsible individual and two other directors of the organisation who were present at various times during the inspection. The files of 6 residents and 4 members of staff were inspected, together with maintenance records, complaints log, staff rotas, medication administration records (MAR), menus, accident records and a pre-inspection questionnaire which had been completed and returned by the service prior to the site visit. A tour of the building was also undertaken as part of the site visit. Prior to this unannounced key inspection, an inspection focusing on medication administration was undertaken by the Commission’s Pharmacy Inspector on the 12th October, 2006, and random inspections were undertaken on the 28th November, 2006 and 6th March, 2006 and evidence from those inspection have also been used to inform this report. Currently there is no registered manager for this service, but discussions were had with the responsible individual regarding equality and diversity issues and she was able to demonstrate an understanding of the many issues associated with this area of need and care. People using this service were asked how they wished to be referred to, and the majority said they wished to be called residents because they lived at the home. This is how they are referred to in this report. What the service does well: Although the care home is registered to take 19 residents, currently there are only 9 residents. It was possible to speak to all of the residents regarding the service, and one told the inspector “I really like it here, I can’t remember how long I have lived here but it is a long time. The girls are really nice and nothing is too much trouble.” Another resident told the inspector “the food is good, always a choice and generally there is more than I can eat.” A visiting relative said that he could visit when he wanted to, and was always made to feel welcome. Two other residents said “if I want to go to my room I can, and the staff will always help me and check that I am okay.” On the day of the inspection one resident was unwell and went to his room to wait for the doctor, but the inspector observed that at least every 15 minutes one of the two staff on duty went to check that he was okay, and took drinks to him. DS0000027906.V343725.R01.S.doc Version 5.2 Page 6 The two care workers were very knowledgeable about the needs of the individual residents, and the inspector observed that all of the staff on duty during the inspection interacted well with residents, and there was a great deal of laughing. Staff were seen participating in activities with some of the residents, and this included helping one resident with her knitting and another with a word puzzle book. One resident who enjoyed reading, was happily sat by the window with her large print novel. There was evidence of community outings, and two residents have joined a club where they can participate in line dancing. In house entertainment also takes place on a regular basis, and residents told the inspector that they also celebrate birthdays and the cook makes a cake, and also other festivals such as Christmas and Easter. What has improved since the last inspection? Many of the bedrooms have been redecorated and the dining room has been redecorated and refurbished with new curtains, tablecloths and napkins. This room is now much brighter and more congenial to the taking of meals. Residents told the inspector “the room is lovely and it seems like going into a hotel.” All staff now have a written contract of employment, and are now receiving supervision on a regular basis which includes attending staff meetings. The staff files were kept in good order and there was clear evidence of application forms, the receipt of appropriate references together with a criminal records bureau disclosure. The provision of fresh fruit and vegetables has improved, and these are now available to residents on a daily basis. The rear garden area was clear of rubbish and was well maintained with seating areas for the residents. The statement of purpose and service user guide have been reviewed and the latter document does include details of a recent quality assurance survey undertaken by the organisation. The registration details for the home have been regularised by the Commission, in that it is an organisation that is the registered provider and not three individual people. Medication administration records have improved and these were inspected during the visit and found to be in good order, with staff involved in the administration of medication having received appropriate training. The provision of training has also improved and there was a schedule of training DS0000027906.V343725.R01.S.doc Version 5.2 Page 7 dates, which have been booked, and these include an update in manual handling, first aid, infection control and health and safety. 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. The summary of this inspection report can be made available in other formats on request. DS0000027906.V343725.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 DS0000027906.V343725.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, 2, 3, 5 (standard 6 is not relevant to this service) People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Prospective residents and their families are given information about the service so that they can make an informed decision about where to live. All prospective residents are given a contract is privately funding their care, or a statement of terms and conditions is they are being supported by a local authority. A comprehensive assessment of his/her needs is undertaken and prospective residents and/or their families/friends can visit the home prior to making a decision. EVIDENCE: During the inspection the files of 6 residents were case tracked, and all had evidence of either a contract or a statement of terms and conditions. Many of the existing residents have lived at the home for several years, but the file of a resident admitted in December 2006 was viewed and this contained a comprehensive assessment of the person’s needs. Pre-admission assessments show evidence that information around a person’s ethnicity, culture and DS0000027906.V343725.R01.S.doc Version 5.2 Page 10 religion are ascertained and recorded. This information is then included in the care plan which is drawn up from the assessment. Some residents spoken to told the inspector that they had been able to visit the home prior to making a decision about living there, and one resident told the inspector “my family came to have a look round because I couldn’t.” Since the random inspections the statement of purpose and service user guide have been reviewed and updated, and these are now more comprehensive and contain the information required by the Care Home Regulations 2001. However, as some residents do have a degree of memory loss and/or varying degrees of confusion, the organisation should look additionally at providing a service user guide in a simpler format such as pictorial. This will prove beneficial to some of the current and prospective residents. DS0000027906.V343725.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, 10 and 11 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Residents are sure that their health and personal care needs are set out in an individual plan of care, and that their health needs are being fully met. They can be sure that staff involved in administering their medication, have been trained and that such medication is administered in accordance with the home’s current policies and procedures. Residents can be sure that they will be treated with respect and that their right to privacy will be upheld, and also that they will be cared for with sensitivity and respect at the time of their death. EVIDENCE: The files of 6 residents were inspected and all showed evidence of the involvement of health care professionals such as the GP, District Nurse (where necessary), the chiropodist, dentist and the optician. During the inspection one resident was feeling unwell and he was taken to his bedroom so he could lie down on his bed. The senior care worker on duty then telephoned his GP who agreed to make a home visit during the day. The district nurse visits another resident regularly for the administration of B12 injections. One of the DS0000027906.V343725.R01.S.doc Version 5.2 Page 12 residents who was speaking to the inspector told her “I see the chiropodist regularly because I like to have feet seen to.” This was also confirmed when viewing her file. The most recently admitted resident had a leg wound which had been dressed and treated by the district nurse, and this has now healed. Currently none of the residents have any pressure sores. Care plans were reasonably comprehensive but these did not always reflect the varying degrees of memory loss or confusion now being experienced by some of the residents, some of whom have lived at the home for several years. It is important that such information is included in the care plans as this will impact on the level of assistance that may now be required from care workers. However, there was evidence on each file that the care plans are being reviewed monthly. Daily recordings were generally quite detailed, but some improvements could be made especially around night care recordings and night care plans. Risk assessments are generally in place. There is one resident who has a history of falls but prefers to use the lift to her bedroom rather than the stairs. There was an appropriate risk assessment in place in that a care worker would always be with her when she was negotiating the stairs to her bedrooms. This is a good example of listening to the choices of a resident, and staff not overriding her wishes with what they think would be ‘better for her’. Several of the residents are diabetic and there is a record of the monitoring of blood sugars, which are being done by the care workers under the supervision of the district nurse. All of the residents are being weighed on a monthly basis, or more frequently if the need is indicated and any increases/decreases in weights are being monitored with the necessary referral being made to the GP. Some residents wore spectacles and these were observed to be clean, as were the hearing aids of those residents who needed them, and they were working according to the residents spoken to. During the inspection staff were observed to be responsive to the varied and individual needs and preferences of the residents. It was apparent through talking to residents that the delivery of personal care is flexible, consistent, reliable, and that staff respect their privacy and dignity. One resident told the inspector “I can ask for a bath when I want one, and this never seems to be a problem for the girls, they help me with getting dressed and are always kind and caring.” Medicating administration records were inspected and these were found to be in good order as was the actual medication. Staff undertaking the administration of medication have received appropriate training and are DS0000027906.V343725.R01.S.doc Version 5.2 Page 13 operating in accordance with the home’s policy and procedure. At the time of this inspection none of the residents were self-medicating. The home does need to develop end of life care in accordance with the recent guidance from the Department of Health. However, from talking to staff it was evident that if a resident was dying staff would support the family and friends, and that the resident would be treated with care, sensitivity and respect. DS0000027906.V343725.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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Residents at the home experience a lifestyle that meets their needs, and is in accordance with their social, cultural and religious preferences. Residents know that their family/friends can visit them and that they will be made welcome, and also that they can enjoy community activities if they choose. Residents are helped to exercise control and choice over their lives, and receive a wholesome appealing balanced diet in pleasant surroundings. EVIDENCE: From observations, talking to residents and viewing records it was apparent that residents can participate in daily activities. During the inspection one resident was doing knitting with the help of a care worker. When the inspector asked her what she was knitting she said “Do you know dear I really don’t know, but I have always knitted and still enjoy it.” Another resident was engaged in doing a word puzzle, and she told the inspector “I can’t always see because I am short-sighted and sometimes I can’t find the words, but the girls are good and they always give me a hand.” Other residents were seen sitting and chatting to staff, and two other residents were reading. DS0000027906.V343725.R01.S.doc Version 5.2 Page 15 It was reassuring to see that the television is not automatically switched on, and that residents were able to either sit quietly in one of the lounges, or to listen to soft music in the other. During discussions with the residents several told the inspector that they had gone for a drive the previous afternoon, and this was confirmed in discussions with one of the director’s who was visiting the home. Two residents visit a local club on a Monday afternoon because there is line dancing , and apparently they enjoy dancing even though they may not understand the instructions from the caller. Residents told the inspector that everyone’s birthday is celebrated and they always have a cake, which is generally made by the cook. They also told the inspector that they often have an entertainer visit the home, and they enjoy this. It was evident that Christmas and other festivals are celebrated, and currently all of the residents are white British, and are either non-practising with regard to religion or are of the Christian denomination. Residents are enabled to practice religious observances according to their wishes. A hairdresser visits weekly and the some of the residents said that they liked having their hair washed and set because it made them feel good. It was possible to speak to a visiting relative who said “it is quite a nice home, the staff always seem kind and I do visit at odd times and have always found the staff to be good.” The cook lets each resident know every morning what is on the menu, and they in turn let him know if they want the menu choice or prefer an alternative. The inspector observed this during the morning, and some of the residents confirmed that this always happens. Lunch was observed and it was evident that care workers gave any assistance necessary in a sensitive and discreet manner. One resident told the inspector “The food is lovely and I am well looked after.” Another said “Lunch was very nice, no complaints all very kind and considerate, I give them full marks.” Some of the residents also said that there was so much food that they could not eat it all. A record of what each resident chooses and eats is maintained within the home. Since the previous inspections the dining room has been redecorated with some refurbishment, and this rooms is now bright and offers a congenial ambiance for the residents. Meals are at the following times, but there is flexibility if this is requested by a resident: Breakfast from 9a.m. Lunch from 12.30p.m. Tea from 5p.m Supper from 7.30-8p.m. (sandwiches, cake or biscuits) DS0000027906.V343725.R01.S.doc Version 5.2 Page 16 Drinks and snacks are available throughout the day and staff were seen offering drinks to residents during the day. Menus were viewed and these were varied, nutritious and balanced and there was evidence of fresh fruit and vegetables being available for the residents. The cook has many years experience in various settings, and much of the food is ‘home cooked’ on a daily basis. He also was knowledgeable around special dietary needs, likes and dislikes of the residents. DS0000027906.V343725.R01.S.doc Version 5.2 Page 17 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 People who use this service experience good outcomes in this area. We have made this judgement based on available evidence including a visit to the service. Residents and their relatives/friends can be confident that their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse and can feel safe when being cared for by the staff. EVIDENCE: There are policies and procedures in place for dealing with any complaints, and staff spoken to were aware of these procedures and knew how to deal with any complaint made to them. The complaints book was inspected and there have been no recent formal complaints. In discussions with the responsible individual she was very clear that any complaints received by the organisation would be responded to in writing and in accordance with the service’s complaints procedure. Concerns or minor complaints are not currently recorded, but in discussions with the staff they told the inspector “if a resident is not happy with something we try to deal with this immediately and put it right.” This was confirmed by several residents, one of whom told the inspector “if there is something I am not happy with, I just let the carers know and they are very good at putting things right.” Another resident said “I would certainly complain if I was not happy, but I don’t have anything to complain about.” DS0000027906.V343725.R01.S.doc Version 5.2 Page 18 The responsible individual visits/works at the home several days each week and knows the residents well, and deals with any concerns raised by the residents immediately. Many of the current staff have worked at the home for some time and those spoken to confirmed that they had received training in safeguarding vulnerable adults and were able to tell the inspector the process they should take if they witnessed any suspected abuse. There was evidence to confirm this on their files, and the training schedule indicated dates for future training sessions for new staff and updates for existing staff. There are currently no outstanding safeguarding adults referrals. DS0000027906.V343725.R01.S.doc Version 5.2 Page 19 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, 21, 23 and 26 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to the service. Residents are able to live in a safe, well-maintained environment and have their own possessions around them. However, there are no bedrooms with en suite facilities, and several rooms are still for shared occupancy. The home is clean, pleasant and hygienic. EVIDENCE: A tour of the premises was undertaken as part of the inspection process and all parts of the home were found to be clean and hygienic with no offensive smells. Many of the bedrooms having been recently redecorated, and these rooms appear much brighter, and one resident told the inspector “I like my DS0000027906.V343725.R01.S.doc Version 5.2 Page 20 bedroom now that it is much brighter and I helped to choose the colour.” None of the bedrooms have an en suite but all do have a washbasin. There are still some shared bedrooms. There are sufficient suitable lavatories and bathrooms available within the home for the residents. The two lounges are of an acceptable standard, and the dining room has recently been redecorated and has been fitted with new curtains and tablecloths. This room is now much more congenial for residents to take their meals. There are a sufficient number of communal toilets and bathrooms with necessary equipment where needed. A record is being maintained of the bath water temperatures prior to a resident taking a bath. Residents are encouraged to personalise their bedrooms, and those viewed appeared very individual with small pieces of furniture and lots of other personal possessions. Locks have been fitted to the bedroom doors, that are operable in an emergency from the outside. This allows residents to choose whether they want to lock their doors but feel safe in the knowledge that if an emergency arose staff could gain access. The kitchen was inspected and this was found to be clean and tidy and there had been an inspection from the local environmental health department. No report had been received by the organisation at the time of this inspection, but verbal feedback from the cook indicated that there had been no concerns or notices raised by the environmental health inspector. Efforts have been made by the Commission to speak to the environmental health inspector, but without success. Food was found to be stored appropriately with dates and labels with fridge temperatures being taken on a daily basis. The laundry area is situated in an external building and all of the equipment was in good working order at the time of this inspection. The front and rear gardens were maintained to a good standard, but there is a garden bench at the front of the house which requires some repairs. Requirements made at previous key and random inspections regarding the maintenance of the premises have been complied with. The organisation is currently considering alternative options for this service one of which involves major building works. If the organisation does proceed with this option this will improve the environment with the provision of single bedrooms with en suite facilities. In discussions with one of the director’s it was evident that consideration is also being given to the replacement of the DS0000027906.V343725.R01.S.doc Version 5.2 Page 21 windows, but again this may happen depending upon the option that the organisation chooses. DS0000027906.V343725.R01.S.doc Version 5.2 Page 22 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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Currently residents’ needs are met by the numbers and skill mix of the care workers, and they can feel that they are in safe hands. The home’s recruitment practices make residents feel that they are supported and protected, and generally staff are trained and competent to do their jobs. EVIDENCE: On the day of the inspection there were two care workers (1 of whom was a senior) and two kitchen staff on duty. During the inspection the responsible individual arrived together with two other directors of the company. All of these people were involved in the care of the residents in varying degrees. One of the directors was attending to the garden areas and cutting the grass, and the responsible individual and the other director were involved with the residents. In discussions with the staff members they confirmed that they had undertaken training in manual handling, safeguarding adults, medication administration, food hygiene and NVQ level 2. This was confirmed by viewing staff files and training records. The Mental Capacity Act 2005 was discussed with the responsible individual and one of the directors. This is an important piece of legislation which comes fully into effect on the 1st October, 2007, and it will impact greatly on the delivery of care to vulnerable people. It is DS0000027906.V343725.R01.S.doc Version 5.2 Page 23 therefore, essential that all staff working at the home undertake training in the implications and implementation of this Act. The staff were very knowledgeable around the needs of each of the residents and there was a very good relationship apparent between the staff and between the staff and residents. The files of the three most recently employed members of staff were inspected and all of these contained application forms, the necessary references and a criminal records bureau disclosure. Staff now have a contract of employment and this was evidenced on the files viewed. DS0000027906.V343725.R01.S.doc Version 5.2 Page 24 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, 36 and 38 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to the service. Currently residents can feel sure that generally the home is being operated in their best interests. However, there is no manager and the organisation is still considering options for this service which will have major impacts for the residents. Staff are being supervised and the financial interests of residents are safeguarded. The health, safety and welfare of residents and staff are generally promoted and protected. EVIDENCE: The previous manager has resigned and in the short term the responsible individual is spending several days each week at the home to ensure that it DS0000027906.V343725.R01.S.doc Version 5.2 Page 25 operates in the best interests of the residents. However, a barrier to this is the current indecision regarding the future of this service. In the past few months a quality assurance survey has been undertaken and the results have been published by the organisation in the service user guide. Staff are being supervised through 1:1 supervisions and staff meetings, but another very important aspect of supervision is through direct observation of care practices. This was discussed with the responsible individual and one of the directors who will be looking at introducing this aspect of supervision. No personal monies are held for the residents, and any expenditure for hairdressing, chiropody or other items are paid for by the service and then the resident or family/representative is invoiced. Receipts are maintained of any expenditure on behalf of a resident. Maintenance records were viewed and these included electrics, gas, water, insurance, weighing machine and hoist, fire safety and alarm testing, lift maintenance and bath water temperatures and all were found to be in good order. The insurance policy has been renewed and this is now for employer’s liability £10million and public liability £5million. Although there are policies and procedures in place, these must be reviewed to ensure that they comply with updated legislation such as equality and diversity, mental capacity and the smoking regulations. From evidence gathered at the random inspections and this key inspection, and from discussions with the responsible individual and another director, there has been some organisational progress. However, more still needs to be done by the responsible individual to demonstrate that there will be sustainable improvements by the organisation around staff training, the environment, office resources such as a suitable photocopier, computer accessibility to the internet to enable the new manager (when appointed) to source up to date information and material. Also it is essential that the organisation comes to a speedy decision regarding the future direction of this service in the interests of the residents and the staff, and advises the Commission of the decision together with staff, residents and any funding authorities. DS0000027906.V343725.R01.S.doc Version 5.2 Page 26 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 3 X 3 DS0000027906.V343725.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 6 Requirement Timescale for action 31/10/07 2 OP7 15 3 OP30 18(1)(a) 4 OP31 8 The registered provider must ensure that all information is available in a variety of formats to suit the varying needs of the residents. This will ensure that all residents have access to appropriate information to enable them to make decisions. The registered person must 31/08/07 ensure that each resident has a comprehensive care plan which includes night care needs and end of life needs. The registered persons must 30/09/07 ensure that staff undertake ongoing training to ensure that they have, and retain, the skills and competencies necessary to ensure a quality of life for the residents, and to protect the health and safety of residents and themselves. This must include training on the Mental Capacity Act 2005. The registered provider must 09/10/07 appoint a manager to manage the care home and to notify the Commission of the name of the person appointed and the date of DS0000027906.V343725.R01.S.doc Version 5.2 Page 28 5 OP33 10(1) 10(2)(b) 10(3) 24(1) 25(1) 26(4) appointment. This will ensure that the home is run and managed by a person who is fit to be in charge, of good character and able to discharge his/her responsibilities fully in the interests of both the residents and the staff. The registered organisation, through the responsible individual, must ensure that the care home is always operated in the best interests of service users, and that management resources are appropriate to enable this to happen, including office equipment. Also that a speedy decision regarding the future of the service is made and advised to the Commission, the residents, the staff and the funding authorities in the interests of the current residents and staff. 31/07/07 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 OP24 Good Practice Recommendations The proprietors should consider changing the shared bedrooms into single bedrooms with en-suites wherever possible. DS0000027906.V343725.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000027906.V343725.R01.S.doc Version 5.2 Page 30 - 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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