Inspection on 15/08/08 for Regents House Rest Home

This inspection was carried out on 15th August 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

Regents House Rest Home 12/08/09

Regents House Rest Home 22/03/08

Regents House Rest Home 28/09/07

Regents House Rest Home 01/02/07

Regents House Rest Home 27/02/06

Regents House Rest Home 12/12/05

Regents House Rest Home 16/02/05

Regents House Rest Home 18/10/04

Regents House Rest Home 09/03/04

Regents House Rest Home 16/01/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Regents House Rest Home 206 Regents Park Road Southampton Hampshire SO15 8NY Lead Inspector Nick Morrison Unannounced Inspection 10:30 15 August 2008 th 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 Regents House Rest Home DS0000012319.V369287.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. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Regents House Rest Home Address 206 Regents Park Road Southampton Hampshire SO15 8NY 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) 02380 322 101 sandra.regent@hotmail.co.uk Mr Ian Newson Mrs Jean Newson Mrs Sandra Pearl Anaszko Care Home 17 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (17), Mental disorder, excluding learning of places disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (17), Old age, not falling within any other category (17), Physical disability (3), Physical disability over 65 years of age (7) Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users in the DE, MD or PD categories may not be accommodated under the age of 55 years A total of not more than 7 service users may be accommodated in the PD and PD (E) categories Not more than 3 service users in total may be accommodated under the age of 65 years 22nd March 2008 Date of last inspection Brief Description of the Service: Regents House is a large period property that has been adapted to provide residential care for up to 17 older people. The accommodation is both single or shared bedrooms available on the ground and first floors with a passenger lift to the first floor. None of the bedrooms have en-suite facilities but do have a wash hand basin. There is a lounge, dining room and garden with patio area for residents to use. The building is accessible. The home is close to local shops and amenities. The home currently charges local authority rates of approximately £410 per week. There are no additional charges. Regents House Rest Home DS0000012319.V369287.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 1star. This means the people who use this service experience adequate quality outcomes. This report represents a review of all the evidence and information gathered about the service since the previous inspection. This included a site visit that occurred on 15th August 2008 and lasted seven hours. Nick Morrison and Carole Payne undertook this. During this time we looked around the premises, looked at service users’ files and met with five people living in the home. We also met with the Manager and spoke with two other members of staff. All records and relevant documentation referred to in the report were seen on the day of inspection. We sent out a number of surveys and received replies from four service users. We also spoke with a relative on the day of the inspection. We have also referred to the Provider’s Annual Quality Assurance Assessment (AQAA). What the service does well: What has improved since the last inspection? What they could do better: There have been twelve requirements made as a result of this inspection. The home needs to re-write the Statement of Purpose, ensure that risk assessments and care plans are clear about the action that needs to be taken in response to identified needs and risks, the level of stimulation for people Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 6 living in the home needs to be greatly improved, the maintenance issues in the building need to identified and responded to in a timely manner, all references for staff need to be verified by the Manager, a comprehensive quality assurance system needs to be introduced and maintained and workplace and environmental risk assessments need to be kept up-to-date. 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. Regents House Rest Home DS0000012319.V369287.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 Regents House Rest Home DS0000012319.V369287.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): 1, 3 and 6 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed prior to moving into the home. They would benefit from clear and comprehensive information about the home being available to them prior to moving in. EVIDENCE: There had been a recommendation from the previous inspection that the manager and provider should produce more usable versions of their ‘statement of purpose’ and ‘service user guide’ documentation that could then be appropriately shared with the service users. The manager had completed a newer, shortened version of the Statement of Purpose with the aim of it being more accessible to people who use the service and their families. The new version does not include the information required by Schedule One of The Care Homes Regulations 2001. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 9 We pointed this out to the Manager and recommended that she refer to the guidance in re-writing the Statement of Purpose again. Since the inspection the Manager has supplied us with a much-improved version of the Statement of Purpose, but this still does not address all the information required by The Care Homes Regulations 2001 Examination of the files of people living in the home demonstrated that there were pre-admission assessments in place that had been completed prior to the person moving into the home. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users benefit from having their healthcare needs met and from being treated with dignity and respect. They are protected by the home’s medication policies and practices. They would benefit further from being involved in their own care plans and from care plans and risk assessments being clear about the support they require. (Evidence need to word as judgement – Care plans and risk assessments are not currently sufficiently clear…) EVIDENCE: There had been a requirement from the previous two inspections that Residents must be protected from unnecessary risks. Any risks to residents must be assessed and risk management plans recorded and reviewed as to how risks will be minimised or as far as possible eliminated. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 11 There were risk assessments in place for service users where necessary and these related to needs identified in the care plans. They were kept under regular review. The risk assessments lacked clear information about what action needed to be taken by staff to minimise the risk of harm to service users. The Manager acknowledged this in discussion and said she was in the process of identifying a different system for the risk assessments and expected to be fully compliant by the time of the next inspection. There had been a requirement from the previous inspection that Service users plans must be kept under regular review, ensuring any changes in their care are appropriately reflected. Examination of care plans showed that they had been reviewed on a regular basis and that changes had been made to update them. The quality of the information in care plans was not good. Two examples of this were the information on supporting one person with their catheter did not adequately explain the support required and one person’s plan said that staff needed to be aware of his needs at mealtimes, but did not specify what those needs were. Other care plans did identify that some people had mental health needs, but there was no information on how those needs should be addressed. Staff spoken with were aware of the care plans of all the people living in the home and said they were involved in writing and reviewing them. Service users spoken with did not know about their own care plans and said they had not been involved in identifying and reviewing their care needs in a formal way. There had been a requirement from the previous two inspections that the recording and storage of controlled drugs in the home must comply with the Misuse of Drugs (Safe Custody) Regulations 1973. There had also been a requirement that Medications must be safely and appropriately stored at all times. Both of these requirements have now been met. New storage facilities had been purchased for medication and were being used appropriately. The home was in the process of changing the chemist they use to dispense medication so that they have a better system in place. The new chemist will deliver additional staff training so that staff are clear about the new system. Staff involved in administering medication had all received training and, on the day of the inspection, demonstrated that they were able to administer medication appropriately and sensitively. One member of staff was responsible for a weekly audit of the medication in the home and this provided a good system for ensuring that medication was stored and recorded appropriately and that any potential mistakes would be highlighted in a timely manner. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 12 Care plans showed that individual healthcare needs were monitored on an ongoing basis and that, where necessary, people were referred to healthcare professionals. The home maintained good relationships with healthcare professionals to ensure that the needs of people living in the home were met. Service users spoken with confirmed that they received support to access healthcare services whenever necessary. The sensitivity of the staff on duty during the inspection visit demonstrated that service users were treated with respect and that their dignity was maintained. This was confirmed in discussion with service users and a visitor spoken with on the day of the inspection as well as by feedback from the GP who said that privacy was “always respected” and that staff provided a good level of professional care. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users benefit from support to maintain contact with their friends and families and are able to exercise some control over their own lives. They would benefit further from more stimulation and activity throughout the day and, where necessary, from support to eat their food. EVIDENCE: There had been a recommendation from the previous inspection that the home should seek to develop and expands the range of in house activities available to residents’. In discussion, the Manager confirmed that this had not been done and that there was no formal programme of activities in the home. Although staff observed during the inspection visit demonstrated good skills in interacting with people living in the home, the lack of an activities programme based on the interests of people living in the home resulted in a low level of activity for most people. Some people were able to organise their own activities and others told us they would not be interested in arranged activities. However, most people living in Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 14 the home needed some staff input in order to be engaged in stimulating activities and this was lacking. A programme of activities based on the needs and interests of people living in the home would contribute to more stimulation. Some service users told us there was “not much going on” in the home and that this contributed to them sometimes being bored. The home had purchased a new, large screen television since the previous inspection. Service users were encouraged to watch the television, although some of the people in the lounge did not appear to be interested in the television. People who were interested in the television were glad of the new television because it was a lot easier to see than the previous one. The daily notes for people living in the home demonstrated the low level of stimulation for people living in the home. They described what time people got up and dressed and where they were during the day. A typical example of this was “showered, helped in the toilet, food and drink provided, he spent all day in the tv room, he had a good day.” There was very little indication from the daily records of any variety or stimulation for people living in the home. People who were able to organise their own activities obviously had more interesting days. Service users were able to exercise some control over their own lives and had choices about when to get up and when to go to bed. Some service users were able to go out on their own and others were supported to go out on occasions. Staff skills in interacting with people contributed to them exercising control over their own lives as the staff gave people choices and the time to make choices for themselves. Service users spoken with said the home was welcoming to their visitors and that they were able to receive visitors as they wished. The home assisted service users to stay in touch with their friends and families. A visitor spoken with on the day of the inspection visit confirmed that she always felt very welcome in the home and was able to visit her relative whenever it was convenient to them both. Food in the home was of good quality and all the feedback from service users confirmed that they enjoyed the food in the home and were given sufficient portions. We observed the lunchtime meal, which appeared to be a social occasion and people were encouraged by staff to interact with each other. Some staff support was available for people who required help with eating their lunch, but this did not appear to be well planned. One person’s care plan identified that staff needed to be aware of his needs at lunchtimes (although these needs were not specified) and give him one to one supervision. Despite this, he did not have one to one support throughout the meal. The two staff on duty appeared very busy because they had to dish up and serve people food as well as administering medication to those people who needed it. A member of staffed asked this service user if he wanted help with his lunch and said she would come and sit with him “in a minute.” She did not come back to sit with Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 15 him, but the other member of staff later supported him in eating some of his lunch. However, she left him during this time because she had to go and answer the door. The home needs to clearly identify the support people require during mealtimes and ensure that sufficient staff are available to provide that support as necessary. Regents House Rest Home DS0000012319.V369287.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): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from a clear complaints procedure and are protected by the home’s safeguarding policies and practices. EVIDENCE: There had been a requirement from the previous inspection that the manager must ensure that the home’s safeguarding practices are robust and ensure people’s safety and that the staff are equipped with the necessary skills and knowledge to effectively respond to an incident of abuse. Since the previous inspection the home had taken steps to ensure that local safeguarding reporting procedures were available in the home and that staff were aware of safeguarding issues. Staff spoken with on the day of the inspection demonstrated awareness of safeguarding issues and of how to report potential safeguarding issues if necessary. Service users spoken with during the inspection said they felt safe living in the home and that all staff were kind to them. There had been a recommendation from the previous inspection that the ‘statement of purpose’ and ‘service user guide’ should be used to convey information relating to the home’s complaints process. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 17 The updated Statement of Purpose did contain information about the complaints procedure. However, the procedure was not clear about the timescales involved for complaints and how they will be responded to. Since the inspection the Manager has supplied us with a revised version of the complaints procedure and this does identify relevant timescales and information on how complaints will be responded to. Service users spoken with during the inspection visit said they felt they were clear about how to complain if necessary. A system was in place to record complaints, but there had been no complaints since the previous inspection. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a clean house but would benefit further by the building being maintained effectively so that their safety is addressed. EVIDENCE: There had been a requirement from the previous inspection that the manager must take steps to ensure the laundry area is revamped and that minor maintenance issues are identified and addressed in a timely manner. That equipment supplied by the home, for use with the service users, is maintained in good working order. We looked at the laundry and found that the work identified had been completed. The door to the laundry is now kept locked so that service users cannot wander into the room unaccompanied. Chemicals that may be Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 19 hazardous to peoples health (COSHH) are now kept locked in a new cabinet bought for the purpose. The floor in the laundry area has been re-laid. Maintenance issues were still not being identified and responded to in a timely manner. Some issues had been identified and dealt with throughout the course of the year, but the number of issues we found during our tour of the premises showed that this process was not identifying and responding to all maintenance issues. Equipment supplied by the home for use with service users was found to be in good working order and there was evidence from records and from discussion with staff that equipment was being regularly maintained. A number of environmental issues were identified through our tour of the premises and brought to the attention of the Manager: - The fire escape stairs from the first floor were blocked with old items that were waiting to be thrown out and the steps presented a further hazard, as there was moss on them. We made an immediate requirement for the fire escape to be made safe and the Manager has informed us, since the inspection, that this work has been competed. - There was a wooden block on the outside doorframe of the upstairs toilet. The Manager was not able to identify any reason for this being there and there seemed to be no purpose for it. The block presented a hazard because it was possible to lock the door from the outside while someone was in the toilet. We required the Manager to have this removed in order to ensure peoples safety. - The flush handle on the other upstairs toilet was broken off making it extremely difficult to flush the toilet. We required the Manager to have this fixed. - The call alarm cord in the same toilet was hoisted up towards the ceiling and not accessible to people who might use the toilet. We required the Manager to ensure that this was made accessible to people. - In the upstairs bathroom there were tiles missing from around the toilet. This makes it difficult to keep the surface clean and we required the Manager to ensure that these are replaced. - In the downstairs toilet there were loose and broken tiles and we have required the Manager to ensure these are replaced in order to maintain hygiene. - In the downstairs bathroom the flooring around the toilet is broken and worn and we required the Manager to ensure that this is replaced. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 20 - The carpet in the corridor between the kitchen and the smoking room has a worn patch, which may present a tripping hazard to some people. We required the Manager to ensure that this is made safe. - The handrail on the steps in the garden leading down from the patio area to the grass area was loose and may not be safe for people to lean on. We required the Manager to ensure that this was made safe. The above issues demonstrate that the home does not have an effective system for identifying and responding to maintenance issues. We have required the Manager to ensure that an effective system is put in place and that all maintenance issues are identified on a regular basis and responded to in a timely manner and also that records are kept of all maintenance issues. There were paper towels and liquid soap in the bathroom and toilet areas and infection control in the home has been improved by the fact that communal cotton towels are no longer used. The previous inspection had identified concerns about the use of communal hygiene equipment such as shaving brushes, razors, deodorant and soap. There was no evidence from this inspection that this was still an issue. Staff spoken with were aware of the issues related to shared toiletries and were clear that items must not be shared. Another issue identified at the previous inspection was that staff are required to perform different duties such as cleaning, personal care and catering and sometimes have to move between these duties and that this may cause hygiene issues. Since that time the home has employed more staff to ensure that cleaning duties are performed separately from other duties. In addition, we observed during this inspection that staff were very thorough and attentive to infection control issues in moving between tasks. They took off the protective clothing and gloves they were using and washed their hands thoroughly before selecting different protective clothing and gloves for the next task. Feedback from service users did not highlight any concerns about the environment or infection control issues. It was clear that some progress has been made in ensuring a clean, safe and hygienic environment since the previous inspection, but there are significant issues in this area that require attention and systems need to be put in place to ensure that improvements are made and sustained. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service Service users benefit from being supported by well-trained, competent and dedicated staff, but would benefit further from a more robust procedure for verifying the references of staff before they begin working in the home. EVIDENCE: There had been a requirement from the previous two inspections that Staff recruitment procedures must ensure that staff are suitable to work in a care home. These must include at least a full job history, two satisfactory written references and satisfactory criminal record and protection of vulnerable adults checks before the post is agreed. Examination of staff records in the home showed that pre-employment checks were undertaken before staff began working in the home and that records were kept to verify this. Although the home had the required two references for each member of staff, we had concerns over how much attention had been paid to those references. Some employment references were not written on headed paper and there was no record of them being verified by the Manager. Some references were written “to whom it may concern” and staff had brought these to the home themselves. There was no evidence that the Manager had verified these Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 22 references. Some references were not written in English and had not been verified. One reference had been translated into English but this had been done by someone who knew the member of staff and had not been independently verified. The verification of references is important in ensuring the safety of people living in the home and we have made a requirement that the Manager must take steps to ensure that all references are accurate and valid. There had been a requirement from the previous inspection that the manager must review the home’s training and development programme ensuring that staff are both appropriately qualified and competent. Staff spoken with on the day of the inspection confirmed they had received for the work they were expected to do. This included all mandatory training as well as training appropriate to the individual needs of people living in the home, such as sight loss training. Both the staff spoken with also confirmed that they were in the process of doing a training course in dementia. Training files in the home showed that records were kept of all training and that a plan was in place to ensure that training is kept up-to-date and that relevant training needs are identified. Records showed that refresher training in Health & Safety had been planned and staff were also about to do some training in the Mental Capacity Act. Staff observed on the day of the inspection demonstrated good skills in communicating with service users and that they had good skills in providing care to people. They were well informed about the needs of service users and knew what to do in order to attend to those needs. They appeared to be competent and dedicated. Feedback from service users spoken with was positive and identified that staff were “very kind” and that they “will do anything for you.” One service user spent a lot of time in their room and said that staff were very kind and helpful but that they did not come into the room very often and the person thought this was because they were often very busy. Feedback in the home from a GP identified that staff were always friendly and helpful. There had been a recommendation from the previous inspection that the manager should review how the staff are deployed to ensure sufficient hours are dedicated to the care of the service users, whilst cleaning and catering duties are not neglected. This review had taken place and, as a result, additional cleaning hours had been made available. This meant that a specific person was responsible each day for the cleaning of the home. This has made more time available for other Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 23 staff to spend directly with service users and also contributed to more effective infection control practices as staff were not alternating between personal care and cleaning duties. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users would benefit from the home being managed and developed in response to their views and from more effective maintenance of the home. EVIDENCE: There had been a requirement from the previous two inspections that the manager must undertake from time to time such training as is appropriate to ensure she has the experience and skill required to manage the home effectively. There was evidence on file that the Manager had undertaken training since the previous inspection and this was confirmed in discussion with her. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 25 The issues identified throughout this report show that there has been some improvement in the management of the home, but that further improvement is needed. Further training for the Manager in areas such as quality assurance and maintaining management systems in the home would contribute to those further improvements in the service being realised. There had been a requirement from the previous inspection that there must be an effective system of quality assurance that measures how well the service is meeting the needs of the residents and monitors compliance with the home’s legal and statutory requirements. Some work had been done on this since the previous inspection and the home had collected some feedback from service users and from one GP. This needs building upon so that there is a clear system for gathering feedback from relevant people, analysing that feedback, developing an annual plan for the service based on addressing issues identified from the feedback, sharing that feedback with interested parties, implementing the plan, monitoring its implementation and then reviewing it over the year. This process needs to be completed each year to demonstrate improvement to the service and to involve service users, their families and others in the development and improvement of the service. There were some individual areas of practice in the home where quality assurance was good. The medication system was monitored very closely and regular checks put in place to ensure that it was working effectively. Building upon this kind of good practice throughout each aspect of the service would contribute to an effective quality assurance system. The Manager told us she was trying to develop the quality assurance system and, since the inspection, has provided us with information on how she plans to do this. The Manager confirmed that the home had no involvement in the finances of people living there and that this was done by service users themselves or by family members. There had been a requirement from the previous inspection that the manager must take steps to ensure chemicals and pieces of equipment are maintained appropriately ensuring the service users welfare. That staff receive appropriate training on the identification and management of health and safety concerns. That risk assessments consider the risks to individuals whilst they maintain their independence. Chemicals in the home are now well managed in way that ensures the safety of people living and working in the there. There was also evidence that equipment was maintained and this was confirmed in discussion with staff. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 26 Health & Safety training had been given to all staff since the previous inspection and this was demonstrated by training records and discussion with staff members. There were some workplace risk assessments available in the home, but these need to be dated in order to demonstrate that they are completed and reviewed on a regular basis. As highlighted in the Environment section of this report, the system for identifying and responding to maintenance issues in the home is currently ineffective and we identified a number of outstanding maintenance issues that had not been addressed by the Manager, including some that had not even been identified. This needs to be addressed so that the safety of people living and working in the home is ensured as far as possible. Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 27 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 2 X 3 X 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 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 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 2 X 2 X 3 X X 2 Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 4 (1) (c) Requirement The Statement of Purpose must be re-written so that it fully addresses all the points covered in Schedule One of The Care Homes Regulations 2001. Service user’s risk assessments must be clear about the action needed in order to minimise risks. This requirement is a partial repeat of the requirement raised at the previous two inspections. Care plans must be specific about the action required in order to meet the needs of service users. The Manager must introduce a programme to ensure that service users receive stimulation throughout the day suited to their needs and wishes. The Manager must ensure that people who require support to eat their food receive that support as directed by their care plan The obstacles and moss on the fire escape must be removed. DS0000012319.V369287.R01.S.doc Timescale for action 30/09/08 2 OP7 13 (4) (c) 30/09/08 3 OP7 15 (1) 30/09/08 4 OP12 16 (2) (m) & (n) 30/09/08 5 OP15 15 (1) 30/09/08 6 OP19 13 (4) (a) 15/08/08 Regents House Rest Home Version 5.2 Page 29 7 8 OP19 OP19 13 (4) (a) 23 (2) (b) 9 10 OP29 OP31 19 and Schedule 2 10 (3) 11 OP33 24 (1) 12 OP38 23 (2) (b) & (c) The block of wood on the outside of the upstairs toilet door must be removed. There must be an effective system in place to identify maintenance issues and to ensure that they are responded to in a timely manner. The Manager must verify all references for staff employed in the home. The Provider and the Manager must ensure that the Manager has any necessary training to ensure that the home is well managed There must be an effective system of quality assurance that measures how well the service is meeting the needs of the residents and monitors compliance with the home’s legal and statutory requirements. This requirement is a repeat of the requirement raised at the previous two inspections. The Manager must ensure that all workplace risk assessments are dated and kept under regular review. 30/09/08 30/09/08 30/09/08 30/09/08 31/12/08 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Regents House Rest Home DS0000012319.V369287.R01.S.doc Version 5.2 Page 31 - 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!