CARE HOMES FOR OLDER PEOPLE
Olivia Residential Care Home (2) 7 Beechcroft Avenue New Malden Surrey KT3 3EG Lead Inspector
James OHara Unannounced 19 September 2005 11:20 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 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. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Olivia Residential Care Home (2) Address 7 Beechcroft Avenue, New Malden, Surrey, KT3 3EG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8949 1701 020 8949 1701 maggie@ktbart.fre/online.co.uk Mrs Lucja Bart Mrs Lucja Bart Care Home 6 Category(ies) of OP Old Age (6) registration, with number of places DE Dementia (6) MD(E) Mental Disorder - over 65 (6) Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7 March 2005 Brief Description of the Service: The home is situated in a quiet residential area, yet close to both local amenities and town centre facilities. The home is much influenced by Polish language, food, religion, media and culture. This meets the needs of residents ideally, as each is Polish and it is clear that this influence is much valued by those who live here. It should be noted that the service is not exclusive to residents from Poland, but any prospective residents should be aware of the influence of Polish culture in the Home. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The home was inspected under the National Minimum Standards. This unannounced inspection started at 11.20am and finished at 1.20pm on a Monday morning/afternoon. The registered manager supported the inspection process. Methods of inspection included, previous inspection experience of the home, a tour of the premises observation of contact between staff and residents and discussion with the registered manager. A number of comment cards were returned to the Commission for Social Care Inspection as feedback from service users relatives. Records examined included the Statement of Purpose and the Service Users Guide, Staff Criminal Records Bureau Checks, care plans, medication and medical records, staff training records, fire safety records and complaints. Previous requirements and recommendations were discussed with the registered manager. What the service does well: What has improved since the last inspection?
The registered manager has recently completed the Registered Managers Award and NVQ level 4 in Care. A new Statement of Purpose and Service Users Guide have been developed that reflects to the homes registration. All bedrooms have now been fitted with call bells and the radiator was covered in the vacant room prior to a new resident moving into the room as required at the last inspection. All training attended by staff at the home is now recorded and all staff have completed Criminal Records Bureau Checks. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 6 The Fire Officer visited the home in order to assess the fire procedures, equipment and systems. Eight new fire doors have been fitted in the home and fire risk assessment has also been completed. 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. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 8 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 standard(s) 1, 3, 4 and 5. The registered manager is Polish and the home is much influenced by Polish language, food, religion, media and culture. This meets the needs of residents ideally, as each is Polish and it is clear that this influence is much valued by those who live here. It should be noted that the service is not exclusive to residents from Poland, but any prospective residents should be aware of the influence of Polish culture in the Home. EVIDENCE: Originally Olivia residential home was part of two adjacent semi-detached properties Olivia 1 and Olivia 2. At the beginning of this year the registered manager applied to the Commission For Social Care Inspection to deregister one of the homes and increase the numbers of residents in the other. The application was agreed and subsequently Olivia 1 was closed/deregistered. As required at the last inspection the registered manager has developed a new Statement of Purpose and Service Users Guide that reflects to the homes registration. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 9 As required at the last inspection the resident who moved into the home from the home next door has had her needs assessment reviewed by her care manager. As required at the last inspection the registered manager has provided a privacy screen for use in the double room. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11. Resident’s health, personal and social care needs are being appropriately met and reviewed. Residents’ medication is well managed to ensure maximised good health. Personal care is carried out in a way that residents prefer so that dignity, privacy and choice are maintained. EVIDENCE: One resident recently passed away in hospital. Feedback in the form of questionnaire returned to the Commission For Social Care Inspection indicated that relatives felt that the care given by Mrs Bart to this resident when she was in hospital was over and above that expected in the circumstances. Other questionnaires were also very positive, one residents relative said “my mothers health has improved considerably since she has been in the home” and another said “we are very happy with this home it is perfect for my mother. These relatives verified during telephone conversations made to them following the inspection that the home is meeting their relatives cultural needs and that the manager is committed to offering a good service.
Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 11 All residents are registered with a local General Practitioner. The registered manager said that when a particular resident stays at the home on respite basis she is temporarily registered with this General Practitioner. At present none of the residents self-medicate. Medication is stored in a locked cabinet in the dining room and on the day of the inspection records accurately reflected administration details. Evidence was seen of medication reviews carried out by the same General Practitioner. Evidence was seen that a local pharmacist visits the home on a six monthly basis to check and offer advice on medication. The home has a book for the receipts and returns of medication. All residents have an individual plan of care that is generated on admission and developed throughout the residents stay. Records reveal care plans are subject to regular review, seeking the views of all appropriate parties. The quality of information recorded by staff is generally good. Reviews involve all relevant parties, including residents, family members or representatives, key-worker and Care Manager. There was evidence that a Chiropodist visits the home every three months and an Optician and a Dentist visit on an annual basis or sooner if need be. The registered managers daughter is a qualified occupational therapist and the other member of staff is a qualified nurse. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. Meals are wholesome, appealing and the diet is nutritious. The meals are served in pleasant surroundings, and at times convenient to the residents. EVIDENCE: Residents are supported to maintain links with the local religious community, both through assistance with transport to and from church, where required, and through visits to the home from a Polish priest. Residents are able to maintain links with the wider Polish community through access to satellite television broadcasting in the Home. The home has developed residents questionnaires in order to identify and record the views of residents, their relatives and friends. This information is used by the home as an effective quality monitoring system. The home’s menu contains a number of Polish dishes, reflecting the preferences of service users. On the day of the inspection lunch consisted of a polish meatballs, potatoes, mixed vegetables followed by fruit in jelly. This was sampled and was well presented and tasty. Residents said that they enjoyed food provided in the home.
Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 13 The registered manager said that residents are offered opportunities to go on car trips to Kingston and Richmond Park, shopping and walks. Activities in the home include group exercise (facilitated by the registered managers daughter, a qualified Occupational Therapist) drawing and knitting, reading newspapers and books and watching Polish television. One resident was working in the garden on the day of the inspection; he said that he likes to keep the place tidy. There is no recorded evidence of social activities attended by the residents. It is recommended that the registered manager record social activities attended by the residents. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. Residents are confident that any concerns they may have are listened to and acted upon. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure residents are so far as reasonable practicable protected from abuse, neglect and/or harm. EVIDENCE: The home has an appropriate Complaints procedure, a copy of which is included on the Statement of Purpose. No complaints have been lodged with the Commission for Social Care Inspection in relation to the service in the last twelve months. The home has adopted the Protection of Vulnerable Adults policy developed by the Royal Borough of Kingston, the host authority for the service. All staff has attended Adult Protection training. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The home provides a safe, well-maintained environment with residents having access to safe and comfortable facilities. Residents have sufficient aids and adaptations to ensure safety. The home is clean and very pleasant. EVIDENCE: The home is situated in a quiet residential area, yet close to both local amenities and town centre facilities. The home has a dining room with tables and chairs however the registered manager stated that given the choice residents generally like to eat in their rooms. The home offers access to toilet and shower facilities on the ground floor, whilst a bath is available on the first floor. Toilets and bathrooms in the home were found to be clean, functional and attractive on the day of inspection. There is a lack of wash-hand basins in the bedrooms. Should the needs of the current residents living at the home change or the assessed needs of
Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 16 prospective residents require wash-hand basins or specific bathing arrangements/equipment then the registered manager said that she will ensure that this is provided in order to meet those needs. The home appears to meet the current needs of residents well. There is evidence of regular consultation with appropriate health care professionals to ensure that the needs of the residents are met. Observation revealed that residents are afforded the opportunity to personalise their rooms to reflect their tastes and preferences. All bedrooms have now been fitted with call bells and the radiator was covered in the vacant room prior to a new resident moving into the room as required at the last inspection. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The home is run as a family business, the registered manager is supported by her daughter a fully qualified occupational therapist and a member of staff, a qualified nurse who lives in. This continuity of care is undoubtedly one of the home’s strengths and contributes to the family atmosphere prevalent within it however given that the home plans to increase the numbers of residents living at the home then the staffing levels will need to be reviewed. EVIDENCE: The registered manager reported that the input of Polish staff members familiar with the language and customs of a Polish Home is of particular value. The ability of staff to converse with residents in their first language is clearly beneficial to meeting their individual and collective needs. The registered manager stated at the last inspection that when the numbers of residents increase at the home then the numbers of staff on shift would need to be assessed. This issue was not discussed with the registered manager on the day of the inspection however following a telephone conversation the next day it was recommended that the registered manager send a copy of the homes staffing rota to the Commission For Social Care Inspection. Criminal Records Bureau Checks were seen for all members of staff. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 18 The registered manager has now recorded all training attended by her and staff at the home. It is recommended that a training programme be developed for the home to include Food Hygiene, First Aid, Fire Safety, Moving and Handling, Medication, Health and Safety and Protection of Vulnerable Adults. There was certificated evidence that staff had attended training on Protection of Vulnerable Adults, First Aid, Infection Control and one member of staff has attended Fire safety training. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 38. The home appears to be well managed whilst maintaining an atmosphere of calm and conviviality however the health, safety and welfare of residents could be compromised unless fire safety procedures are set in place for the home. EVIDENCE: The registered manager has recently completed the Registered Managers Award and NVQ level 4 in Care, she registered manager has a good deal of experience in the management of small care Homes and brings her range of skills to bear in the day-to-day operation of the service. As required at the last inspection the Fire Officer has visited the home in order to assess the fire procedures, equipment and systems. Eight new fire doors have been fitted in the home and fire risk assessment has also been completed. The registered manager was not able to produce a copy of the fire officer’s last report but will forward this onto the Commission For Social Care Inspection.
Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 20 The registered manager must complete a fire safety procedure for the home and ensure that all staff is aware of the procedure. The registered manager must ensure that regular quarterly fire drills occur in the home and records of these are kept in the home and all members of staff must attend training on Fire Safety. Certificates were seen for Portable Appliance testing 18/05/05, Legionella testing 12/09/05, Fire Equipment Checked 26/05/05 and Environmental Health visited the home on the 16/08/05. The last Landlords Gas Safety check was completed on the 17/03/04 so is over due. The registered manager must ensure that a Landlords Gas Safety check is carried out at the home. Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x x x 2 Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 22 No. Are there any outstanding requirements from the last inspection? 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 38. Regulation 23 (4) a. Requirement The registered manager must complete a fire safety procedure for the home and ensure that all staff is aware of the procedure. The registered manager must ensure that regular quarterly fire drills occur in the home and records of these are kept in the home and all members of staff must attend training on Fire Safety. The registered manager must ensure that the a Landlords Gas Safety check is carried out at the home. Timescale for action 31/12/05 2. 38. 23 (2) p. 31/12/05 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 12. 27. Good Practice Recommendations It is recommended that the registered manager record social activities attended by the residents. It is recommended that the registered manager send a copy of the homes staffing rota to the Commission For Social Care Inspection.
G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 23 Olivia Residential Care Home (2) 3. 30. It is recommended that a training programme be developed for the home to include Food Hygiene, First Aid, Fire Safety, Moving and Handling, Medication, Health and Safety and Protection of Vulnerable Adults Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 24 Commission for Social Care Inspection Croydon, Kingston & Sutton Office 8th Floor, Grosvenor House 125 High Street, Croydon CR0 9XP 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 Olivia Residential Care Home (2) G53-G53 S13427 olivia2UI V248425 190905 stage4.doc Version 1.40 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
