Inspection on 21/09/07 for Rookstone

This inspection was carried out on 21st September 2007.

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

Rookstone 31/07/06

Rookstone 29/11/05

Rookstone 25/10/04

Rookstone 25/10/04

Rookstone 19/04/04

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 Rookstone 1 Lawrie Park Crescent Sydenham London SE26 6HH Lead Inspector Rosemary Blenkinsopp Unannounced Inspection 21st September 2007 08:15 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 Rookstone DS0000038682.V348663.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. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rookstone Address 1 Lawrie Park Crescent Sydenham London SE26 6HH 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 8778 0317 020 8778 0349 christine.fell@salvationarmy.org.uk Salvation Army Mrs Christine Fell Care Home 31 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (30) of places Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st July 2006 Brief Description of the Service: The home is part of the Salvation Army Social Care Division and is a registered care home for 31 residents. The home is staffed by an experienced team of carers, with ancillary staff in support. The home accesses health care services in the local community including those of the GP and District Nursing services. Opticians, Dentist and Chiropodist services are supplied through a domiciliary service. Rookstone is a large detached property that has been adapted as a residential home. There are 29 single rooms, adequate bathroom and washing facilities. The home has a lift to the upper floor. The home is located in a very quiet road, close to shops and public transport. The home has a large garden that is accessed via patio doors from the lounge area. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was conducted unannounced by one inspector. At the time of the inspection the Manager, Mrs Fell was on duty and she facilitated the visit. Prior to the inspection the Manager had completed and forwarded their AQAA and this contained good information. During the site visit the inspector had an opportunity to meet with residents’ relatives, staff on duty and two members of the multi disciplinary team who were visiting the home. Feedback obtained from all of the parties is incorporated into this report. Questionnaires, which were returned, confirmed that a good service was provided. The inspector undertook a tour of the premises including individual bedrooms and communal areas. During the course of the morning the inspector observed the interactions between residents and staff as well as noting signs of wellbeing. There were many signs amongst residents of well being evident in both terms of verbal and non verbal communication. Staff engaged positively with residents, supporting and offering choice, whilst promoting independence. Following the periods of observation the inspector spent time interviewing staff, viewing personnel files and other documentation including health and safety service certificates. Feedback was provided to the Manager at the end of the site visit. Overall the inspector had evidence that residents where provided with a good service and were satisfied with their level of care. Staff were said to be professional, helpful and kind and the outcomes for residents were positive. There were areas where greater attention to detail is required and these are in two of the key areas for outcome ratings. What the service does well: The inspector evidenced that residents were provided with good care and support, by staff that demonstrated a professional but caring approach. Staff were said to work collaboratively as a team and engage positively with other members of the multi disciplinary team. Mealtimes are a pleasant affair, where residents can enjoy the company of one another, and family should they wish to stay, can partake of a meal. The meals were served in congenial surroundings and in an unhurried fashion. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 6 There have been improvements in documentation and that which was inspected was well organised and easily accessible. 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. Rookstone DS0000038682.V348663.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 Rookstone DS0000038682.V348663.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are subject to assessments procedures, which provides sufficient information on the individual’s needs and how they can be met. Supporting information from multi disciplinary professionals is supplied and that provides a more comprehensive picture of the resident. Residents are able to sample the service offered, with visits to the home. Residents are provided with information about the home prior to admission. EVIDENCE: The inspector selected three assessments and care plans to view. In the first one the resident had been admitted two weeks earlier. There were details including personal information, medications, next of kin and medical history. There was an application form for the admission and another form detailing the financial arrangements. The assessment conducted by the Occupational Therapist provided good information on the resident’s condition. Other reports obtained prior to admission included the physiotherapists report from when the Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 9 resident had been attending the stroke unit. A community discharge letter was also available. In the second set of notes there was a clear photograph of the resident and the admission summary completed. Important information such as MRSA status was recorded. In addition there was Bromley Social Services review form. Assessment information and the FACE overview were supplied and this was comprehensive in content. Discharge information, from the referring hospital, as well as that relating to rehabilitation of the resident was also supplied. The application for admission and a dependency profile were completed. A third care plan also contained good assessment information obtained through the homes own procedures and the multidisciplinary reports supplied. Residents are issued with a residency agreement, which details the level of service and room to be occupied. These documents were signed by the next of kin in two files. The Salvation Army clearly states that there is a trial period for all new admissions. The home has a Statement of Purpose and Service Users Guide, which are sent out to the residents during the initial contact stage. The Statement of Purpose is under review currently as this is an unwieldy document and is due to be condensed into a user-friendly format. This document was available in the home. Neither of the residents had been in a position to undertake a trial visit. The inspector was advised that residents are usually invited to the home for a one day stay where the assessments would be conducted Overnight stays are available although rarely taken up due to dependency of the resident. The home writes to confirm that they are able to meet the identified needs of the prospective resident. Rookstone DS0000038682.V348663.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans are in place and care needs addressed through the staff and with the assistance of the multi disciplinary team. More robust systems of auditing care plans must be implemented to ensure these are in place and reflective of needs with supporting risk assessments. Medications are well managed although some poor practices were observed which introduces a margin for error and poses a risk to residents. EVIDENCE: At the time of the inspector there were 28 residents in the home. The inspector was advised that there were no residents who had a pressure sore, two were suffering MRSA. The inspector selected two care plans to randomly inspect, including one of the residents who was said to be suffering MRSA. There was one resident in the home who was prone to wandering. This resident requires extra supervision and staff need to be vigilant at all times. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 11 The care plan of the first resident case tracked was inspected. The care plan is made up of standard documentation including those for addressing care needs and reviews. In addition there are supporting risk assessment records for manual handling and other general risk areas. These were incomplete as was the care plan documentation. On querying this, the inspector was advised, that this was due to the key worker being on annual leave. There was however a short “ working care plan “ which is a document used by staff to assist in care delivery. The second care plan had standard forms detailing the areas of need identified and the interventions to address these. Reviews indicated that the residents the key worker were involved in this process. Risk assessments were in place for manual handling and those risks specifically identified relating to that individual. All of the risks had interventions on reducing the problem with reviews in place. This resident required specialist equipment and this had been obtained the delivery note was confirmation of it. The resident had been referred to specialist services provided through the Occupational Therapist and Physiotherapist earlier in the year. In addition the multi disciplinary sheet indicated regular input from the Chiropodist, Reflexologist and District Nurses. The GP sheet referenced regular input. A general observation chart was completed which included weight records. In both care plans the inventory sheet was not fully completed and without staff signatures. A third care plan was selected as this resident had met the inspector during the visit. The care plan detailed physical health needs and had supporting risk assessments in place. Multi disciplinary and GP input were recorded. This care plan included accident reports and Regulation 37 notifications. On the ground floor there is a Parker bath. In some bedrooms cot sides with the padding were in use. The home has had a new cal bell system installed. Wheelchairs in use had the footplates attached. The home has three hoists and one Parker bath for use with residents who have mobility impairment. The inspector met with the visiting District Nurse. She was complimentary about the service provided at Rookstone and the competence of staff .She confirmed that staff were knowledgeable about the residents and that good outcomes had been achieved for some resident in this home. She also said that the staff refer residents appropriately and in a timely manner. The inspector also met with the visiting CPN. She stated that she had no concerns regarding residents in the home. She felt that she was kept advised of developments in the resident’s conditions and that staff were always polite Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 12 and professional. She stated that her visits were written up in resident’s notes and discussed with staff Medications. The inspector observed the morning medication administration of medications whilst sat in the dining room. The staff member administering the medications was a senior staff. The staff member was observed to be signing medication charts before the resident had actually taken the medication. Once this was raised the practice ceased immediately and the staff accepted that this was not the correct procedure. This is poor practice and could pose a risk to residents. Within the AQAA documentation the home themselves had identified that “medication administration and recording is good but there is need for constant monitoring and supervision and there is always room for improvement”. The medication systems were checked including the records and storage. The home has two trolleys, which were securely stored in the clinical room. One trolley is for those medications that are to be returned to the pharmacy. Records in respect of returned medications were in place with two staff signatures and that of the receiving pharmacist. In the medication records was list of staff signatures of staff that administer medications .A record of staff who had administered medication, under supervision, as part of medication proficiency training was in place. All staff have completed the NVQ level 3 module in safe handling of medication prior to administering medications. The homely remedies policy was dated 2003 and signed by the two GP’s serving the home. This should be kept under review it is recommended that this be reviewed annually. Those medication charts, which are hand transcribed, should have two staff signatures in place to confirm the accuracy of the information recorded. On a few of the medication administration records punch holes partly obliterated the information relating to the medication. This can introduce a margin for error and alternative ways should be explored to ensure information is complete and fully legible. There was information in respect of the medication system in use, namely the monitored does system. The medication charts were complete with resident’s photographs and allergies recorded. Those medications received into the home were recorded and signed. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 13 Medications that are to be administered “ as required “ need to have full instructions recorded including uses and maximum dosage. One prescription for “Gaviscon” had nothing else recorded including the dose and frequency. The home has Temezepam in use that is stored in the trolley in a lockable tin although recorded in a controlled drug book. The records for this were well completed except that the medication name and dose should be indicated at the top of the page. On checking the medications with a staff member it was evident that there was no tablet counter and the medications were in fact being handled for checking purposes. This was brought to the attention of the Manger and a tablet counter was obtained immediately and before the end of the site visit. Please see requirements 1 and 2. Rookstone DS0000038682.V348663.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in this home have choice and preferences are incorporated into their daily lives. Independence is promoted. Contact with their families is encouraged and facilitated. EVIDENCE: The home employs an activities coordinator two days a week, Monday and Thursday. In addition there is a religious service held every morning. The inspector observed the activities and practice during the morning session. Breakfast was underway as the inspector arrived. The dining room had been newly decorated and the tables were nicely presented for the meal. There were signs of well being amongst the residents as they had breakfast, this was also evident during the lunch. Residents were chatting amongst themselves and staff were seen to be actively offering residents choice and enabling resident to partake of the meal in an independent manner. On the breakfast tables were racks of toast, individual teapots, milk jugs and sugar bowls. Residents who were unable to manage were assisted although many managed independently. The inspector sat with three ladies who were having breakfast. There was a sense of camaraderie as they assisted one another over the meal. Comments Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 15 received from the residents were positive. The breakfast and the lunch were over a long period and there appeared to be no hurry. Both meals looked appetizing and nicely presented Positive comments were received about the food except one resident who commented, “ Well you can’t get worked up about a meat ball “, she laughed when saying it. The menu was on display and in clear print. Visitors were seen to come and go throughout the day of the site visit. Visitors with whom the inspector met said that they were well received welcomed offered a hot drink and meals if they wanted to. During the lunchtime period two relatives were spending the lunchtime period with their mother and enjoying lunch. Meals are provided free and this appeared to be an enjoyable experience for all parties. There is a resident’s notice board, which advises residents of forthcoming events these included a visiting choir, relaxation session, and a presentation headed the “Good olde days “. One resident stated that she would like to do more, when asked what she said she wanted to do she stated “wash up”. Residents with whom the inspector met were aware of the notice board and some of the planned events. A selection of daily newspapers were available in the sitting area. The hairdresser comes in weekly and this was something the residents said that they enjoyed. The majority of the residents were alert and reasonably orientated. The home has a body called the “Friends of Rookstone”, who are involved with fund raising. This group of people seek out ways of raising money to improve the quality of life for residents. They have been involved in raising money for equipment in the past, and they actively monitor the benefit to residents. Rookstone DS0000038682.V348663.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has in place a complaints procedure, which included avenues for external reporting of such. Staff had a good knowledge of adult protection procedures. Evidence of checks made on staff to ensure resident’s protection was not in all files. EVIDENCE: The complaints procedure was on display in large print and included with documentation such as the Statement of Purpose .The complaints book was viewed it contained minutes of resident meetings as this had been advised by a previous inspector. The residents meetings are a forum to raise any areas of concern and this was why the inspector had requested it be attached. The Manager minutes resident meetings then attaches the record of the action she has taken to address these concerns. The last complaint recorded in this book was dated October 2006. The complaints log detailed the nature of the complaint, date and the response. Any investigation information would be retained. The outcome needs to specifically state if the complainant is satisfied with the outcome or not. Mrs Fell said this would be addressed immediately. The CSCI have received no complaints about this service. The Salvation Army has a specific policy on dealing with complaints and abuse. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 17 Residents with whom the inspector met cited the Manager or their relatives as avenues for raising concerns. Those staff who were interviewed by the inspector demonstrated a good knowledge of adult protection procedures and the reporting of such. Staff included external agencies as well as internal procedures when dealing with suspected or actual abuse. Within the section headed “staffing” there is reference to recruitment checks and the absence of one POVA/CRB confirmation. Rookstone DS0000038682.V348663.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has worked hard to improve the environment for residents although the programme of refurbishment and redecoration needs to continue to ensure all areas are to their optimum standard. EVIDENCE: The home is an older style building located over three floors. The bedrooms are on the ground and fist floor and communal areas on the ground floor. There is parking to the front of the building and a garden accessed by patio doors from the lounge. All areas which were inspected during the site visit were clean and odour free. There is a lift facility within the home. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 19 The home has undergone some upgrading of the building including redecoration of communal areas and individual bedrooms. The home plans to complete the interior work,including redecoration of all corridors, toilets and bathrooms. Some resident’s bedrooms have been redecorated and in many cases, personalised with furnishing to the residents requirements including wall decorations, pictures etc. In some bedrooms resident’s had their own telephones, TV’s and radios. Some clocks and calendars were evident. Communal areas which have been redecorated were bright and pleasant On the ground floor there were a number of areas, which required attention. The toilet doors were badly marked, as were the walls. Other corridor areas were also in need of redecoration. These were all part of planned redecoration. On the first floor a new shower and toilet had been installed in the last eighteen months. The dining areas have been redecorated in vivid colours with nice pictures to enhance it. There is a staircase in the hallway entrance. The space underneath this is used as storage for wheelchairs and other items. This is unsightly as you enter the home although stores these items out of the main communal areas. CCTV is in operation in the corridor areas and the external grounds. Bedroom doors are fitted with fireguards, which automatically release once the fire alarm has sounded. Rookstone DS0000038682.V348663.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet resident needs and spend time with them. Training is addressed through in house programmes and external courses, which enables staff to do the job for which they are employed. Evidence of POVA first or CRB clearance was not always retained for inspection. EVIDENCE: During the morning of the inspection there were two care assistants with Mrs Fell the Manager and a principal care worker. In addition there was one cook, and kitchen assistant, a dining room assistant three cleaners and a handyman. The morning of the site visit, staffing was below the usual numbers as there are normally three care staff for the morning shift. Even with the reduced staff member the inspector was unable to identify any shortfalls in care, nor was this expressed by any of the residents with whom the inspector met. Two care staff and a principal care worker covered the afternoon shift. Between the hours of 2pm-4pm there is a staff overlap when handover is conducted. Night duty is covered by two waking staff plus on call support. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 21 There is one staff vacancy in the home that of a weekend cook. This is being actively recruited to. The inspector met with staff who were on duty, including one member of the team who had started September 2007.This staff member had previously worked in a nursing home before applying to Rookstone. She confirmed recruitment procedures, which included completion of an application form, and interview as well as CRB and reference checks. She stated that she was currently on induction and shadowing another staff member. Prior to her employment in this home she had completed NVQ level 3. She demonstrated a good knowledge on the subjects selected for questioning namely adult protection and infection control. A second staff member had been in post for 20 years. She was a principal care worker having worked in this home as a care assistant before she was promoted. She outlined her experience as well as her responsibilities in this management role. She confirmed training in a number of subjects and had completed NVQ level 3 and was due to start NVQ level 4. She advised the inspector that she had completed the mandatory updates and had completed the four day first aid certificate. In addition she had attended training in adult protection, Dementia, COSHH, and infection control. She felt that training provided was appropriate and kept her updated with developments. She confirmed that supervision was conducted where her training needs were identified. Supervision also offered a forum to problem solve, provide guidance and support. She stated that she received supervision every three to four weeks. This staff member also demonstrated a good knowledge on adult protection procedures, infection control, management and had a reasonable awareness of Dementia. All staff in the home have completed NVQ level 2 or 3 except 1. Within the staff group five have completed NVQ level 2 and eight level 3. Training on abuse was conducted 13 March 2006. In the personnel file of a newly recruited staff there was information relating to her recruitment and subsequent appointment. The application form indicated a work history back to 2000 and some of the information provided had been explored at interview. The staff had supplied two references one from her previous employment, which was in a care home. Photocopies of proof of checks, made in respect of identity, including her passport and address were on file. The list of interview questions were retained. Photocopies of previous training certificates were available. The inspector was unable to locate the POVA first check, although the Manager stated that the CRB from her previous employment had been checked and that the information was probably retained at head office. The Manager also explained that this staff was “shadowing” another staff whilst on her induction and at no time would be let unsupervised. An induction form was in place. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 22 A second file was inspected of another new staff. This file contained CRB and POVA first confirmation. The application form was fully completed wit no gaps evident and a work history back to 1998. Only one reference could be located. Another personnel file contained similar information although two references were in place. Staff with whom the inspector met confirmed supervision and training. New staff stated that they had, or were completing induction training. Please see requirement 3. Rookstone DS0000038682.V348663.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is managed by a trained and experienced individual. Health and safety is well addressed in the home, which provides a safe environment for resident to live. Quality assurance systems are in place, which take account of the views of resident relatives and staff. The results of such audits are acted upon to improve the service provided. EVIDENCE: Mrs Fell is the Registered Manager for this facility and has been for a number of years. She is a qualified nurse and has completed the Diploma in Management and NVQ level 4. She also holds a social work qualification. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 24 The home conducted a relatives survey some eighteen months ago. Thirty questionnaires were sent out and ten returned of which some were limited in content. Relatives meetings are held every six weeks. These are minuted and where applicable responses and action taken. The inspector selected three residents’ finances to check including those residents who had been part of the case tracking. There are individual records in place, which include a transaction/balance sheet and receipts are retained. Two staff sign for all transcriptions or the residents when able. Of the three checked two records were incorrect although receipts for the expenditure were retained. Individual finances need to be audited more frequent to ensure records are correct. This was not the case at the site visit, and although money could be accounted for records were not accurate. The Salvation Army has introduced a quality assurance system throughout all of their homes. This was felt to be unworkable in this home and the Manager had developed her own documentation for this purpose. This was yet to be implemented hence its usefulness could not be tested. This quality assurance is one obtained through a care publication. The audit tool has sections dealing with specific areas. The Manager stated that she would be involving staff members in conducting the audits to enhance their understanding and promote a sense of responsibility in the process. The Salvation Army also conduct an annual “compliance monitoring” audit. This is a full audit of the home conducted by senior staff in the organisation. This had been conducted July 07 and the results were awaited. Within this report requirements and recommended action would be stated. Compliance on these items would be monitored by the Assistant Director of Elder Services within the Salvation Army. Various forums for staff meetings are facilitated, usually on a four to eight week basis. The agenda is left open; minutes are taken and circulated to all staff. Health and safety. The kitchen had been issued with the clean food award 2006. In addition, Bromley Environmental Health had inspected the premises 17/5/07 and good practices were observed for the food premises and storage. The LFEPA had inspected the premises February 2007 and found all items satisfactory. The fire risk assessment was dated 2007 and had been devised in conjunction with advise from the LFEPA. In addition there was a fire emergency plan as well as policies and procedures. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 25 There were records in respect of checks made on weekly fire alarm testing, emergency lighting and means of escape .The fire fighting equipment is subject to inspection regularly as well as on a service contract. The fire equipment had been serviced April 2007 and the fire alarms November 06. Fire training had been conducted regularly and the records included a list of attendees and some staff signatures. All staff should sign as confirmation of attendance for all raining received. Electrical portable appliance testing was conducted 17/7/07 by the handyman who is trained in this. The home needs to forward the five year electrical inspection, which deemed the system as satisfactory as work was required to bring it up to standard on the report seen. Mrs Fell was aware this had been conducted although the certificate was not located. Since the inspection documentation has been sent to the CSCI office regarding this issue. The annual gas certificate was dated March 07. The equipment inspection under the LOLER regulations was current. The lift inspection and insurance were both available. The legionella testing was addressed 8/6/07. The public liability insurance was current. The first aid boxes contained appropriate items. All night staff have received training in first aid as have al of the principal care workers. Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 2 X X X X X X 3 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 2 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 Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement The Registered Manager must ensure that care plans, risk assessment and all supporting documentation is completed on all residents with comprehensive interventions on how to address the problems identified. Previous time frame for action 15/4/07. This had been partially met . The Registered Manager must ensure that staff follow the correct medication administration procedures and that all records are fully completed. The Registered Manager must ensure that all staff are subject to robust recruitment procedures and evidence of these is retained on site. Timescale for action 15/11/07 2 OP9 13 15/11/07 3 OP29 19 15/11/07 Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rookstone DS0000038682.V348663.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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. 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