Inspection on 08/05/08 for Perrygrove

This inspection was carried out on 8th May 2008.

CSCI found this care home to be providing an Adequate service.

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

Perrygrove 25/06/07

Perrygrove 05/09/06

Perrygrove 02/09/05

Perrygrove 11/04/05

Perrygrove 26/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Perrygrove Rectory Fields Crescent Charlton London SE7 7EN Lead Inspector Ms Pauline Lambe Key Unannounced Inspection 09:30 8th & 15th May 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 Perrygrove DS0000006855.V362991.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. Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Perrygrove Address Rectory Fields Crescent Charlton London SE7 7EN 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 8856 3995 020 8319 1663 www.kcht.org Kent Community Housing Trust Sonia Clair Williamson Care Home 43 Category(ies) of Dementia (7), Old age, not falling within any registration, with number other category (36) of places Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 36) 2. Dementia - Code DE (maximum number of places: 7) The maximum number of service users who can be accommodated is: 43 25th June 2007 Date of last inspection Brief Description of the Service: Perrygrove is a Care Home for up to 43 older people. Accommodation and personal care is provided to 36 older people and to 7 older people with dementia in s separate unit. Kent Community Housing Trust manages the service. The property is situated in a quiet road in Charlton close to local shops and bus routes and the town centres of Lewisham, Greenwich and Woolwich are within easy access. Accommodation is provided over three floors. The home has one shared room and the rest are for single occupancy, which is currently used for single occupancy. Fifteen rooms have en-suite toilet and wash hand basins and adequate shared assisted bathing and toilet facilities were provided. Adequate communal space is provided on the ground floor and the home has a designated smoking room. To the rear of the property is a pleasant enclosed garden, which is accessible to residents and well maintained. To the front there is some parking space. The current fees ranged from £442.96 - £545.00. Residents pay privately for items such as hairdressing, private chiropody, toiletries, newspapers and outings. Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The site visit for this unannounced key inspection was carried out over two days, 8th and 16th May 2008. On the first day of the inspection 76 residents were in residence and the home had two vacancies. The registered manager was on duty and assisted with the inspection. The last key inspection was done on the 25th June 2007 and the service had a follow up random inspection on 25th September 2007. The inspection process included a review of information held on the service file, a tour of the premises, inspecting records, talking to residents, relatives, staff and management and reviewing compliance with previous requirements. Feedback on the service was obtained during the inspection from residents, relatives and staff and from some relatives, residents and staff through survey questionnaires sent out by the Commission. During this inspection time was taken to look more in depth at systems in place to safeguard people. Positive feedback was received from Greenwich Social Services Commissioning department regarding the improvements the new manager has made to the service. The new manager has had a positive affect on the service and the atmosphere in the home was noticeably more relaxed, bright and livelier than observed at previous inspections. Improvements had been made to resident’s lives through the redecoration programme and the increased social activities. Further refurbishment was planned and the provider had plans in place to increase the number of dementia care beds from 7 to 14. Work was in progress in relation to the environmental changes this required. A new care plan format was due to be implemented and these new documents should improve the care planning process and ensure these are prepared with the residents. What the service does well: Provide information for prospective residents. Staff had a good understanding of the residents and their care needs. Resident’s healthcare needs were met. Staff worked together to provide a homely and relaxed environment for residents. Staff received training relevant to their roles and adequate staffing levels were maintained. Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 6 The new manager has worked with senior management and staff to raise standards in the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 4, standard 6 did not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prior to admission residents had their care needs assessed and received written confirmation that based on assessment the service could meet their needs. EVIDENCE: An admission policy and procedure was provided. An assessment officer was employed by the organisation and completed all pre-admission assessments. Three sets of care records were inspected. Two files contained pre-admission and social care manager assessments and one file, for a person who moved from another home in the organisation with the same category of registration, had a pre-admission assessment completed for that service. From information in the Annual Quality Assurance Assessment (AQAA) the manager planned to review the ‘service user guide’. Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 9 All three files inspected had evidence to show that residents received written confirmation that based on assessment the service was suited to meeting their needs. Perrygrove DS0000006855.V362991.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): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans seen did not provide adequate information for staff as how to meet residents assessed needs. Satisfactory systems were in place to manage medicines but some errors were noted in resident’s medicine records checked and with homely remedy medicines. Resident’s healthcare needs were met and residents were satisfied with the way staff respected their dignity. EVIDENCE: Care plans for four people were inspected. The care plan format used in this service has not helped staff to write care plans that provide adequate information on how to meet care needs. However plans are in place to introduce a new care plan format, which will help staff to write more person centred and detailed care plans. The new care plan format was discussed with the Commission and suggestions made to the responsible person on the design and layout of the new care records. In the meantime not all the care plans seen provided adequate information for staff as to how assessed needs were to be met. A daily routine record was prepared and this provided some guidance for staff as to how care for resident and recorded resident choices. A Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 11 requirement made at the last inspection in relation to care planning was not met but in view of the plans to introduce new care plans it was agreed with the manager to extend the timescale to allow staff to rewrite all resident’s care plans. The manager said in the AQAA that new care plan documentation was due to be implemented. Staff spoken with displayed a good understanding of residents and their needs. Residents spoken with were generally satisfied with how their care needs were being met. Requirement 1. All residents were registered with a GP. A district nurse visited the home regularly to provide advice and nursing care. Residents were supported to access other healthcare such as dental and optical care. Specialist services were accessed through GP referral and staff could refer residents to a psychiatrist and the community psychiatric nurse (CPN). Residents paid privately for chiropody care, as this was difficult to access from the NHS for people in residential services. Residents spoken with said they could see a GP when needed and the care records seen showed that this did happen and that residents were seen by other healthcare professionals such as optician, podiatrist, CPN and district nurse when needed. A medicine policy and procedure was provided and was last reviewed in September 2005. Medicines were safely stored and senior staff took responsibility for medicine management. Controlled drugs were correctly managed and no inaccuracies noted in records viewed. Records were kept for receipt, administration and disposal of medicines. Medicine supplies and records were checked for four residents. Medicines for one person were correct and inaccuracies were noted for the other three people. The errors noted were that two medicines for one resident and one medicine each for two other residents were incorrect. It was also noted that staff had not recorded the dose given to one resident when a variable dose had been prescribed. This meant an audit trail could not be completes for this item. Although improvements had been made to records for homely remedy medicines it was still not possible to complete an audit trail for all medicines, as the original amounts supplied had not been recorded. It was also noted that the GP had agreed residents could have one type of cough linctus as a homely remedy but a different preparation was being given to residents. A record was kept to show that topical medicines were being administered. At the second visit to complete the site visit for this inspection the manager said that a decision had been made to stop using homely remedies in the home. Requirements 2 and 3. A number of residents spoken with and those who completed survey forms indicated that staff listened to them and that they were satisfied with the way staff treated them. Comments received from relatives supported these comments. Care plans seen included information on the residents ‘daily routine’ which indicated preferences were considered but there was no evidence in the care plans seen to show that residents were involved in Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 12 preparing these. The new care plan format has been designed to ensure this happens in the future. Perrygrove DS0000006855.V362991.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): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements had been made to the provision of social activities. Residents said they enjoyed contact with family and friends and relatives did not raise any concerns about visiting arrangements. Overall residents were satisfied with meals provided. EVIDENCE: From information in the AQAA activities had improved in the home and the manager continued to tray and employ a full time activity organiser. Care plans seen included social histories but information in the social care plans seen was very limited. The new care plan format should improve this aspect of care planning and with this in view it was agreed with the manager to extend a timescale for compliance with the development of social care plans. Since the last inspection efforts had been made to improve activities in the home. While the manager continues to try and employ a full time activity organiser, two staff from other homes in the organisation were providing activities five days a week. Residents spoken with said that activities had improved and some talked about recent sessions such as celebrating special days like St Patrick’s day, Easter and today a number of people went to another home for a VE day party. The daily care records viewed for three residents over the last month Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 14 showed that had the opportunity to take part in activities such as bingo, board games, a Mayday party, sing-a-long and a reminiscence session. It was also clear in the records seen that some residents reserved their right to refuse to take part in activities. The manager said she was encouraging care staff to lead additional activities when time permitted. Besides daily records regarding activities staff maintained a diary to show what activity was provided on specific days and the names of the residents who took part. Although activity provision had improved some residents said they would like more stimulation. Having a full time designated employee for this role would help the continued development of social activities particularly as this service has a number of active residents. Requirement 4. The home had an open visiting policy, which enabled residents to maintain contact with family and friends. A number of residents said they enjoyed outings with and visits from their family. No concerns were raised by relatives seen or in feedback surveys in relation to visiting the home. Residents who spoke to the inspector said staff encouraged them to make choices about things such as meals, what to wear and about taking part in activities. The ‘daily routine’ record seen in care records indicated that residents made some choices about their lives. However there was little evidence in care records seen to show that residents were involved in preparing their care plans. Lunch was observed in the main dining room and the dementia unit. From information in the AQAA improvements had been made to the dining room and the menus through discussion with residents. The main dining room had been redecorated since the last inspection and a new flat screen TV fitted to the wall. Residents commented on the improvements to the dining area and said they had been involved with choosing the colour scheme. Tables were nicely laid for lunch and the meal served in a calm and organised manner. Residents made a choice from a menu the day before and the meals for the day were displayed in the dining room as a reminder. Staff were attentive to residents during the meal and ensured they had the meal of their choice and assistance if needed. There was a choice of two main meals and a salad alternative if people did not like either meal. Resident’s views about the food provided varied and comments made included “the food is nice”, “food is usually ok” and “it would be nice if sauces were served with foods such as apple with pork and mint with lamb”. Residents spoken with during the meal said the meal for the day was very nice. The manager had discussed meals at resident meetings and had introduced some changes suggested such as having pie and mash and jellied eels occasionally. Some residents spoken with said how much they enjoyed these meals. The kitchen was clean and tidy, kitchen maintenance records such as fridge, freezer, food temperatures and the cleaning schedule were up to date. A new dishwasher had been provided. The cook said the main large cooker could not be repaired and had been removed, in the meantime a smaller cooker was being used, which the cook found adequate. Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 15 The manager said a new large cooker had been ordered and they were waiting delivery. Perrygrove DS0000006855.V362991.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements had been made to the provision of social activities. Residents said they enjoyed contact with family and friends and relatives did raise any concerns about visiting arrangements. Overall residents were satisfied with meals provided. EVIDENCE: A complaints policy and procedure was provided and made available to residents and others. A system was in place to record complaints made about the service. From information in the Annual Quality Assurance Assessment (AQAA) 14 complaints had been made about the service in the last 12 months. Records for four complaints were viewed and showed that these had been properly managed, investigated and responded to. Residents spoken with said they would talk to their key worker, the manager or their family of they had any concerns. The policy and procedure in relation to safeguarding adults was reviewed in April 2008. The document provided information on types of abuse and included a flowchart for staff on what action they must take if they suspect or have an allegation of abuse reported to them. As part of an in depth look at safeguarding systems during this inspection three staff were asked about their recruitment checks, their training and understanding of safeguarding. All of the staff spoken with provided satisfactory information on these areas, displayed a good understanding of safeguarding, knew about the whistle Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 17 blowing policy and what it meant to them and records seen showed they had received training on this topic in the last 12 months. Other staff training records seen for all staff showed that a further 14 staff members had received safeguarding training in the last 12 months. Three residents were asked if they felt safe in the home and if not did they know who to talk to. All three residents said they felt safe in the home, they knew the manager by name and said they would talk to her if they had a concern or worry. The manager was asked questions in relation to safeguarding including the recruitment process, staff training, implementation of and content of the safeguarding policy and how to manage an allegation or suspicion of abuse. The manager was very aware of the roles she, the organisation and external organisations play in safeguarding adults. Perrygrove DS0000006855.V362991.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): Standards 19, 20, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A lot of work had been done to improve the environment with further improvements planned and this was well received by the residents. All areas of the home seen were clean and tidy and residents were satisfied with the communal and private space provided. EVIDENCE: From information in the AQAA it was evident work had been done to improve the environment and further work planned including the extension of the dementia care unit from 7 to 14 beds. The improvements made included repainting the dining room and providing a new TV and curtains, the ground floor entrance area used as a seating area by residents had been repainted, new curtains, carpet and a new CD player provided. Residents said how much they liked using this area now and said they were involved in choosing the colour scheme. A number of bedrooms had also been repainted and residents consulted on colour schemes. Bathrooms and toilets had been repainted and Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 19 made more homely and the hairdressing room had been refitted and redecorated and made into a pleasant area for residents. At the time of this inspection work had commenced on alterations to extend the dementia unit. Residents had been consulted about the changes and the work was being carried out with as little disruption as possible to the residents. The manager was aware of the need to involve the Commission in the planned changes to registration and the environment. The dementia unit will be redecorated once the building work is completed. Further environmental improvements planned included new fencing and landscaping round the property, upgrading the laundry, sluices and completing the redecoration of the bedrooms. Residents were very complimentary about the improvements and were happy to be included in the decision-making. As mentioned bathing and toilet facilities had been redecorated and made more homely. Assisted baths were last serviced on 5/2/08. Bedrooms viewed were clean, tidy and personal. Residents spoken with were satisfied with the communal and private space provided. Some residents said they did not have keys to the lockable spaces in their bedrooms and this was something the manager should address. Recommendation 1. Hand washing facilities were provided where waste was handled and staff were provided with protective clothing. Supplies of cleansing hand gel were located round the home. Perrygrove DS0000006855.V362991.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): Standards 27 – 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team had the skills and experience needed to meet the needs of the resident’s. Staff received the training and support needed to do their work. Recruitment details had improved but some omissions were noted in two files viewed. EVIDENCE: Since the last key inspection the home a new full time registered manager was in post. The manager was assessed by the Commission and found to have the skills, experience and qualifications needed to manage the service. The staff team comprised of a manager, two assistant managers, team leaders, care assistants, domestic and ancillary staff who worked together to meet the needs of the residents. Staff rosters seen for a two-week period showed that adequate staffing levels were maintained. As the home was currently not fully staffed a number of shifts were covered by agency and bank care staff. The manager said that the recruitment of new care staff was ongoing with two people due to start work soon and that efforts were always made to use regular bank and agency staff. The staff rosters clearly identified staff on duty in the dementia unit at all times and included the full name of employees. Once the extension to the dementia unit is completed the manager said that staffing levels for that unit would be reviewed. Residents spoken with were complimentary about the staff team and many knew their key workers and the manager by name. Residents enjoyed positive interactions with the domestic Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 21 staff and regularly shared a joke and a laugh with them when they were doing their work. Surveys and comments received from relatives showed they were satisfied with the contact staff made with them. Information in the AQAA showed that 26 care staff were employed and 23 had achieved NVQ level 2 or above. A further 2 people were working towards this qualification. Recruitment policies and procedures were provided. Four staff files were viewed. The files were well maintained and included most but not all of the information required by regulation. Two files viewed for people employed since the last key inspection lacked information. One file did not have a recent photograph of the person and one reference was not verified as genuine and in the second file two references had not been verified as genuine. Requirement 5. Three staff training records were viewed and showed that the people had received three days training on topics relevant to their role in the last year. The manager provided a copy of the training matrix for all staff and this showed that staff had the opportunity to attend training courses such as moving & handling, infection control, pressure area care, dementia care and continence awareness in the last 12 months. Staff spoken with said they received adequate and relevant training and support to enable them to do their work. Perrygrove DS0000006855.V362991.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): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service was sell managed and the views of the residents about the service were sought. A system was in place to review the quality of care provided and safe systems were in place to manage resident’s personal allowances. Attention was given to providing a safe environment for residents and others. EVIDENCE: As mentioned the service had a full time manager in post and she was registered with the Commission. The manager had worked hard with her team and senior management to raise standards in the service. Residents knew the manager by name and said they saw her frequently round the home. The manager had made positive improvements to the service and residents, staff and relatives were very complimentary about her management ability. In the Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 23 AQAA the manager said that staff interaction with residents had improved, staff worked better as a team and the number and meetings had improved. A number of residents were able to voice their opinion on the service and offer suggestions on how it should run to suit them. The new manager ensured meetings were held to provide a forum for residents to discuss the service. Two resident meetings were held since January 2008 and residents spoken with confirmed they had been invited to attend. Residents spoken with said staff and management listened to them and acted on what they said. In October 2007 a Forum was held for residents, staff and others. Residents, staff senior management and the local Councillor attended the meeting. An external provider completed the quality assurance assessment under ISOQQA 9001. Action plans to improve deficits in the service were prepared based on the quality assurance findings. The organisation had a system in place whereby managers completed audits on services they did not manage. Action plans were prepared based on audit findings to ensure issues identified were addressed. Visits were made to the home as required by regulation 26 and reports kept in the home. The manager also held meetings with staff in the home these included general meetings for all staff and meetings with separate designations. Some residents managed their own finances and some had the help of family to do this. Management offered residents support with managing personal allowances if required. The systems in place ensured resident’s money was safely managed, that residents had access to their personal allowance and that money held for individual residents earned them interest. Receipts were kept for money received and spent. Individual personal finance records were kept and made available to residents/relatives on request. Records seen in relation to three residents was checked and found to be accurate and up to date. A safe was provided to store valuables and the administrator kept a list of the safe contents. The service had a full time maintenance technician who carried out routine maintenance and safety checks. Safety records seen included service for the lift, the hoists, assisted baths and the electricity and gas supply. All of these were up to date. The maintenance person completed weekly checks on areas such as wheelchairs, call bells, hot water temperatures and fire safety equipment. Fire safety records were seen and showed the system and emergency lighting was last serviced on 25/9/07, weekly alarm tests were undertaken and the last fire drill was held for day staff was held on 3/2/08 and for night staff on 8/12/08. Since September 2007 14 employees had received training on fire safety. Accident records were kept and regulation 37 notices sent to the Commission. Accident records seen were fully completed however staff should ensure they time the report correctly and either use the 24 hour clock or indicated the correct time of the accident. The manager completed monthly audits for head Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 24 office. The quality of accident reporting could also be improved to ensure full details of the incident were recorded. Recommendation 2. Perrygrove DS0000006855.V362991.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 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 26 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 Requirement Care plans must be prepared for all residents that provide adequate information for staff as to how to meet assessed needs. Efforts must be made to involve residents in preparing their care plans this evidenced in care records. (Timescale of 16/11/07 was not met). Accurate records must be kept for all medicines brought into the home to enable an audit trail to be completed including homely remedies. (Timescales of 10/08/07 and 16/11/07 were not met). Staff must only administer homely remedy medicines agreed by the GP to residents. Social and leisure care plans must be prepared for and with individual residents to ensure they meet their needs and preferences. (Timescales of 20/04/07 and 10/08/07 were not met). All information required by regulation must be obtained for employees and available to DS0000006855.V362991.R01.S.doc Timescale for action 30/09/08 2 OP9 13 30/06/08 3 4 OP9 OP12 13 16 30/06/08 30/09/08 5 OP29 18 30/06/08 Perrygrove Version 5.2 Page 27 inspect including a recent photograph and evidence that references requiring verification are verified as genuine. 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 OP24 OP38 Good Practice Recommendations Residents should have access to a lockable area in their bedrooms. Staff should ensure the correct time an accident is recorded. Staff should use either the 24 hour clock or indicate whether the accident occurred am or pm. Perrygrove DS0000006855.V362991.R01.S.doc Version 5.2 Page 28 6855 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Perrygrove DS0000006855.V362991.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. 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!