Inspection on 29/08/06 for Parkview

This inspection was carried out on 29th August 2006.

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 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

Parkview 16/08/07

Parkview 21/02/06

Parkview 23/08/05

Parkview 21/02/05

Parkview 09/08/04

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

CARE HOMES FOR OLDER PEOPLE Russell House Woolwich Road Bexleyheath Kent DA7 4LP Lead Inspector Lorraine Pumford Unannounced Inspection 29th August 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Russell House DS0000006794.V309589.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. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Russell House Address Woolwich Road Bexleyheath Kent DA7 4LP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8303 7889 020 8304 8017 jane.kingsmill@kcht.org.uk www.kcht.org Kent Community Housing Trust Mrs Jane Louise Kingsmill Care Home 69 Category(ies) of Dementia - over 65 years of age (69) registration, with number of places Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: Russell House, by which name the Home was previously known, is a purpose built care home providing accommodation to 69 older people who are physically frail or have dementia care needs. All rooms in the home are for single occupancy; forty of the bedrooms have en-suite facilities, the other twenty nine rooms having easy access to communal toilets and bathrooms within the four units in the home. The home is located in a residential area in Bexleyheath in the London Borough of Bexley, and has good road, rail and bus links with access to local shopping and leisure facilities. The home is part of the Kent Community Housing Trust, a charity established in 1990 and now operating 22 care homes throughout East Kent, West Kent, Medway, and the London Boroughs of Bexley and Greenwich. The organisation provides a range of care services to people in need within local communities. The home has undergone an extensive building and refurbishment programme over the last three years, the final phase being completed in January 2006. The home is now able to offer 69 en-suite bedrooms, arranged in four units over two floors, 31 rooms on the ground floor and 38 on the first floor; the first floor is served by two passenger lifts. Each of the four units has their own lounge and dining room. The home has a day centre on site, which offers care to elderly people with specialist dementia care needs. The home has car parking to the front of the building and two attractive, well equipped, integral garden areas accessible to the residents and their visitors. In August 2006 KCHT opted to change the name of the Home from Russell House to Parkview, and it is by this name that the Home will be referred to in future Inspection Reports. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors who spent approximately 6.5 hours in the home. The inspectors spoke with the manager, and assistant managers. Three members of staff were interviewed in private and a number of staff were spoken with additionally during the course of the inspection. Information they contributed has been incorporated into this report. Seven CSCI comment cards were completed by relatives and two by service users’ GPs. These comments have also been included. During the course of the inspection a number of documents and records were examined and the files of six service users were examined specifically relating to their care. Additionally parts of the premises were inspected. Fees for the care and service provided are currently £460.95 to £484.19. There are additional cost for newspapers, hairdressing, chiropodist, reflexology and massage. What the service does well: Procedures are in place that protect service users’ finances. Service users are enabled to maintain contact with family and friends. The home operates a key worker system and staff clearly understand the additional responsibility of this role. Service users are provided with a varied nutritional diet. Service users are provided with appropriate community health care support. Staff ensure service users are enabled to participate in a varied range of activities. Service users and their representatives can be confident that action will be taken to address any concerns brought to the managers attention. The majority of staff hold relevant NVQ qualifications in care and are provided with regular training opportunities. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 6 Service users live in a clean, well-maintained and suitably furnished home. What has improved since the last inspection? What they could do better: The home must not accommodate service users outside of the home’s category of registration. In this instance service users assessed as requiring nursing care need to be found a suitable placement where their nursing needs can be met. Whilst the responsible individual is undertaking a visit to the home each month to ascertain the quality of care and service provided, a copy of the findings must be forwarded to the CSCI in accordance with regulation 26 of The Care Homes Regulations 2001. It is apparent that staffing in the home requires urgent review and action needs to be taken to ensure that suitably qualified and competent staff are employed in a sufficient number to meet the needs of the service users accommodated. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 7 A photograph of service users should be attached to their medication records and staff need to ensure that rooms housing medication are maintained at a safe temperature. Service users’ care plans need to be updated to the new format and be completed comprehensively. A full record of all activities service users participate in should be maintained. Sluice rooms need to remain clear to reduce the risk of the spread of infection. 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. Russell House DS0000006794.V309589.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 Russell House DS0000006794.V309589.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are offered a place following a comprehensive assessment of need. EVIDENCE: The manager informed the inspectors that Kent Community Housing Trust {KCHT} has recently introduced a new assessment and care plan for service users. Senior staff were currently working on changing information from one system to another. All of the service users are admitted via the local authority and in the first instance information regarding a service user’s needs is supplied by care managers. The manager stated either she or one of the two assistant managers would visit prospective service users in hospital or their own home to undertake an initial assessment. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 10 Samples of six service users’ files were examined. The format seen covered information regarding the service users’ personal history, health and social interests. There was evidence of risk assessments being completed and moving and handling assessments; however, due to the current transition taking place, it was difficult for the inspectors to gain an overall view in relation to these records at this stage. Some parts of the new format were still incomplete. The manager confirmed that, prior to admission, letters were sent to all prospective service users or their advocates, stating that following the initial assessment the home could meet the new service users’ needs. Discussion took place with the manager regarding the high needs of some of the service users accommodated. The manager stated that a minority of service users had been assessed by relevant health and social care professionals as requiring nursing care. The Manager stated that in some instances service users had been assessed some months before and alternative appropriate placements had still not been found by those people responsible for the task. In these instances service users assessed as needing nursing care are being accommodated outside the home’s terms of registration; this matter needs to be addressed as a priority. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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 good. This judgement has been made using available evidence including a visit to this service. However, to maintain this judgement it will be essential that the new care plan format is implemented comprehensively. Service users’ privacy and dignity is respected by staff working in the home. Medication procedures in place safeguard service users accommodated. EVIDENCE: As previously stated KCHT are currently introducing a new care plan format. As with the pre admission assessment the inspectors found the quality of paperwork varied; for two new residents information was minimal giving just basic information and did not specify needs and how these needs were to be met on a daily basis. There was no nutritional assessment to indicate if a service user had a special diet, required food supplements etc, even when a service user had been assessed as having a specific need in relation to nutrition at the time of admission. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 12 There was no information around pressure area care to enable staff to identify the need for appropriate pressure relieving equipment. Care plans are kept in the main office to enable senior staff to use them as a point of reference for relatives, or social and health care professionals making inquiries during the day. A member of staff from each unit is then responsible for collecting, completing and returning the documents between shifts. The inspectors voiced the opinion that care plans should be available to staff working on the units as a point of reference and to record relevant information as and when it occurred, the first issue being particularly important in the event of agency and bank staff working on the units. The home operates a key worker system; staff spoken with were able to provide the inspector with a clear picture of the additional responsibilities this entails and the way in which they provide help and support to service users they are responsible for. The inspectors discussed with the manager the fact that documentation varied, dependent on the person who had completed the assessment and care plan. Discussion took place regarding the need for staff responsible for completing the documentation to have appropriate training to ensure that the standards of performance were being completed consistently and appropriately for the benefit of the service user being cared for. Relatives who completed CSCI comment cards stated they were kept informed and consulted about the care and important matters affecting their relative or friend living in the home and were involved in the review process. All service users seen were wearing clean, appropriate clothing. It was evident that care staff provide support to service users to enable them to attain an individual and personal identity. Good interaction was seen between staff and service users. Staff addressed service users by their preferred name, and spoke with them in a respectful manner. Service users spoken with stated that staff were kind and helpful. Staff were seen to respect the service users’ privacy and dignity when assisting with personal care, and provided reassurance when service users became anxious. The majority of service users the inspectors met with appeared relaxed and comfortable, one service user stated I wasnt very well when I came here, the staff helped me and now I feel a lot better. All of the relatives who completed comment cards stated they were satisfied with the overall care provided. The storage, medication and medication records for six service users were examined. Medication trolleys for each unit are stored in secure rooms on each Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 13 floor. The medication room on the first floor felt warm on the day of inspection and the manager was asked to keep an ongoing record of room temperatures to ascertain if further action was required to maintain medication at an appropriate temperature. A record of staff signatures was being maintained, this enables persons inspecting the records to undertake an effective audit. Staff spoken with stated that they have received formal training before undertaking the task. MAR sheets were found to be completed appropriately with no unexplained gaps; there were instances of handwritten entries and staff were asked to ensure that hand written entries were signed by two members of staff to reduce the risk of an error occurring. There were no photographs attached to medication records for two of the service users, one had only recently been admitted and the other service user was due to stay in the home on a short-term respite basis; this matter was discussed with the manager who stated that photographs would be taken and attached to the relevant documents as soon as possible. Documentation seen completed by the manager at the time of the inspection indicated that service users receive regular medical support from service users GPs and other relevant health care professionals when required. It was not possible from the sample of care plans seen to ascertain if this was being recorded in service users’ care plans on a regular basis. GPs who completed CSCI comment cards stated they had a good working relationship with the home and they felt staff acted appropriately to meet the health care needs of service users accommodated. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are enabled to maintain links with family, friends, and the local community. Service users are provided with a varied balanced nutritional diet and have opportunities to participate in appropriate activities. EVIDENCE: The home employs two activity coordinators and has a designated room for the purpose. Unfortunately on the day of the inspection neither person was working in the home and no activities seemed to take place with service users. Staff stated that service users’ participation in activities is recorded in their care plan using green ink. With the assistance of staff three service users files were examined and the small minority of entries pertaining to activities were found. Staff felt that this was unrepresentative and felt that information was not being recorded on a regular basis. Senior staff agreed to discuss the issue with the activity coordinators who are responsible for updating records. Entries seen indicate service users participate in a range of age appropriate activities and outings. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 15 Relatives who completed CSCI questionnaires stated that they are always made to feel welcome in the home and are able to meet with service users in private if they wish to. The menus seen at the time of the inspection indicated that service users are provided with an either/or option at breakfast, lunch and tea and an alternative is provided if service users do not like what is planned on the menu. Staff spoken with stated that special diets are provided for service users with diabetes or other health or cultural needs. The food provided was fresh and there was sufficient for service users wanting a second helping. Service users spoken with stated they generally enjoy their meals. The Cook had finished for the day; it was not possible for staff to locate her records to ascertain if a record was being maintained of alternative meals provided to service users. Soup is provided as an option seven days a week and the manager was asked to discuss with the Cook the need to record the type of soup provided to prevent service users requiring a soft diet from receiving a repetitive meal. The manager stated that the organisation was currently reviewing the delivery of meals within their homes and she would ensure that this issue was addressed. The inspectors observed lunch on two separate units the Red unit and Park View unit. The atmosphere on the Red unit was found to be calm and relaxed with staff assisting service users who required help in an unrushed manner. The staff stated they had worked together for a number of years and worked well together and understood the needs of the service users accommodated. The staff team on the Park View unit consisted of agency and bank staff (see standard 27). The staff began to assist service users to the tables before the food had arrived in the dining area. None of the tables had tablecloths, cutlery or condiments, which would have been a helpful prompt for some of the more dependent service users. Although staff had prepared information as to the food chosen by the by each service user they did not have additional information such as the preferred size of portion, or service users likes and dislikes regarding items of salad which accompanied the cold meat. This led to some service users becoming agitated and aggressive towards staff when they did not get the meal they wanted. One service user told the inspector its not normally like this and concluded that the usual staff must be on holiday. The mealtime on this unit remained unsettled for both service users and staff alike. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Service users and their advocates can be confident that appropriate action will be taken to address any concerns they raise. Adult protection training is in place to safeguard the wellbeing of service users. EVIDENCE: Service users and their advocates are given information about the organisations complaints procedure as part of the admission pack; this includes the document making your views known. Comment cards completed by relatives and their advocates indicated that they have been made aware of the homes complaints procedure although to date none stated they had felt the need to make a complaint. The policy and procedures regarding making a complaint are clear, concise and easy to understand and all relevant contact details for the organisation and with the CSCI are provided. Record seen indicate that the manager keeps a record of any complaints brought to her attention and the action taken to address the issues raised. The CSCI have received no complaints regarding this service since the last inspection. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 17 Staff spoken with stated they had received adult protection training and were aware of the term whistleblowing. Staff spoken with stated they felt confident that they could go to senior staff working in the home if they had any concerns regarding the practise of colleagues. Russell House DS0000006794.V309589.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 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 good. This judgement has been made using available evidence including a visit to this service. Service users are accommodated in clean, well-maintained, appropriately furnished accommodation. EVIDENCE: All of the service users are accommodated in single bedrooms some of which are provided with ensuite facilities. The home has recently undergone a major refurbishment and has benefited from an extensive redecoration and refurbishment programme. There is a central courtyard, which has a garden and seating areas and is well maintained. Service user day space consists of one of four lounge and dining areas with a small satellite kitchen area. Lounges have a choice of seating for service users. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 19 Building work has recently concluded to enable Park View to accommodate service users from another KCHT home. Whilst the home has physically benefited from such a major refurbishment and redecoration programme, staff expressed concern regarding the difficulties they experienced in monitoring the whereabouts of service users particularly with the additional length of corridors between lounge and bedrooms. Staff stated that relatives had commented regarding the lack of staff in the lounge areas when in fact staff may have been needed to assist service users elsewhere on the floor. Bathrooms have either showers or baths which provided service users with a choice. Bedrooms seen were individually personalised and comply with the National Minimum Standards in relation to furniture and fittings. A service user spoken with stated that she liked her bedroom and had been provided with everything she needed. A visitors room appropriately furnished for the purpose is situated on the ground floor and available for service users who wish to meet with relatives in a room other than their bedroom. Service users also have access to a telephone to enable them to make phone calls in private. The home has an emergency call system in all areas used by service users; there are handrails in communal areas and grab rails in bathroom and toilets. Baths are provided with appropriate aids to assist service users with bathing. Staff spoken with stated that the laundry equipment provided meets the needs of the current service users accommodated. All areas of the home were clean and free from unpleasant odour. The Inspectors observed the build up of clutter in some sluice areas, this was drawn to the managers attention who stated that action would be taken to remove any unnecessary items to ensure the area can be effectively cleaned and reduce the risk of the spread of infection. Russell House DS0000006794.V309589.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29.30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An over reliance on bank and agency staff means service users are not always cared for by a sufficient number of staff who understand their needs. Sound recruitment procedures are in place, which safeguard service users. EVIDENCE: A number of issues arose in relation to the current staffing levels within the home. This had occurred primarily as a result of KCHT awaiting the closure of another of their homes with the residents and staff being amalgamated with Park View. The manager stated that during the period leading up to be the amalgamation she had been unable to recruit care staff as employees from the home due to close would be transferring over to work in Park View. This has led to a high number of a bank and agency staff working in the home in the interim period. The manager stated that this issue was now being addressed and she was currently recruiting a number of new care staff. A number of relatives who completed CSCI comment cards stated they felt that there was insufficient staff employed to meet the needs of the service users. Staff employed by KCHT acknowledge that it was necessary to employ temporary staff in order to attain a minimum staffing level. however, they also stated that the additional time needed to explain and show temporary staff Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 21 how to provide care for the service users was time-consuming and delayed them in performing their own care tasks. On the day of the inspection there were three members of staff working on the a.m. shift on Park View unit, this unit provides care for approximately eighteen service users and on this occasion all staff were either bank or agency staff. The effect of this was apparent and service users appeared less settled. This escalated over the lunch period once staff were involved in serving lunch and trying to provide assistance to those requiring help with eating. During this time a number of the other service users in the lounge became very unsettled to the point a confrontation between two service users occurred and in this instance the inspector intervened to prevent a service user being assaulted by a peer. With the increased number of service users accommodated on each unit a member of staff stated that in her opinion staff were finding they had to deal with conflict and aggression between service users more frequently. It is apparent that staffing in the home requires urgent review and action needs to be taken to ensure that suitably qualified and competent staff are employed in a sufficient number to meet the needs of the service users accommodated. Additional staff are employed to undertake administration, cleaning and cooking; the home also benefit from having a full-time maintenance person. The majority of staff employed hold a NVQ 2 qualification with 11 members of staff currently undertaking this qualification. Staff also have the opportunity to undertake the NVQ three qualification and a number of staff hold this qualification or are currently undertaking the course. Staff spoken with stated that they had received statutory training regarding manual handling, food hygiene and fire safety. Staff have also received training in relation to caring for service users with dementia as well as understanding the needs and care of people with diabetes and strokes etc. Staff spoken with felt that the organisation provided them with good training opportunities. A designated member of staff has responsibility for monitoring staff training and a matrix is kept in relation to this. Staff spoken with stated they receive supervision from a senior member of staff on a regular basis who discusses both practical issues and relevant personal development and training opportunities. Records seen indicate that the senior staff are provided with appropriate leadership and supervision training to enable them to undertake this task. Records were examined in relation to the homes recruitment procedures. Three members of staff were interviewed in private and the files of three members of staff were examined. All of the staff employed had received appropriate POVA/CRB checks. There was confirmation that identity checks had been made as part of the employment process. From Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 22 records seen and discussion with staff it apparent that sound recruitment procedures are in place. Relatives who completed CSCI comment cards all stated that staff were dedicated excellent and provided care above and beyond the call of duty. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 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 area is good. This judgement has been made using available evidence including a visit to this service. There is a system in place for reviewing and improving the quality of care provided. Health and safety practises and staff training protect service users and staff working in the home. EVIDENCE: The manager has a number year of years experience working with older people and holds The Registered Managers award and a Certificate in Management qualification. The manager stated she undertakes her own audit of the care and service provided in the home and provides regular reports to her line manager. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 24 The manager stated that the home receives regular monthly audits from KCHT in accordance with regulation 26 of the Care Standards Act 2000. A copy of this report should be forwarded to the CSCI and to date this has not happened; this matter needs to be addressed. Relatives who competed CSCI comment cards stated they were satisfied with the overall care provided. Staff spoken with stated they had never seen a copy of the inspection report and were only told the negative points, i.e. the things they were getting wrong and action required by them to improve the service. They were surprised that inspectors always endeavoured to highlight positive aspects of a service as well. Sharing the report may in the long term improve staff job satisfaction and help them to work together towards improving the service. The manager stated that the final report was kept in the reception area and was always available to anyone wishing to read it. Records seen indicate that a number of service users are unable to manage their finances independently; in these instances they are assisted by relatives or a local authority financial advocate acts on their behalf. Small amounts of money are retained for individually named service users. The sample examined indicated that service users personal allowance tallied with the house records. Relatives are provided with a receipt when depositing money on behalf of service users and a record is kept of money deposited and withdrawn. Records seen indicated the home has recently had safety and maintenance checks to the electrical wiring, gas supply and the fire detection system. The lift has also recently been serviced. Staff stated and records seen indicate that staff also received first aid training. Staff confirmed they have also undertaken infection control courses and moving and handling training. KCHT have policies in place regarding the storage and use of potentially hazardous substances. Russell House DS0000006794.V309589.R01.S.doc Version 5.2 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 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 X X 3 Russell House DS0000006794.V309589.R01.S.doc Version 5.2 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 OP33 Regulation 26 Requirement Where the registered provider is an individual but not in day-today charge of the home he shall visit the home in accordance with this regulation. The registered provider must supply a copy of the report record to be made under paragraph 4(c) to the commission. Undertake a review of service users’ dependency levels, with a view to employing suitably qualified and competent staff in a sufficient number to meet the needs of the service users accommodated. The Registered Manager must liaise with the placing authority to prepare an Action Plan for the movement of the small group of residents whose needs can no longer be met to more suitable placements. Timescale for action 30/10/06 2 OP27 18 02/01/07 3 OP7 14 02/01/07 Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 27 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 OP7 Good Practice Recommendations Care plans need to be updated on the new format and be completed comprehensively. Staff need to ensure that rooms housing medication are maintained at a safe temperature. Photographs of service users should be attached to their MAR sheet to reduce the risk of error. The Home should maintain a record of all activities service users participate in. The Home must ensure that sluice rooms remain clear to reduce the risk of the spread of infection. 2 3 4 5 OP9 OP9 OP12 OP26 Russell House DS0000006794.V309589.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Russell House DS0000006794.V309589.R01.S.doc Version 5.2 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. 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