Inspection on 31/01/08 for Mapleton Road

This inspection was carried out on 31st January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mapleton Road 26/01/09

Mapleton Road 28/03/07

Mapleton Road 23/06/06

Mapleton Road 10/03/06

Mapleton Road 06/12/05

Mapleton Road 31/01/05

Mapleton Road 03/08/04

Mapleton Road 13/03/04

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

CARE HOMES FOR OLDER PEOPLE Mapleton Road 87 Mapleton Road Chingford London E4 6XJ Lead Inspector Lea Alexander Key Unannounced Inspection 10:00 31st January 2008 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 DS0000058682.V341690.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. DS0000058682.V341690.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mapleton Road Address 87 Mapleton Road Chingford London E4 6XJ 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 529 2266 0208 524 6564 London Borough of Waltham Forest Ms Christina Adamu Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places DS0000058682.V341690.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th March 2007 Brief Description of the Service: 87 Mapleton Road is a care home registered to provide personal care for a maximum of twenty-four older people with mental health needs. The home is a large detached, single storey building with twenty-four bedrooms. All bedrooms are single rooms with a washbasin and two bedrooms have ensuite facilities. There is a large main kitchen where meals for service users are prepared. In addition, there are two small kitchenettes where drinks and snacks can be prepared. Facilities for service users include two large communal lounges with dining areas. There are seven toilets, two bathrooms and two shower rooms. One of the bathrooms has an assisted bath. DS0000058682.V341690.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two Inspectors carried out this inspection over the course of two days. In addition an “expert by experience also visited the home. The expert by experience is an independent person with experience in the field that is able to give the Inspector their view of the service provided. During the course of the inspection the Inspectors and expert by experience spoke with staff, people who use the service and some of their relatives. The Inspectors also met with the Manager and examined paperwork and documentation relating to the running of the service. This included resident’s personal files and staff personnel files. The lead inspector carried out a random unannounced inspection in June 2007 in response to adult protection concerns, and information from that inspection is also included in this report. What the service does well: The expert by experience spoke with some family members and relatives of residents visiting the home during the inspection. They said that they felt welcomed and were offered light refreshments. They also said staff were approachable and that they were happy with the service provided. The expert by experience observed that there was a familiarity between residents who appeared to enjoy each other’s company. Both the Inspectors and expert by experience found the home to have a relaxed atmosphere that seemed to suit the residents. All of the homes residents are from a white British background. Care workers are from more diverse backgrounds, and reflect the cultural make of the Borough. Potential residents are assessed prior to their moving in. Each person who uses the service has an individual plan; it includes some information about their life and history. Residents are supported to access a range of healthcare services. The home helps residents with their finances, and keeps appropriate records relating to this. Residents are well groomed and have a chose of male or female carer to help them with personal care. The home has an activity programme that residents can take part in. During the summer month’s residents can participate in day trips in the local community. People who use the service help choose the meals and enjoy the food provided. DS0000058682.V341690.R01.S.doc Version 5.2 Page 6 Residents have their own rooms that they can personalise. The home is comfortable and generally well maintained with a range of communal and private space. The home is set in small, pleasant landscaped gardens. Permanent staffs receive regular training and supervision and are supported to undertake external NVQ qualifications. The homes recruitment process safeguards people who use the service. The home benefits from a qualified experienced Manager. The home maintains appropriate records relating to health and safety. What has improved since the last inspection? What they could do better: Nine requirements were made as a result of this inspection, seven of which were restated. The registered manager must ensure that service users or their representatives agree to the plan of care. Individual plans must reflect the current mobility needs and any assistance required with transfers. Individual plans must address the residents, personal, social and healthcare needs. The Registered Manager must ensure that residents receive their medication in accordance with its prescription. All staff must be aware of the circumstances in which to administer “as required PRN” medication. DS0000058682.V341690.R01.S.doc Version 5.2 Page 7 The Registered Manager must ensure that residents are supported to undertake individual social and leisure pursuits. The Registered Manager must ensure that information is presented in an accessible format to support people who use the service make informed choices. The home must maintain a log of all meals provided including morning and afternoon teas, and evidence that soft fruits are offered at least twice per day. In the shower rooms of both units water damaged doors, mouldy grouting and missing tiles must be repaired or replaced. The missing or broken handles on emergency pull cords must be replaced. The registered manager must take action to address the mal odours in some service users bedrooms. The registered persons must review staffing levels and undertake any actions identified out of the review so as to ensure it has sufficient staff to meet the assessed needs of service users throughout the day and night. A report of actions undertaken following this review must be forwarded to the inspector. The registered manager must develop a quality assurance system that reflects the communication needs of the service users. 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. DS0000058682.V341690.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 DS0000058682.V341690.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): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. EVIDENCE: The Inspectors sampled the personal files of four residents. These evidenced that each resident was assessed by the home prior to their moving in. The Manager advised the Inspectors that the home does not provide intermediate care. DS0000058682.V341690.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has an individual plan, but it is not evidenced that they are involved in its development. The plan includes basic information and is regularly reviewed. Risk assessments relating to the plan are also completed. EVIDENCE: The individual plans seen for two residents at a random inspection in June 2007 residents evidenced that they were occasional wheelchair users. There was no information indicating when, why or the frequency of this use. There was also no information on the assistance they might need to transfer to the wheelchair. Both were also evidenced as using a hoist, one occasionally and one regularly. No moving and handling risk assessment was evidenced as being completed for either service user. DS0000058682.V341690.R01.S.doc Version 5.2 Page 11 One of the residents case tracked at the June 2007 random inspection had suffered a broken femur. The risk assessment available on their personal file did not address the risk of falls despite accident records evidencing they had fallen five times in recent months. The Inspector noted that their individual plan and risk assessment had not been updated, and at monthly review had been annotated “no change”. At the key inspection in January 2008 four residents were case tracked by the Inspectors. Each was evidenced as having an individual plan, some of which was in a picture format. However, the content of the plans was found to basic, with sections such as likes and dislikes left blank. It was also not clear how the person who uses the service is supported to participate in their development. The plans did contain some personal, social and healthcare information but did not address areas such as contact with family or preferences regarding the provision of personal care. One resident is diabetic, and their plan did not contain information about how this is managed. The plans were annotated to evidence that they were reviewed on a monthly basis. However, the Inspectors noted that any changes in need were added to the existing plan, and for one service user a number of changes to the plan made it difficult to follow. For each of the residents case tracked there was some evidence of life story work. The home has a “safe system of working” tool that assesses mobility needs. The Inspectors noted for one resident part of this form was missing, and no information about assistance they may require with transfers was available. A completed form was available for each of the other residents case tracked, although again for one resident the original assessment had been updated on several occasions making it difficult to establish exactly what the current needs were. A risk assessment form had been completed for each of the service users case tracked. The risk assessment form is a comprehensive document that identifies potential risks and hazards, possible triggers or contributing factors and management strategies. Each of the residents sampled had been assessed for the risk of falls. The Inspectors noted that multiple risks were recorded on each form, and this again made the tool difficult to follow. A record of medical appointments attended and the outcome was found for each of the resident’s case tracked. Recent healthcare appointments included visits by the GP, District Nurse, Psychiatrist, Optician and Dentist. The Inspectors sampled the Medication Administration Records (MAR) and available medication for several residents. The available medication corresponded to that recorded on the MAR sheets, which were correctly DS0000058682.V341690.R01.S.doc Version 5.2 Page 12 completed. However, the Inspectors noted that the medication for one resident was being administered at half the dosage it had been prescribed. Agency staff working within showed one agency worker angina. They were able to not know the circumstances the home administers medication. The Inspectors a PRN (as required) medication for one resident’s identify how to administer the medication but did under which it should be administered. The Manager told the Inspectors that the home is able to provide a choice of male or female carer in line with resident’s preferences when providing personal care. The Inspectors and expert by experience observed that residents were well groomed and dressed in their own clothes. DS0000058682.V341690.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to remain in contact with their families. Activities within the home are not person centred or dementia focused. Opportunities for community activities outside of the home are limited. EVIDENCE: The Manager showed the Inspectors the homes daily activity schedule. The Inspectors noted that this was rather limited and that staffs were also expected to provide care and fulfil other duties at the same time. Activities regularly offered within the home included a quiz, however the Inspectors noted that none of the activities offered were derived from specialist dementia materials. Other regular activities offered within the home-included singalong, coffee mornings and board games. The individual plans of four people who use the service were sampled. These evidenced people who use the service being slotted into the existing activities DS0000058682.V341690.R01.S.doc Version 5.2 Page 14 programme rather than an individualised programme being developed for them. For example, one of the residents case tracked by the Inspectors was identified in their individual plan as being a keen follower of horse racing, but there was nothing about how the home might support them to keep up this interest. Another residents individual plan identified that they had been a prize-winning gardener, however it was not evidenced how this interest was supported within the placement. Discussion with residents evidenced that some have been supported to develop ‘memory boxes’ that contain items of significance for them. During the course of the inspection some residents were observed to be using art materials while others received manicures from staff. The Manager advised the Inspectors that a small number of people who use the service are able to access the community “once or twice” a month with staff support to visit local shops. One person who uses the service told the expert by experience that they were “bored” and wanted more activities that interested them. During the summer the home organises additional activities. In the previous summer a fete was held at the home and day trips to a local garden centred and farm were organised. Photographs of these events were displayed in the foyer area of the home. The Manager and people who use the service told the Inspectors that the selection of meals is decided at residents meetings. Residents told the expert by experience that they were “happy” with the meals provided. During the course of the inspection residents were observed being given the choice of where to eat their meals. The home displays a weekly menu, and the meals provided during the course of the inspection were found to correspond with this. The small grid format of the menu was not considered by the Inspectors to be particularly accessible to people who use the service. The weekly menu did not record the morning and afternoon snack provided, and the home must evidence that soft fruits are offered at least once a day in addition to the lunchtime desert. The home is able to provide meals for specialist diets, including diabetic. An alternative dish to the main choice is offered each day. During the site inspection the homes kitchen was found to be well stocked with a variety of foods. The Inspectors observed that residents who required support to eat their meals were provided with this discreetly and sensitively. DS0000058682.V341690.R01.S.doc Version 5.2 Page 15 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 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure. Recent adult protection concerns have highlighted shortfalls in the homes practise and procedure. However over recent months the home has made improvements in this area. EVIDENCE: The Inspectors viewed the homes complaints policy. This is a corporate London Borough of Waltham Forest local government policy. It states that the home aims to deal with complaints within 28 days, and gives contact details for the Commission for Social Care Inspection. The Inspector viewed the homes complaints log, and noted that none had been received since 2006. A random inspection was carried out at the home on the 14th June 2007 as a result of two adult protection matters. One resident sustained an unexplained broken femur and a second resident sustained an unexplained cut to their leg that required stitches. The resident initially alleged that a staff member had caused the injury whilst providing personal care. DS0000058682.V341690.R01.S.doc Version 5.2 Page 16 There had been a delay of three weeks in notifying the Commission and local authority of the adult protection allegation made by one person who uses the service. The Inspector was concerned to note that the home had not put in place measures to safeguard the resident who alleged a staff member had injured them. For a three week period after their allegation staff continued to provide unsupervised personal care. After this period the Manager advised the Inspector that two staff would be providing personal care until the adult protection investigation concluded. At the time of the random inspection there were no records of any investigation carried out by the senior officer on duty at the time of either unexplained injury. The Registered Manager subsequently submitted some weeks later a record of their investigation, which had been carried out when they had returned to work, both injuries having occurred whilst they were on annual leave. During the random inspection the Inspector viewed the minutes of recent staff meetings, and was concerned to note that in April 2007 an extraordinary senior staff meeting took place. This followed an argument during handover from night to day staff. The minutes state that some service users had not had their day clothes changed for three days. A different group of service users had been put to bed in their day clothes, and another service user had urinated on their breakfast tray when this was not cleared after their meal. As a result of the meeting it was agreed that handover checks would be introduced. However, there were no records of these checks for the Inspector to sample, and the Registered Manager subsequently advised that these were not routinely recorded. The Inspector also enquired whether any staff had been subject to disciplinary measures, as the allegations are tantamount to neglect, and was told that staff had been informally warned, but that this was not recorded outside of the minutes of this meeting. Since the random inspection in June 2007 a further adult protection concern had been received, and at the time of this inspection the investigation was ongoing. The home has provided adult protection training to staff since the last inspection, and discussion with three care workers on duty evidenced that each demonstrated a good understanding of safeguarding issues and their responsibilities. Sampling of the homes staff meeting minutes evidenced that adult protection issues had been regularly discussed since the random inspection in June 2007. The supervision and training records for four staff were sampled. These evidenced that each had received adult protection training since the last DS0000058682.V341690.R01.S.doc Version 5.2 Page 17 inspection and that adult protection issues had been discussed in 1:1 supervision. Discussion with the Manager evidenced a good understanding of the homes adult protection policy and procedure and they were able to describe to the Inspector the steps they would take should an adult protection allegation be made. DS0000058682.V341690.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, generally well-maintained environment. Residents are encouraged to personalise their bedrooms and there are a range of communal spaces. EVIDENCE: The home is a purpose built single storey building located in a residential area. The home has a reception area, and secure entry on and off the premises. Offices are located off a large entrance foyer as is a quiet room and hairdressing salon. Resident’s accommodation is provided in two units, ‘Yellow’ and ‘Blue’, both of which are accessed from the foyer. Each unit has its own lounge and dining areas and bedrooms, toilets and bathrooms are located on a corridor off this. DS0000058682.V341690.R01.S.doc Version 5.2 Page 19 A large kitchen area and staff rooms are located off of the ‘Blue’ unit lounge/diner. Each unit has a small kitchen that can be used for providing light refreshments. The home is set in pleasant landscaped gardens. Some minor repairs and maintenance issues were identified as a result of this inspection, and these are detailed in the requirements section of this report. During the site inspection it was observed that significant pictures had been used to identify some residents bedrooms. However, other residents had no name - or the wrong name written on their bedroom door. The Inspector also noted that some Christmas decorations were still displayed around the home that could impact upon the orientation of some residents. Each person who uses the service has their own bedroom and the Inspectors and expert by experience observed that these had been personalised with the resident’s mementos. One person who uses the service told the expert by experience that they had bought their own furniture with them to the home. During the course of the inspection the home was noted to be generally clean and hygienic. However, a strong smell of urine was noted in the bedroom of one resident and in two toilets. A used incontinence pad had also been left in one toilet. DS0000058682.V341690.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Permanent staff members undertake external qualifications and receive regular training. However, dementia care training is limited to one day for care workers. Half of care workers posts are vacant, and currently covered by agency or bank staff. The outcomes of any staffing reviews have not been made available to the Commission for Social Care Inspection. EVIDENCE: Since the last inspection the Deputy Manager post has been appointed to, and the person has recently started work at the home. A previous inspection had required the home to undertake a staffing review to ensure that sufficient staff was on duty at all times. The Manager told the Inspectors that since the last key inspection the Responsible Individual had carried out a review of staffing levels, but that this had not resulted in any changes. The Inspectors noted that any staffing review and its outcomes had not been provided to the Commission for Social Care Inspection as required. DS0000058682.V341690.R01.S.doc Version 5.2 Page 21 The Manager told the Inspectors that 8 support worker posts - half the homes complement - remain vacant, and that regular bank and agency staff cover these. The Inspectors viewed the homes current staffing rota and found that this corresponded with the situation found within the home. During the day in addition to management staff two care workers are present on each unit with an additional staff member “floating” between units, as they are required. Domestic staff and a cook are also employed. At nights two waking care staff are deployed on the unit with an on call manager. All of the homes permanent care staff have successfully completed NVQ level 2 training, although the Manager was unclear which bank and agency staff had obtained this qualification. The Inspectors sampled the personnel records for three care staff. A summary sheet containing information on the pre-employment checks undertaken for each was found on file. This evidenced that the home had obtained two satisfactory references and an enhanced Criminal Records Bureau (CRB) for all of the care workers. Sampling of personnel information also evidenced that each had completed an induction when they first joined the home. The Manager advised the Inspectors that the home provides one-day dementia care training to care workers. The home has not developed any links to nationally recognised dementia care organisations or identified a particular dementia care model that it works to. Discussion with two care workers evidenced little awareness of the models of care for dementia, or concepts such as reality awareness. The Inspectors sampled the training records for three care workers. These evidenced that in the last year they had undertaken a range of training including adult protection, dementia care, moving and handling, medication and risk assessment training. DS0000058682.V341690.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes manager is suitably qualified and experienced. They are aware of the need to promote safeguarding. Health and safety practises comply with regulations. The Manager has an understanding of person centred planning and some developments in this area have been made. EVIDENCE: The Manager advised the Inspectors that they have obtained NVQ level 4. They also advised that they had completed a four day dementia care training course run by the local authority, but had not undertaken any other specialist DS0000058682.V341690.R01.S.doc Version 5.2 Page 23 dementia care training. During conversations the Manager did demonstrate an awareness of the different types of dementia. The Manager told the Inspectors that the Borough was developing a new quality assurance system across its homes, and two residents from 87 Mapleton Road will be asked to participate in this. The Inspectors noted that this quality assurance process would not obtain the views of all residents and their families, or take into account the communication needs of some residents at the home. The Manager advised the Inspectors that each person who uses the service has a family member or appointee who assists them with finances. The home retains a small amount of money on behalf of each resident. The Inspectors sampled the records and monies available for four people who use the service. A logbook with a record of the date, amount and nature of each transaction was available for each. Each residents monies are kept separately and securely, and the monies available corresponded to that recorded in the log. Sampling of personnel records for three care workers evidenced that one had received supervision on five occasions in the current inspection year; another had received six supervisions and a third care worker had received three supervisions since joining the home in July 2007. The Inspectors sampled the homes log of fridge and freezer temperatures. These were recorded on a daily basis and found to be within acceptable limits. During an inspection of the homes main kitchen the Inspectors found started processed foods and prepared dishes had all been appropriately date labelled. The home displays a current insurance certificate with appropriate cover. The Inspectors read the daily logs for four service users and cross-referenced these with the accident and incident logs. This evidenced that each time an accident or incident was recorded in the daily log a corresponding entry had been made in the accident and incident log. Where the accident and incident report had identified follow up action, the daily log evidenced that this had occurred. The Inspector viewed the Commissions record of correspondence received from the home since the random inspection in June 2007, and noted that occurrences affecting the well being of residents had been promptly reported. The Inspectors viewed the homes fire records. These evidenced that the homes fire alarms and smoke detectors are tested on a weekly basis and the outcome of these recorded in a log. DS0000058682.V341690.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 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 2 X 3 3 X 3 DS0000058682.V341690.R01.S.doc Version 5.2 Page 25 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 Timescale for action The registered manager must 30/06/08 ensure that service users or their representatives agree to the plan of care. This is a restated requirement. The previous target of 20/09/07 was not met. Individual plans must reflect the current mobility needs and any assistance required with transfers. Individual plans must address the residents, personal, social and healthcare needs. 2. OP9 12 13 17 The Registered Manager must ensure that residents receive their medication in accordance with its prescription. This is a restated requirement. The previous target of the 20/09/07 was not met. All staff must be aware of the DS0000058682.V341690.R01.S.doc Version 5.2 Page 26 Requirement 30/06/08 circumstances in which to administer “as required PRN” medication. 3. OP12 12 16 The Registered Manager must ensure that residents are supported to undertake individual social and leisure pursuits. This is a restated requirement. The previous target of the 20/09/07 was not met. 4. OP14 12 The Registered Manager must ensure that information is presented in an accessible format to support people who use the service make informed choices. This is a restated requirement. The previous target of the 20/09/07 was not met. 5. OP15 12 The home must maintain a log of all meals provided including morning and afternoon teas, and evidence that soft fruits are offered at least twice per day. The home must consolidate and further develop recent improvements in its adult protection and safeguarding practises. In the shower rooms of both units water damaged doors, mouldy grouting and missing tiles must be repaired or replaced. The missing or broken handles on emergency pull cords must be replaced. DS0000058682.V341690.R01.S.doc Version 5.2 Page 27 30/06/08 30/06/08 30/06/08 6. OP18 12 13 30/06/08 7. OP19 13 23 39 30/06/08 8. OP26 23 The registered manager must take action to address the mal odours in some service users bedrooms. This is a restated requirement. The previous target of the 25/09/06 was not met. 30/06/08 9. OP27 18 The registered persons must review staffing levels and undertake any actions identified out of the review so as to ensure it has sufficient staff to meet the assessed needs of service users throughout the day and night. A report of actions undertaken following this review must be forwarded to the inspector. These are restated requirements. The most recent target of the 25/09/06 was not met. 30/06/08 10. OP33 24 The registered manager must develop a quality assurance system that reflects the communication needs of the service users. This is a restated requirement. The most recent target of the 25/09/06 was not met. 30/06/08 # DS0000058682.V341690.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP8 Good Practice Recommendations When individual plans and assessments are reviewed any changes made, a new document should be drawn up. A separate assessment should be completed for each identified risk or hazard to make it more accessible and user friendly. The home should consider the use of specialist dementia materials in its activity programme. 3. OP12 DS0000058682.V341690.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 DS0000058682.V341690.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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