Inspection on 30/06/06 for Lord Harris Court

This inspection was carried out on 30th June 2006.

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

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

Other inspections for this house

Lord Harris Court 31/01/09

Lord Harris Court 31/01/07

Lord Harris Court 17/01/06

Lord Harris Court 02/08/05

Lord Harris Court 22/02/05

Lord Harris Court 05/07/04

Lord Harris Court 20/01/04

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 Lord Harris Court Mole Road Sindlesham Wokingham Berkshire RG41 5EA Lead Inspector Julie Willis & Lorna Somerville Unannounced Inspection 08:30 30th June & 11th July 2006 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 Lord Harris Court DS0000011003.V292943.R02.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. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lord Harris Court Address Mole Road Sindlesham Wokingham Berkshire RG41 5EA 0118 978 7496 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) arichards@rmbi.org.uk Royal Masonic Benevolent Institution Miss Elizabeth MacIntyre Hunter Fleming Care Home 90 Category(ies) of Old age, not falling within any other category registration, with number (90), Physical disability (1) of places Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Lord Harris Court is Royal Masonic Benevolent Institution Home that provides accommodation and care for up to ninety-four service users over the age of sixty-five years, of which up to forty-four service users may require nursing care. Lord Harris Court is situated in Sindlesham and is close to local shops, supermarkets and train station. There is an in-house shop one day a week, and transport in the homes mini bus to local shops for those more mobile. There are a number of garden areas and 3 large lounges for the residents and their visitors to use and a large dinning room. The home has a wide ranging activity programme, a library and hairdressing facilities. Lord Harris Court DS0000011003.V292943.R02.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 2 days. The first site visit was made to the home by one inspector on Thursday 30th June between 8:30am – 3.40pm. The second unannounced visit was carried out on 11th July between 10am – 1.15pm. During the 2nd visit the Pharmacy Inspector carried out an inspection of the medication system. The accumulated evidence used to inform this report includes a pre-inspection questionnaire completed by the manager of the home; examination of the records on file; receipt of 17 service user surveys; discussion with 19 residents and 6 relatives. The inspector had the opportunity to interview 6 staff and to observe care practice in various parts of the home. Records in relation to care, staffing, training and health & safety were examined. All requirements from the previous inspection had been met. There were 7 new requirements made as a result of this inspection. What the service does well: Staff are caring and kind and there is enough care & nursing staff on duty to meet the personal & healthcare needs of residents effectively. Staff recruitment practices are well carried out and well documented to protect the safety and welfare of residents. Written records are good and provide staff with enough information to give quality care. The home offers users a wide range of activities including trips out, games, crafts and quizzes as well as outside entertainers who come to the home regularly. Service users confirm that they are treated with dignity and respect at all times by the staff. Personal care is provided in a discreet and sensitive manner. The manner of address used by staff to speak to users is friendly, respectful and courteous. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: There is a need to ensure that all medication is given as prescribed by the Doctor and that all medication is signed for in the drug record. The food varies in quality. A complete review of meal provision is needed which takes the opinions of residents into account. Fluids should be available at all times and water jugs should be refreshed frequently. There is a need to ensure that there are enough cleaners on duty to ensure that bins are emptied regularly and crockery and cutlery are washed immediately after use. The complaints procedure should be easy to access to enable residents to express their views and concerns. Complaints should be dealt with properly. A quality assurance system should be put in place, which seeks the views of users and provides an action plan for improvement. All persons in charge of the home should know how many residents are in the home and whereabouts they live. The fire checklist needs updating. The coffee table in front of the fire exit in the nursing wing should be moved to ensure that users could evacuate from the wing in safety in the event of a fire. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 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. Lord Harris Court DS0000011003.V292943.R02.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 Lord Harris Court DS0000011003.V292943.R02.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 Quality in this outcome area is good. Service users needs are fully assessed by the home prior to admission to ensure the home will be able to effectively meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five service users spoken with during inspection confirmed that they had been visited by the homes staff pre-admission and had been provided with sufficient information about the home to enable them to make an informed decision as to whether to live there or not. One user said that the person that carried out the assessment answered their questions “openly and honestly” and as result felt that they were “able to have a say in their future”. Service users confirmed that this part of the admission process had “been comforting” and “took the worry out of a life changing decision”. Others said that visiting the home informally had been an opportunity to experience the homes routines and general ambience. Examination of 7 service user care and admission files demonstrated that a comprehensive and holistic assessment had been undertaken on each user Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 10 prior to admission. This was carried by one of the homes management team or senior nurses. The majority of the current service users have been referred through the Care Management system. In each case the home obtains a summary of the Care Management assessment and referral prior to admission. The home then carries out its own assessment of the individual either at home or in hospital and this forms the basis of the service user care plan. In cases of privately funded admissions a full needs assessment is carried out by the Registered Manager or a Registered Nurse, which conforms to the requirements of the National Minimum Standards and includes all aspects of the individuals health and welfare including a social history. Service users and their relatives confirmed that they had been provided with information about the home prior to admission and been offered the opportunity to visit the home informally to meet staff and other users. After an initial settling in period they had made a decision to stay. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 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 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. Most aspects of this outcome area were found to be of a good standard including effective multi-disciplinary working and good care to users. However, the standards regarding recording of medication and administration of medication were poor, reducing the overall rating in this area as a whole. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the care plans for 7 service users living in various parts of the home evidenced that the users health and personal care needs were being well met. The inspector had the opportunity to case track these individuals from their referral and pre-admission assessment to their permanent residence in the home and to meet and discuss the process with them. Service users are provided with access to health and social care professionals for advice and support as necessary. General practitioners, community nurses, occupational therapists and physiotherapists are regular visitors to the home and provide advice to the staff on all aspects of health and personal care. Service users confirm that they regularly see their GP and are referred to hospital when necessary for further advice, support and treatment. Routine Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 12 screening and preventative treatments are provided to all residents of the home. The use of clinical tools to identify risks to users in relation to tissue viability, nutrition, dependency rating, environmental risks, bathing and falls were fully developed. Care plans, treatment plans and appropriate equipment were in place to reduce the risks identified. There was evidence in the files that body maps & photographs are used when necessary to evidence resolution of wounds. Examination of the daily records clearly evidenced that care was being delivered in accordance with the individuals care plan and that users had been involved in the formulation of their care plan and on-going review. The principle on which the homes philosophy of care is based is to respect the privacy, dignity and autonomy of the individual. Staff were observed in practice to promote these values by ensuring that personal care was provided in a discreet and sensitive manner. Service users were addressed courteously and staff knocked on doors and waited to be invited in before entering. The inspector spoke at length to 19 of the 90 service users and to others in small groups in various parts of the home. The inspector also had discussions with 6 relatives that were visiting at the time of inspection. The users were complimentary about the qualities and caring attitudes of the staff. They said that staff were “kind, helpful and attentive”. One service user said “that they felt that they were sometimes kept waiting for attention” and “the staff are sometimes slow at answering the call bells, particularly at weekends”. In general however, the feedback from users was very positive about the quality of services on offer. Two users expressed dissatisfaction with the way that the GP’s visits were conducted. They said that they were unhappy that they had to queue on chairs outside the medical room and felt that the GP should visit them in their own bedroom. This matter was discussed at the time of inspection with the Manager who said that the practice would be revisited at the next residents meeting and undertook to discuss the matter with the GP. Resident’s medication charts were viewed. There were some blanks where it was not clear if medication had been given or not. Staff should sign for all medication given. Some medication that should have been given once a week had not been given for over two weeks. Medication is stored safely in the home. It is recommended that staff are re-trained in using the thermometer in the medicines fridge, as it seems that they may not be resetting it each time. Clear records were seen of medication received into the home and unwanted medication removed. A suitable medication policy and procedures are available for staff and to help to protect residents. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 13 Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in the outcome area is adequate. Service users are provided with the opportunity to participate in a wide range of leisure activities and entertainments and are encouraged to maintain contact with the local community, their friends and relatives. The meals in the home however, are the source of dissatisfaction to a large number of service users. Lack of appropriate fluids and delayed meals for diabetics could pose a risk to users safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with one of the Activity Organisers, staff and service users it was clear that residents are offered the opportunity to participate in a wide range of activities and social events. Throughout the period of inspection numerous guests visited the home. There was an open and inclusive atmosphere and staff appeared warm and welcoming. The front vestibule appeared to be the main hub of activity with users meeting and chatting to friends and relatives. On the first day of the inspection celebrations were taking place for a ladies 106th birthday. Family and friends had joined the residents in a celebratory party. The ambience in the home was lively and exuberant throughout the course of the day. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 15 External entertainers are regular visitors to the home including singers and musicians and there are a large number of activities and trips out organised by the Local Freemasons Lodge. A number of the current users attend the local Lodge Meetings and avail themselves of the neighbouring Lodge facilities. Service users confirm that their visitors are made most welcome at any time and are offered appropriate hospitality during their visits. A number of social events are held throughout the year which promotes community involvement and which provide residents families with the opportunity to engage with the staff and users on an informal and regular basis. The food provided by the home was a source of dissatisfaction for a large number of residents who said that the quality of the meals had deteriorated since the catering had been contracted out last year. One user has started to cook their own food whilst others admitted to snacking between meals to satisfy their hunger. Examination of the menu indicated that there was a choice of 3 dishes at lunchtime Monday to Friday and a choice of a hot meal or salad for lunch at weekends. 13 service users expressed their unhappiness about the quality of the food prepared which some said ranged from “passable” to “awful”. The way the meal was distributed was a further area of concern. 7 service users said that they would like to serve themselves from tureens whilst others said they didn’t mind if it was already plated. Two users said that the dining room service appeared chaotic and one user said “those serving the meals had been reduced to tears at times in the chaos”. One user was concerned that he was made to wait for a meal if he was late into the dining room. This posed a risk to his safety as he was an insulin dependent diabetic. The provision of fluids is likewise problematic. Six users said that they had complained to staff that their water jugs had not been changed from between 2 to 5 days. Dirty tea things were left in the corridor outside kitchenettes all night. One user told the inspector that by morning the items left on the trolley were becoming “smelly”. One user said that all the drinking water was tepid and unpleasant and the provision of ice cubes was not always available. This is clearly an area of the service that requires a comprehensive review and should be addressed as a matter of urgency. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 16 Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 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 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 poor. The homes complaints system requires review to ensure that service users feel their views are listened to and acted upon. Service users are protected from abuse and exploitation by well-trained and competent staff that demonstrate knowledge of the homes abuse of vulnerable adults and whistle-blowing policies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaint policy in the home meets the requirement of Standard and Regulation. There is however, little evidence that service users concerns are listened to and acted upon effectively. There have been 10 complaints recorded in the last 12 months by the home, 4 of which have been fully substantiated and 1 was partially substantiated. Two complaints have also been reported to the CSCI that have been referred back to the home for the management’s attention. The service users told the inspector that they have made repeated complaints to staff about poor access to fluids and poor quality of meals but do not feel that that these issues have been dealt with effectively. A comments book was put in the dining room for users to express their satisfaction but service users told the inspector “that they don’t bother to write anything in it because nothing is done”. Service users say that the lack of action to right the issues does not instil them with confidence in the complaints system overall. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 18 There was evidence in staff files that all staff receive training in the abuse of vulnerable adults as part of their formal induction and NVQ training in which it is a core module. Refresher training courses are also offered regularly to staff by the homes management team. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate. The standards of décor and furnishings in this home are satisfactory and offer residents a comfortable and homely place to live. However standards of hygiene are compromised by the lack of domestic staff at weekends and bank holidays. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector toured the home and saw a number of bedrooms and all of the communal areas. The central hub of the home is the vestibule. Service users said that they enjoy sitting in this area as it spacious, light and airy and they can watch the comings and goings of visitors to the home. The communal lounges throughout the home are used less frequently and are mainly used for organised activities and large communal events. Several gentlemen were seated in one of the front facing lounges. A delivery of computer equipment and other extraneous items had been made that morning and the items were being temporarily stored in this room pending storage Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 20 elsewhere. The boxes detracted from the overall appearance of the room and could have posed a trip hazard to users. The dining room is large bright and spacious and the majority of users eat their meals in the dining room. At 11.30 am the tables were being laid for lunch. The floor was covered in food debris left over from breakfast. The inspector asked a member of the catering staff who was responsible for cleaning the dining room floor? The inspector was told that it would be cleaned before the users came down for lunch. The tablecloths cutlery, water glasses, jugs and condiments were already on the tables. It would be advisable for the floor to be cleaned before laying the table to avoid any air borne dust or bacteria contaminating the eating utensils. Care staff were observed entering the kitchen to make service users their morning drinks without wearing any tabards, aprons or whites whilst the chefs were preparing lunch. The carers were wearing the same uniforms that they had been wearing previously whilst carrying out personal care for users. There is a need to discuss this practice with the Environmental Health Officers as this practice appeared hazardous and could lead to cross contamination. Service users told the inspector that at weekends and over bank holidays service users waste bins were rarely emptied. One user said that he was aware of one 5-day period when his bin wasn’t emptied causing it to overflow onto the floor. Another said that it was a common occurrence for bins to go unemptied for 2 to 3 days. Other users told the inspector that their beds were rarely made until after 4 pm when they requested staff assistance. Two users told the inspector that trolleys with dirty crockery and cutlery are frequently left outside kitchenettes until the following day. The inspector observed this practice on the 2nd day of inspection and brought the matter to the attention of the Manager who undertook to deal with it. These practices are indicative of staff shortages and poor practice. There is a need to review the domestic staffing levels at the home to ensure the home can be kept clean and hygienic and free from risk of cross infection. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. Service users are provided with care by well-trained and knowledgeable staff that are robustly recruited. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of inspection their appeared to be sufficient care and nursing staff on duty to effectively meet the needs of users. A recent review of staffing levels has increased the levels from 7 to 9 carers in the morning and from 6 to 8 carers in the afternoon on the residential wing. Team Leaders are in charge of the shifts and are responsible for allocating work and administration of medication. The nursing wing staffing levels have increased to 2 nurses and 5 carers in the morning and 2 nurses and 4 carers in the afternoon. Sufficient staff are on duty to meet the needs of the frail elderly residents some of whom have complex needs. The home also employs two Activity Organisers. One works 30 hours per week on the residential wing and the other works 19 hours per week on the nursing wing. This has benefits for the service users who are provided with additional Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 22 opportunities to participate in a wide range of organised activities including trips out in the minibus. There is a need however to review the levels of domestic staff throughout the home. Consideration should be given to employing a housekeeper that can allocate duties and sure routine tasks such as the emptying of bins are carried out. Examination of the recruitment files for the 6 most recently recruited employees indicated that all necessary checks are undertaken on prospective staff to ensure the safety and protection of service users. Records were well kept and met the required standard. Staff appeared to have a good understanding of how their individual role benefits the work of the team and a thorough knowledge of the key values that underpin their work with service users. All new staff receive induction to Sector Skills Council standard and complete both induction and foundation training in their first 6 months in employment. Over 51 of the care staff have achieved a National Vocational Qualification at levels 2 or 3. Staff are also provided with a range of frequent refresher training including fire safety, first aid, manual handling, food hygiene, infection control and POVA (Protection of Vulnerable Adults). The home has developed a training plan, which identifies the training needs of all staff at the home which links to the homes business plan. In discussion with staff and examination of records it was evident that all staff are supervised at least 6 times a year and appraised twice yearly. Staff said that they enjoy working at the home; they feel well supported by management and appreciate the training opportunities offered. Staff said they attend team meetings and staff handover sessions at the beginning of each shift. Service users were highly complimentary about the qualities of staff and said that “staff are always kind and helpful”, and “they seem to be happy in their work”. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome is poor. Deficits in health & safety put service users at risk. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager is competent and experienced to run the home for the benefit of the residents. The manager is currently undertaking the Registered Managers Award to further enhance her knowledge and skills. Staff confirm that the Manager leads by example and is pro-active in supporting staff to further their own personal development. Service users confirmed that they liked the new Manager and felt that given time the quality of service provision in the home could improve under consistent management. There is a need to improve the homes quality assurance systems to seek the views of residents more pro-actively. Service users should be provided with additional opportunities to express their views and concerns. The residents Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 24 meetings should be more focused on the outcomes for users and should provide a basis for an action plan to address areas of concern. Currently the outcome of the annual survey is collated by head office. It would assist the quality assurance process if the results of these surveys could be shared with staff, service users and other stakeholders which would help the home measure its success in meeting its started aims and objectives. The inspector examined the policy and procedure for managing service users monies. The system appeared well managed and safe guarded users finances from financial abuse. The users cash accounts are held on computer and also in hard copy as a back up. Receipts were on file for monies spent on behalf of the users. There were some serious deficits in relation to health & safety, which could pose a significant risk to users. At the commencement of inspection no one was able to inform the inspector how many service users were on site and whereabouts in the home they were situated. The fire checklist was significantly out of date and did not include the 13 service users situated on the top floor. On the 2nd day of inspection a coffee table had been placed in a front of the nursing wing fire door blocking the exit. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 3 3 x x x x x x 1 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 3 x x 1 Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 26 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 OP9 Regulation 13 (2) Requirement The Registered Manager should ensure medication is given as directed by the prescribing doctor and accurate records are kept of all medicines given The Responsible Individual in consultation with service users should ensure that a review is undertaken on the quality of food provided by the home The Responsible Individual should ensure that the mechanisms for responding to service user complaints are robust and transparent The Responsible Individual should ensure that the person in charge of the home is aware of who is resident and whereabouts they are situated in the home. Ensure that the fire check list is accurate and up-to-date at all times The Responsible Individual should ensure that there are sufficient domestic staff on duty at all times to keep the home clean & hygienic Timescale for action 21/07/06 2 OP15 16 (2) i 30/07/06 3 OP16 22 30/06/06 4 OP38 13 (4) c 30/06/06 5 OP26 13 (3) 30/06/06 Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 27 6 OP33 24 7 OP15 16 (4) The Responsible Individual should ensure that a quality assurance system is developed which actively seeks the views of users The Registered Manager Should ensure that service users have access to fluids at all times 30/09/07 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The Registered Manager should ensure that staff are retrained on using the thermometer in the medicines refrigerator. Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 Lord Harris Court DS0000011003.V292943.R02.S.doc Version 5.1 Page 29 - 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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