Inspection on 11/07/06 for Rowallan House

This inspection was carried out on 11th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Rowallan House 24/02/06

Rowallan House 01/02/05

Rowallan House 02/12/04

Rowallan House 11/03/04

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 Rowallan House 17 Little Heath Chadwell Heath Romford Essex RM6 4XX Lead Inspector Ms Harina Morzeria Key Unannounced Inspection 10:00 11th July & 18th August 2006 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 DS0000025922.V303796.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. DS0000025922.V303796.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowallan House Address 17 Little Heath Chadwell Heath Romford Essex RM6 4XX 020 8597 4175 020 8597 1118 info@rowallenhouse.co.uk 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) Mrs Marina Stack Mr Laurie George Taylor Justice Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places DS0000025922.V303796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24th February 2006 Brief Description of the Service: Rowallan house is located in a residential area in Chadwell Heath, in the London Borough of Redbridge, close to public transport links. The home provides residential care to residents over the age of 65 who have physical illnesses or conditions associated with the ageing process. It is registered to provide care for 41 residents, offering personal care and assistance in a homely environment. The bedrooms are situated on the ground and first floor, which are served by a lift and stairs. There are three lounges, one of which is used as a smoking room plus a separate dining area. There are 37 single bedrooms, of which 13 rooms have en-suite facilities. The home also has two double bedrooms. Adequate bathing and toilet facilities are also provided. Various activities are planned such as listening to music, board games, exercise classes and bingo as well as outings during fine weather, which are actively enjoyed by the residents. Staff also take some of the more able residents out individually and those residents who are able and willing to go out independently are encouraged to do so. The residents are offered a varied, nutritious and culturally appropriate diet. They are able to have their meals flexibly at different times or in their rooms if the wish. The home provides a Statement of Purpose that clearly sets out the objectives and philosophy of the service. A Service User’s Guide is also available to prospective residents which includes information about the accommodation, qualifications and experience of staff and how to make a complaint. This information can be made available in different formats and languages upon request. The fees range from £420.00 - £525.00 per week. DS0000025922.V303796.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection that took place over two separate days and lasted for 12 hours in total. The inspector spoke to a large number of residents about their experience of living at the home. Discussions took place with the manager, deputy manager and members of the senior staff team as well as the care staff. Staff were spoken to about care practices that they have implemented in the home. They were also observed directly and indirectly providing care to the residents. Feedback questionnaires were received from eight members of staff plus a community staff nurse. Two relatives and three residents’ questionnaires were also returned to the inspector. A tour of the home took place and a number of residents’ and staff records were examined. What the service does well: The home has a welcoming atmosphere and is very clean and tidy. The residents’ commented that staff are very helpful and approachable. Staffing levels are appropriate with sufficient numbers of care and ancillary staff to meet the needs of the residents. The residents have a choice of lounges to sit in as well as the garden. The bedrooms are spacious and personalised by the residents. There is a varied selection of home made meals and the cook is aware of the residents’ likes and dislikes. A comprehensive training programme is available for the staff to attend. All necessary healthcare services are accessed for the residents in order to meet their assessed and specialist needs. Two members of staff take responsibility for arranging a weekly programme of activities, which is posted on the notice boards outside the lounges on the ground floor. One resident said that, “There are always outings and things to entertain us, to stop us getting bored.” DS0000025922.V303796.R01.S.doc Version 5.2 Page 6 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. DS0000025922.V303796.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 DS0000025922.V303796.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is good. The judgment has been made using the available evidence including a visit to the service. A Statement of Purpose is available and includes all the information residents need to make an informed choice about where to live. A comprehensive pre - admission assessment is undertaken of all prospective residents prior to their admission to the home, in order to establish their needs and whether these can be met at Rowallan. All residents have a written contract with the home. Residents and their representatives are invited to visit the home so that they know that the home they enter will have the staff who are able to meet their needs. They are also able to obtain a Service Users’ Guide. Intermediate care is not a service provided by Rowallan. Therefore standard 6 is not applicable. EVIDENCE: The Statement of Purpose includes information about the service provided by the home and is written in a clear and precise manner to enable prospective DS0000025922.V303796.R01.S.doc Version 5.2 Page 9 residents and their representatives to make an informed choice about where to live. Evidence was seen that the Statement of Purpose is available in the lobby area at the home for any visitors to look through. It is also available in different formats upon request. The manager is in the process of reviewing and updating these documents. Each resident has a contract and a copy of the home’s terms and conditions. This sets out what is included in the fees, the role and responsibility of the provider, and the rights and obligations of the resident, giving residents a clear understanding of what they can expect. A Service Users’ Guide to the home is also issued to each resident. These documents are also available in different formats upon request. Two files for newly accommodated residents were examined, which included an in-depth assessment of their needs as well as an assessment from the local authority. Further information was also obtained from health professionals, family members and the resident, prior to the resident’s admission to the home. Residents and relatives are invited to visit the home prior to the resident moving in. The newly accommodated resident was able to confirm that she visited the home with her family prior to making a decision. The home does not provide intermediate care. DS0000025922.V303796.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,10 and 11 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. The health and personal care needs of each resident are set out in individual plans of care. These plans provide the staff with sufficient information to ensure that care needs are being met on a daily basis. However care plans must be updated promptly when a residents’ needs change. There is a medication policy and procedure for staff to follow and the medication records are being completed correctly which safeguards residents with regard to their medication. Generally residents are treated with respect and arrangements for their personal care ensure that their right to privacy is upheld. Residents’ wishes in relation to death and dying are identified in their care plans. EVIDENCE: Each resident has their own care plan. Four of these care plans were examined by the inspector. The care plans were being updated at the time of inspection and therefore did not include updated information regarding changes in a resident’s needs. DS0000025922.V303796.R01.S.doc Version 5.2 Page 11 The care plans generally identify residents’ personal, social, cultural, religious and health needs and how these needs should be met. The plans include a risk assessment element. When developing the plan the home has complied where possible with the relevant clinical and social care guidelines. The daily records show how residents’ needs are being met on a daily basis. The manager is aware that the daily records should be informative and relate to the specific care plan goals and the outcomes. Residents have access to healthcare services that meet their assessed needs both within the home and in the local community. All residents have access to dentists, opticians and other community services. The residents’ health is monitored and appropriate action is taken. The home seeks professional advise on healthcare issues, acts upon it and generally is able to provide the aids and equipment recommended. There is evidence in the care plan of healthcare treatment and intervention and a record of general healthcare information including weight monitoring and nutritional information. However, there are some gaps in information recorded, particularly, for one resident who is bed bound and requires to be turned frequently. Upon examination of the turning charts, the inspector noted that not all the staff completed the charts as required and gaps appeared in this. However, a member of staff spoken to, was able to give a verbal update about the residents’ particular needs and how these are met and confirmed that the resident is regularly turned by the staff but they failed to record this. The manager must ensure that evidence of the care provided for each resident is fully recorded in order to show how residents’ needs are being met. Any changes in residents’ needs must be fully recorded and the care plans must be updated/amended promptly to reflect any changes to the care required by the resident, in consultation with the resident, so that staff can provide appropriate care to the residents at all times. DS0000025922.V303796.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. Staff on duty have responsibility to ensure that the residents have a varied programme of activities which suits individual needs, preferences and capacities. Visiting times are flexible and people are made to feel welcome, when visiting the home enabling the residents to maintain contact with their family and friends. Residents are assisted to exercise choice and control over their lives. The meals in the home are well presented and nutritionally balanced. They offer both choice and variety to the residents. EVIDENCE: The inspector spoke to a number of residents to seek their views about living the home. All the residents spoken to stated that they receive good care from the staff and all their needs are being met in a caring and professional manner. The visitors book showed that there is a steady stream of visitors to the home on most days. As well as friends and family, other visitors included a hairdresser, a reflexologist, an entertainer, as well as church visitors. DS0000025922.V303796.R01.S.doc Version 5.2 Page 13 There are a wide range of activities provided within the home as well as outings on a regular basis. The inspector saw the activities and outings leaflet which reflected a varied programme of activities. Some of the residents spoken to stated that they enjoyed a pub lunch outing recently. Other activities include quizzes, bingo sessions, gardening, and watching videos. Residents confirmed that they are free to choose if they wish to participate in the activities or not. Although several residents said they appreciated and enjoyed the activities offered, one person spoken to said she would like to participate in other more stimulating activities such as art and painting as well as more outings. The inspector has advised the resident to speak to her key worker regarding her preferred choices in order to devise an individualised activities plan which may be more suitable and stimulating for her. Key workers should also seek feedback from residents about the kind of activities they enjoy doing so that consideration can be given to providing some of these. Evidence was seen that residents are consulted via residents’ meetings which are held on a regular basis. Family and friends feel welcome and know they can visit the home at any time. Staff make time to talk to visitors and share information with the agreement of the resident. It is clear that the home encourages individuals and groups from the community to visit the home. Residents have a choice of where to see their relatives, including one of the lounges or in their own bedroom. Residents finances are handled by their family members or representatives. There is a clear financial policy and procedure in place to protect the residents. Residents are encouraged to bring their own personal possessions with them when coming to live at the home and this was evident when the inspector visited some of the residents’ bedrooms. Meals are mostly served in the dining room, but there were some residents who choose to eat on their own in the lounge or in their own bedroom. The meals observed on the day of the inspection looked appetising and nutritionally balanced and the residents were complimentary about the food. Alternatives are offered if a resident does not like the choices on offer. Care staff are sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. They are aware of the importance of feeding at the pace of the resident, making them feel comfortable and unhurried. Tables are set attractively with the necessary cutlery and aids to help individuals during their meal. DS0000025922.V303796.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents and their relatives are confident that their complaints will be listened to and acted upon. Residents legal rights are protected. An adult protection policy and procedure is available within the home, however the policy and procedure need to be reviewed and updated in order to ensure that proper procedures are followed in the event of an allegation being made. EVIDENCE: The complaints book was examined during the inspection and the complaints made have been recorded adequately. The inspector noted that all of the concerns and complaints were recorded and dealt with appropriately by the staff, the manager and the deputy. The residents spoken to on the day of the inspection, were asked if they were unhappy about anything in the home and if they knew who to make a complaint to. The residents said that they would talk to the staff or the manager or the deputy. All the residents said that they felt confident that they would be listened to and their complaints would be acted upon. The majority of the residents have relatives, friends or advocates who can advocate on their behalf, if they so wished. The manager has ensured that an advocacy service is offered to residents who do not have any relatives/representatives to represent their views. The policies and procedures regarding protection of residents do not cover all areas required. They are not regularly reviewed or updated. Links with DS0000025922.V303796.R01.S.doc Version 5.2 Page 15 external agencies i.e., CSCI, police adult protection teams and adult protection teams must be clearly defined and developed. Staff spoken to demonstrated an awareness of the issues relating to adult protection and stated that they would report any issues to the manager. However, upon examination of the adult protection policy and procedure, the inspector noted that these must be reviewed and updated in line with the Regulations and other external guidance. Within the policy, it must be clear when incidents need external input and who to refer the incident to. Links with external agencies must be satisfactory and include CSCI, police and local authority adult protection teams. At the time of the inspection, the inspector was concerned about non-compliance with the procedure regarding an adult protection issue. The registered person to ensure that all staff receive updated adult protection training and that all staff demonstrate an awareness of the content of the adult protection policy and know what immediate action to take and when and who to refer any incident on to by following the home’s policy and procedures. The residents and others associated with the home state that they are satisfied with the service provision and feel safe and supported except for one resident who made an adult protection allegation following which although appropriate action was taken in relation to suspending the member of staff, the proper procedure was not followed as the incident was not referred to or investigated via the proper channels. The home’s aims and objectives include the Rights of residents. Residents are supported to live as independently as possible, exercising their rights to make choices and decisions with assistance when needed. The home is aware of the need to facilitate advocacy services and makes efforts to access advocacy services on the resident’s behalf. The home facilitates the right for all residents to vote in elections whenever possible. DS0000025922.V303796.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome is good. This judgment has been made using available evidence including a visit to the service. The home has a welcoming atmosphere and provides the residents with a safe and well maintained environment. There are sufficient numbers of suitable toilets and bathrooms for the number of residents accommodated. Residents bedrooms meet their needs and are furnished with their own personal possessions. Residents live in a home that is comfortable, clean and hygienic. EVIDENCE: The standard of decor, furnishings and fittings in the home are maintained to a good standard. There is an ongoing programme of refurbishment and redecoration. A handyman has been employed to carry out any minor day-today maintenance to the home which ensures that the residents live in a comfortable and safe home. There is an effective system in place for the staff to report items requiring repair or attention. DS0000025922.V303796.R01.S.doc Version 5.2 Page 17 The external areas of the home are well maintained and secure. The garden is now re - turfed and provides a safe and attractive area for the residents to enjoy during fine weather. At the time of the second inspection visit, the staff and residents were looking forward to a garden party which is organised annually during the summer period, when relatives and friends are invited to the home. Residents said that they are very pleased with their individual bedrooms and communal facilities. The inspector noted that bedrooms are personalised by the residents and contain family photographs, ornaments and small items of furnishings. On each floor there are sufficient bathrooms and toilets. Each bathroom has an assisted bath and all the toilets are wheelchair accessible. The standard of cleanliness in the home is high and there are sufficient numbers of ancillary staff employed to maintain it to this standard. Staff have attended training on infection control and take all the necessary precautions to ensure that there is no spread of infection within the home. There are adequate control systems in place to ensure that the home is free from any offensive odours. DS0000025922.V303796.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. Residents benefit from a committed and experienced team of staff in the home, who have the skills and training to meet the residents’ individual needs. The home have a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of residents. EVIDENCE: Residents have confidence in the staff that care for them. They confirmed that immediate action is taken by the management team to deal with any staffing issues or concerns, as was evidenced during a recent complaint against a member of staff. On the day of the inspection, staffing levels were observed to be sufficient to meet the needs of the residents. Staff rotas were examined and the rota correlated with the number of staff on duty to ensure that the residents and needs continued to be met. The home have a generally stable workforce with some staff who have worked there for a number of years and have built up a good knowledge and understanding of the needs of the residents. There is an ongoing programme of relevant training courses on offer to staff and evidence was seen of the various courses available to them, which staff DS0000025922.V303796.R01.S.doc Version 5.2 Page 19 are encouraged to attend by the manager, in order to ensure that the staff develop the skills necessary to meet the needs of the residents. The following comment was received from staff members “I have worked at Rowallan house for three years and find it a very warm and relaxing place to work for, everyone is very friendly. I have become very close to the residents and their families. Everyone is cared for and looked after”. Staff files showed that they have done training in essential areas such as health and safety, adult protection, dementia awareness, assisted movement, fire safety, manual handling, infection control, complaints handling, from painting, bereavement and loss, administering medication and NVQ levels two and three have been completed by 80 of the staff group. The service is also able to recognise when additional training is needed, and intends to plan over time to provide for this training. Staff are competent and trained to do their jobs in an efficient and professional manner. A good deal of quality feedback about the staff at the home was received from the residents. They reported that the staff working with them are able to meet their needs and know what they are meant to do. Evidence was seen that newly recruited staff are receiving induction training, although the manager needs to use the induction book to show that staff received induction over a six week period and then foundation training within six months of starting employment and that their understanding was tested during supervision, to ensure that they clearly understood the information given to them. Upon examination of staff files, the inspector noted that the recruitment procedure is followed, staff files contain all required information including a photographs of each staff member which were in place by the time of the second inspection visit. DS0000025922.V303796.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is good. This judgment has been made using the available evidence including a visit to the service. Residents live in a home that is run in their best interests by an experienced and qualified manager and deputy. Residents’ financial interests are safeguarded by the policy and procedures of the home. The staff team work well together to make sure that residents are safe and secure whilst living at Rowallan. Staff receive supervision however this needs to occur on a regular basis and evidenced. The residents’ rights and best interests are safeguarded by the home’s recordkeeping policies and procedures. Residents and staff health, safety and welfare are promoted and protected. EVIDENCE: DS0000025922.V303796.R01.S.doc Version 5.2 Page 21 The manager has the required qualification and experience and is competent to run the home. He is supported by a deputy who is in the process of completing her NVQ level 4 qualification. The management team work closely together to improve services and provide increased quality of life for residents. Feedback from both the residents and staff was positive about the way in which the home is run. Regulation 26 visits are undertaken by the responsible individual on a monthly basis and the reports are forwarded to the inspector. However these visits need to be more detailed and thorough in order to reflect the quality of the service provided, noting any improvements required to make it an “excellent” service. The inspector is also notified of significant events and developments in the home. A quality assurance survey to seek satisfaction levels amongst the residents, staff and relatives has been sent out. The results and outcome of this survey will be available in a report published by the providers in order to assess whether the home is meeting its aims and objectives according to the Statement of Purpose. The home has policies and procedures, which are in the process of being reviewed and updated in line with current thinking and practice. Efficient systems are in place to monitor staff adherence to policies and procedures during practice. The home works to a clear health and safety policy, which all staff have been made aware of and must be working to it. The home has a good record of meeting relevant health and safety requirements and legislation. Records are generally of a good standard and are routinely completed however some of the records need detail. Residents are aware of safety arrangements and have confidence in the safe working practices of staff. The home has an appropriate policy and procedures regarding safeguarding residents’ finances. If they wish and are able to, the residents are helped to take responsibility for managing their own money. They are provided with facilities to keep their valuables and money safe. Where the home is responsible for residents’ money the home maintains clear records that are routinely kept up-to-date and can be used to track individual residents’ finances. However the inspector was informed that most of the residents’ finances are handled by their family members. A supervision policy and procedure is in place. Staff confirmed that they receive supervision on a regular basis from the senior officers. However upon examination of the supervision records the inspector noted that there was no evidence that all staff receive regular supervision. The manager is aware that formal supervision is important as it allows the staff time and space to reflect on their practice with their manager/senior. DS0000025922.V303796.R01.S.doc Version 5.2 Page 22 Recording the supervision is important, as it provides a retrospective picture of development and change. The home must be able to demonstrate that all staff are receiving regular supervision which is accurately recorded. All staff delivering supervision are required to attend a supervisory training course in order to deliver effective supervision to the staff. The manager is committed to keeping records up to date and a requirement has been made elsewhere in this report regarding keeping care plans, risk assessments and other essential information regarding care given to residents up-to date. The manager has carried out all health and safety checks. Fire drills and alarm testing is undertaken regularly. DS0000025922.V303796.R01.S.doc Version 5.2 Page 23 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 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 DS0000025922.V303796.R01.S.doc Version 5.2 Page 24 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 person must ensure that evidence of the care provided for each resident is fully recorded in order to show how residents’ needs are being met. Any changes in residents’ needs must be fully recorded and the care plans must be updated/amended promptly to reflect any changes to the care required by the resident, in consultation with the resident, so that staff can provide appropriate care to the residents at all times. Timescale for action 31/10/06 2 OP18 12/13 3 OP30 18 The policies and procedures 31/10/06 regarding protection of residents do not cover all areas required. They are not regularly reviewed or updated. The registered person to ensure that the home’s adult protection policies and procedures are reviewed/updated and all staff receive updated training with in the stated timescale. The registered person to ensure 31/10/06 that newly recruited staff DS0000025922.V303796.R01.S.doc Version 5.2 Page 25 receive induction training over a six week period and then foundation training within six months of starting employment and that their understanding is tested during supervision, to ensure that they clearly understood the information given to them. 4 OP36 18 The registered person to demonstrate that all staff are receiving regular supervision which is accurately recorded. All staff delivering supervision are required to attend a supervisory training course in order to deliver effective supervision to the staff. 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations Key workers should seek feedback from residents, (especially active residents) about the kind of activities they enjoy doing so that consideration can be given to providing some of these. DS0000025922.V303796.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000025922.V303796.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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