Inspection on 21/08/07 for Rowena

This inspection was carried out on 21st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rowena 12/07/06

Rowena 22/11/05

Rowena 17/05/05

Rowena 27/01/05

Rowena 24/05/04

Rowena 04/03/04

Rowena 05/12/03

Rowena 14/10/03

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

CARE HOMES FOR OLDER PEOPLE Rowena 28 Oakwood Avenue Beckenham Kent BR3 3PJ Lead Inspector Sue Meaker Unannounced Inspection 21st August 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rowena DS0000006965.V345139.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. Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowena Address 28 Oakwood Avenue Beckenham Kent BR3 3PJ 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 8650 3603 F/P 020 8650 3603 Mr Cader Mrs Bibi Cader Mrs Bibi Cader Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2006 Brief Description of the Service: Rowena is a residential care home located in a residential area of Beckenham. The home has been registered to the current owners since March 1995 and provides accommodation for up to 22 persons in the category of Dementia. The home is a detached property and has had some adaptations in order to make it more accessible to the service users. A passenger lift links the ground and first floor accommodation. There is a large lounge and dining room where service users are able to spend time with each other, watch television and participate in various activities and welcome friends and relatives. In addition there is a large garden where service users can sit out in the warmer weather. The Home provides staffing throughout the 24-hour period .Mrs Cader is the Registered Manager. Support services are offered via the Local Primary Care Trust including the GP and district Nursing Services. The chiropodist, optician and dentist are provided via the domiciliary service every six months. Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Statutory Unannounced Key Inspection that took place over seven hours; the visit included a tour of the home, meeting the residents, the staff, visiting relatives and friends and discussions with the Registered Manager. A number of questionnaires were received about the service; these were from relatives of people in the home; some of whom were complimentary about the home and the care service provided. An AQAA was completed by the Registered Manager and provided information about the home and the service provided as well of information about how the home meets the National Minimum Standards – Care Homes Regulations – Care Standards Act 2000. Care Plans, personnel files, training plans, health and safety documentation and medication documentation was inspected. The service of lunch was observed and the laundry and kitchen facilities were inspected. The inspector would like to thank the residents and relatives and the management and staff for their input into the inspection. What the service does well: What has improved since the last inspection? Since the Key Inspection in July 2006 and the subsequent random inspection in February many improvements have been made including the following:• Staff training has significantly improved particularly relating to how to treat people with cognitive behavioural problems; more training is being accessed relating to the care of older people with dementia and challenging behaviour. • Activities have improved but work is still needed in this area; this can be improved further with staff training; there are plans to use the garden more, access entertainers to come into the home and to provide transport to make days out more possible. Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 6 • • • • The garden area has been refurbished making it more accessible for residents and giving a good outside space for residents to enjoy. Concerns and complaints are being documented accurately and the procedure implemented and documented. The staff supervision and appraisal system is now fully implemented. The home is now using visual aids to inform residents and staff of the weather, activities being done that day, the menu and any special accessions such as birthdays, holidays and anniversaries. 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. Rowena DS0000006965.V345139.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 Rowena DS0000006965.V345139.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, 2, 3, 4, 5 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a Statement of Purpose and a Service User’s Guide that provides information to prospective residents and their families to help them make a decision as to the suitability of the home. Terms and conditions of residency were on the files and the room to be occupied was specified. The registered manager must ensure that all residents are appropriately assessed prior to admission and must confirm in writing its ability to meet the service user needs. No service user is referred solely for intermediate care. . EVIDENCE: The home has a Statement of Purpose containing the information specified in the National Minimum Standards; there is also a Service User Guide available Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 9 giving information about the home enabling relatives to make an informed decision about whether the home can meet the health, personal and social care needs of their relative. Residents are provided with a written statement of terms and conditions with the home; or a contract if purchasing the care privately; this document includes details of their accommodation, the care and services included in the fee paid, additional services such as the purchase of toiletries and hairdressing service that are not included in the fee, the rights and obligations of the residents and their relatives and the terms and conditions of the placement including terms of notice. This home provides a service for elderly people with a diagnosis of dementia and referrals are made by local social services; the Registered Manager of the home must be sure that an appropriate assessment is made so that relatives can be sure that the home is able to meet the complex needs of this vulnerable group of residents. Concerns have been expressed that in some circumstances the home is not able to meet the needs of some of the residents in their care, from questionnaires received it was evident that some relatives were concerned about the level of appropriate care provided to their relative; one relative stated that the home does not appear to be “fully aware of my relatives needs, it appears from some of the problems experienced that they might not be”; another stated that “basic needs are met to some extent but residents do not seem to receive the appropriate level of support, encouragement and assistance required”. However on speaking to some of the relatives visiting the home during the inspection they stated that they felt the home met the needs of their relatives and that they were very happy with the standard of care provided. There was no evidence in the files inspected that residents had visited the home prior to their admission, due to the nature of their diagnosis this is not always possible but relatives spoken to did say that they had visited the home prior to making a decision as to its suitability in providing the appropriate level of care required by their relative. Rowena DS0000006965.V345139.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, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care plans reflected the assessed personal; health and social care needs and gave clear guidance on how their specific needs were to be met. Resident’s health care needs were identified at the pre-admission assessment ensuring that appropriate health professional input was accessed. The homes’ medication policy and procedures ensured residents felt protected when medication was administered. The registered manger must ensure that resident’s privacy and dignity is respected at all times. Residents and relatives feel that their wishes and preferences and sensitively handled at the time of death. EVIDENCE: The home is to be commended on the care planning process it uses; the care plan is in the form of a booklet titled the Assessment for Good Care Planning. Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 11 This is a comprehensive document that contains every aspect of the service user’s care; giving a comprehensive picture of the resident and their specific health, personal and social care needs and how those needs are to be met. It gives a personal profile of the service user and contains Mental Health, physical health, Nutrition, Behaviour, pressure sore and Nutrition Screening assessments. There are also risk assessments for falls and Service User ‘s Needs and preferences. This underpins the care and action plan of each service user. There are also six monthly or yearly reviews included in the booklet. The book includes an in depth personal profile of the resident including a family history there was evidence of some input from relatives however one relative stated that there had been not been consulted or been asked for information relating to the formulation of the care plan and felt that the care plan did not give an accurate description of the relatives needs or how they could be met. Four care plans were looked at during the inspection and the four residents identified were case tracked; the care plans were individualised and the appropriate risk assessments were in place, daily evaluations were clear and concise and accurately reflected how the resident had spent the day. It was evident from the care plans and supporting documentation such as the GP, District Nurse, podiatrist, optician books kept by the home; where all referrals are recorded with the date and time of visits, the name of the resident, the reason for the visit and action taken. The home is able to access the services of the tissue viability nurse, physiotherapist and community psychiatric nurse via the GP surgery, psycho-geriatrician input from the Bassetts Centre and input from the dietician, speech therapist and continence advisor from the local primary care trust. Currently no resident self administers their medication; the home receives a weekly delivery of medication from the local pharmacy; medication comes in a blister pack personalised to the individual resident; giving details of the medication, dosage and time, all blister packs and the Medication Administration records are all computer generated; the residents are identified by means of a photograph in the medication file; the medication policy and procedure is in the medication file as well as a list of staff and their signatures who have been trained to administer medication. The MARS sheets were inspected and were found to have computer generated labels stuck on them, this practice is incorrect and medication should be handwritten with two authorising signatures; quantities of medication recorded on the Mars sheet should also be authorised with two signatures; other than this oversight the MARS sheets were correctly completed. It was pointed out at the inspection that the medication trolley should be secured to an outside wall to maintain security. The home does not keep any homely remedies and the registered manager regularly audits the medication. During an inspection in February 2007; concerns were raised about the lack of respect for the dignity and privacy of the residents, this issue has been addressed and there appeared to be a significant improvement in the way in which the residents were treated by the staff and there was evidence of staff empathising with residents and being aware of their specific needs; the Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 12 atmosphere in the lounge area was one of peace and calm, residents appeared to be at ease with one another and the staff on duty The wishes and preferences of the residents and their relatives, in the event of their death, are documented in the personal profile section of the careplanning booklet; all four care plans seen had this information documented. Rowena DS0000006965.V345139.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. The Registered Manager needs to improve the range of activities and social events appropriate to the assessed social needs of the residents. The residents enjoy a good standard of food with choices available; served in congenial surroundings. EVIDENCE: In the report of July 2006 and of February 2007, it was stated that the range in house activities were limited and a recommendation made that visual aids be used in the home displaying the day, date, weather and the daily menu. This has now been implemented and it was good to see the display on the notice board in the main lounge; an activity plan has also been introduced and is on display in the hallway of the home; a part time activity person has been appointed and it is hoped to improve the range of activities on offer and to arrange appropriate social events and hopefully days out and maybe a week end in the country or at the seaside. It was evident from the questionnaires Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 14 received that the lack of appropriate activities was an area of concern for relative’s comments made included the following: “ The care home has recently built an extension that has enhanced the property. It is used as a dining area, but the additional space is not used by the residents when they have finished their meals. Likewise the improved garden has not been used it can be assumed that the residents are not encouraged to use the garden; so they remain seated together with no obvious stimulation apart from the incessant television”. And “Providing entertainment for the residents would make a huge difference to their quality of lives. Listening to and engaging with residents on a human and social level, and if they ask for something try and give ”. it to them, whether it be a drink or a snack, and treat their concerns with consideration and respect with regard for their dignity at all times”. In discussion with the registered manager about appropriate activities for the residents in the home; the registered manager stated that she has approached the Alzheimer’s Society for information about suitable activities and social events for people suffering from dementia. A part time activity coordinator has been appointed; an activity programme has been devised and all events are recorded in the activity log, which is completed weekly. Consideration is being given to purchasing a mini bus and to arranging day trips to local events, the countryside and seaside and ultimately a week-end away for some of the more able residents. It is good to see that efforts are being made to improve the quality of activities offered by the home and look forward to a continued improvement in this area and that the registered manager has taken on board the recommendations in previous reports. The new dining area is a welcome improvement to the home, providing a really nice space for the residents, it is well decorated and furnished to a good standard; the tables were set with linen tablecloths and looked very nice, lunch was served during the inspection and it was a good social occasion with staff interacting and helping the less able residents to eat their meal and supporting and encouraging other residents. The Registered Manager stated that she was hoping to utilise the space for a range of activities including arts and crafts and gentle exercise, leaving the lounge in the front of the home as a quiet area for visitors to talk with their relatives, for meetings and for some staff training. The home implements a four weekly cycle menu and there are plans to introduce picture cards to make it easier for the residents to choose what they would like to eat; choices are available and residents’ likes and dislikes are taken into account; the home provides healthy, nutritious and balanced meals; input from the PCT’s dietician is requested where appropriate and food and fluid supplements are available. Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The complaints and the Protection of Vulnerable Adults policies and procedures should ensure that residents feel safe and protected in their environment; relatives should be confident that their relatives are safe and protected by the management and staff of the home, to be sure they have the experience, skills and training to be aware of any concerns and to be able to identify signs of abuse. EVIDENCE: The home has adequate polices and procedures relating to complaints; the policy and procedure forms part of the Statement of Purpose and the Service User Guide and a copy is also displayed in the hallway of the home. There is a complaints log that is completed when a concern or complaint is made, details of the concern/complaint are recorded as are details of the investigation, action taken and details of the outcome communicated to the complainant; comments are also recorded as to whether the complainant is happy with the outcome or further information is required. There have been two complaints since the last inspection both of which had been recorded, investigated and resolves in compliance with the homes’ complaint polices and procedures. Staff confirmed that they receive training on how to deal with concerns/complaints during the induction process and where aware of the Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 16 procedure to be followed relating on who needs to be informed and where to document information. In the event of an allegation of abuse; management and staff are aware that these allegations are investigated by implementing the social services guidelines; the registered manager demonstrated that the correct procedures were followed when making a referral to the POVA register. Staff also evidenced that they had received POVA training and were aware of social services guidelines and the homes’ policies and procedures; they also had knowledge of the homes’ policy and procedure relating to “Whistleblowing”. From questionnaires received one of the questions asked related to the complaints policy and procedure, one relative said that, “I have not been made aware of an official complaint procedure or policy” and another relative stated that, “I am not aware of a complaints system”. Another question was whether the home had responded appropriately when concerns were raised about their relatives care; one relative stated that, “unfortunately, when I have raised certain concerns, I am told there is no such thing as concerns, only complaints; also that my concerns are met with an initial denial which is sometimes followed up late by a version of events that does not reflect the reality of the situation”. Another relative stated that “ When I have tried to discuss a concern it has been very difficult to do so. There appears to be a reluctance to admit there is a problem, unless it is one the home is raising”. The Registered Manager must ensure that the complaints policy and procedure is easily accessible to all relatives and should have a discussion with relatives during the admissions process about the complaints procedure; it would probably be a good idea to give a copy of the complaints procedure to relatives and ask them to sign to say they have received a copy. The registered Manager must ensure that all concerns are documented and that relatives feel that any concerns are listened to and acted upon, thereby giving them confidence that their concern will be amicably resolved to the satisfaction of the resident in their care. The Registered Manager must ensure that staff can access the policies and procedures relating to POVA and that training relating to these issues is updated on a regular basis. The CSCI is aware of a complaint referred to the local social services Protection of Vulnerable Adults Co-ordinator and is under investigation the outcome is not yet known. Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is clean, pleasant, hygienic, comfortable, safe and well maintained with access to safe and comfortable indoor and outdoor communal facilities. Residents have their own comfortable bedrooms specific to their needs and have easy access to suitable lavatories and washing facilities. Residents are provided with specialist equipment to maximise their independence EVIDENCE: Since the last inspection the building works have been complete; the home now has a spacious extension to the lounge providing a light and airy space for the residents to have their meals and this area is also to be used ad an Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 18 activities space a toilet/shower facility is also to be part of this extension. The building work has been finished, decorated and equipped to a good standard. The home has an ongoing redecoration and refurbishment programme in operation and the home also has a maintenance person who keeps the home in a good state of repair. The communal areas within the home are of a good size and decorated and furnished to a good standard, there is now a quiet area where a resident and their relatives were chatting, there was also activities taking place in the lounge/dining area, residents were listening to music and some of the staff were chatting to residents. Considerable work has been done in the garden and it is more accessible to residents with residents have a paved garden area with shrubs and flower beds and some nice garden furniture; the Registered Manager stated that the garden had been used a lot by the residents and their relatives weather permitting. Many of the residents bedrooms are now single occupancy and are arranged on three floors, residents are also able to access separate toilets and bathrooms close to their rooms. Residents are able to access all parts of the home via a passenger lift and the home provides grab rails, hoists and assisted toilets and baths a enabling the home to meet the assessed needs of the residents. The home has a call bell system that is easily accessed by residents, relatives and staff in the event of an emergency. During a tour of the home with the registered manager a number of residents rooms were seen; the rooms were well decorated and furnished; it was evident that residents and relatives were encouraged to bring their own personal items into the home and that they could choose how their room was decorated and furnished. Residents also had access to a lockable space in their rooms and were able to have a key to their room if they appropriate and that risk assessments were carried out related to this issue. It was evident from checking health and safety records and from observations during a tour of the premises, that the home meets the relevant environmental health and safety requirements in respect of heating, lighting, water supply and ventilation of the residents’ accommodation and also considers and meets the individual needs of the residents. The laundry was also inspected, the laundry person had a good knowledge of COSHH regulation; and confirmed that the laundry person also had a good knowledge of infection control information relating to these issues was displayed in the laundry. The laundry was well equipped with washing machines, tumble dryer and ironing equipment; all the equipment was in good working order and well maintained. The laundry seen was in plentiful supply and in good condition, the residents clothing seen was well cared for, labelled and in good repair. Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff on duty with the required skills to meet the needs of service users. Over 50 of the care staff have obtained the National Vocational Qualification (NVQ) Level 2 in care. Residents can feel confident that the homes recruitment and selection policies and procedures ensuring that they are supported and protected. The staff of the home has access to training opportunities and a training plan is drawn up to ensure the training needs of staff are addressed. EVIDENCE: The home’s rota was examined which accurately reflected the numbers of staff on duty the day the inspection was carried out. It was also evident through observation that there was more than sufficient staff available to meet the needs of service users. It was reported that to date that four care staff have successfully completed NVQ level 3 and that the home is able to access NVQ training whether it be Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 20 level 2 or 3 for all staff; the deputy manager is currently undertaking the Registered Managers Award and hopes to complete this year; the home is able to met the target stated in the National Minimum Standards – Care Homes Regulations 2000. Four staff personnel files were inspected and all were found to comply with schedule 2 (regulations 7, 9 and 19) 0f the National Minimum Standards –Care Homes Regulations – Care Standards Act 2000; evidence was found that the home complied with the CRB and POVA checks being undertaken for all employees; however it would be prudent for the Registered Manager to undertaken a review and reorganisation of all personnel files making sure that all the relevant documentation is recorded and the document files in compliance with the Data Protection Act 1998. It is recommended that The Registered Manager undertakes an audit of all the personnel files and reorganising the information so it is easily accessible; it is suggested that there is one file for each staff member should be used and there would be separate sections for application information, training, supervision and annual appraisal documentation. Ii is recommended that all staff files contain a copy of the terms and conditions of employment, signed copies of the homes’ policy and procedure relating to equal opportunities, confidentiality, death of a resident, a missing resident, what to do in the event of a fire and the acceptance of gratuities. It is understood that all staff employed have access to all the homes’ policies and procedures and the code of conduct and practice set by the GSCC. The four personnel files inspected included individual certificated training undertaken by the staff in the home; the staff spoken to confirmed that they had received induction training and the mandatory training in moving and handling, food hygiene, health and safety and fire training. Staff are also supported and encourages to undertake NVQ training and the home offers NVQ 2 and 3 in social care; staff skills and competence is also enhanced by specialist training in dementia care, challenging behaviour, diabetes, palliative care, first aid, safe handling of medication, food and nutrition, POVA, care planning, infection control and wound care; this training is accessed via Orpington and Bromley Colleges, Asset Training and Guardian training. Currently the registered manager does have an annual training plan in place, as she is to approach Bromley Care Home Training Consortium and the Alzheimer’s Society for some specialised training relating to dementia, activities for those with a diagnosis of dementia and the Protection Of Vulnerable Adults. The Registered Manager is awaiting information regarding courses to be offered from training providers. Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 21 Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home, the residents, relatives and advocates benefit from having a qualified, competent, accountable and committed manager and management structure in place. The home has open and transparent quality assurance systems in place ensuring that the aims and objectives can be measured and are achievable. The home has systems in place to ensure the health and safety of the residents. EVIDENCE: The registered manager is qualified and has achieved the Registered Managers Award; she also has the experience, skills and competency to manage this care Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 23 facility; she is also the proprietor and registered provider of this service. There is also an experienced deputy manager who has also achieved the Registered Managers Award. The Registered Manager committed to training and regularly updates her knowledge and skills. It was evident from observations between the manager, the staff on duty, the residents and relatives visiting the home at the time of the inspection; that they find her approachable and she is also very knowledgeable about staff and the resident’s complex health, personal and social care needs. The Registered manager is committed to the homes’ quality assurance process and has introduced a number of quality assurance audits that are completed on a monthly basis, documents were seen in support of this process. The home would benefit from an effective quality assurance system based on seeking the views of residents, relatives, staff and healthcare professionals and reporting the findings back in a report which is then made available to residents, relatives, their representatives, other stake holders and also to CSCI In respect to service users’ money it was reported that where possible the home encourages residents to manage their own finances or relatives to do this on their behalf. The registered manager will request monies on behalf of the resident to buy personal toiletries, clothing and hairdressing; she makes sure that receipts are kept and available to relatives when needed and invoice the relatives for any expenses. Currently three residents have their finances administered by the Court of Protection. A previous requirement that staff must receive regular supervision has been met and evidence of supervision and appraisal documents were seen in the staffs personnel files. The home has health and safety policy and procedures in place. A sample of maintenance certificates was seen including that of the home’s gas boiler, electrical equipment, the passenger lift and for hoist equipment. There was evidence that water temperatures are regularly checked to prevent against the risk of scalding and also tested for the risk of Legionella. A building and fire safety risk assessment are both in place; it was noted that the fire risk assessment complied with the fire brigades regulations; complemented by individual residents and room risk assessments. The home had received a visit from Bromley Environmental Health Inspector on the 15th February 2007 and everything was found to be in order. The homes’ Business Plan was seen and gave details of the homes’ aims and objectives, business, the managers voice and an action plan. Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 24 Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 2 2 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The Registered Manager must ensure that all residents are appropriately assessed prior to admission and must confirm in writing that the home’s ability to meet the service user’s needs. The Registered Manager must ensure that all residents and relatives are aware of the homes’ complaints policy and procedure. The Registered Manager must ensure that where appropriate residents hand their relatives visit the home prior to admission; so they can be satisfied as to the suitability of the home and that is is able to meet their assessed health, personal and social care needs. This visit should also be documented. The Registered Manager must ensure that the residents engage in appropriate social activities. The Registered Manager must ensure that all staff receive DS0000006965.V345139.R01.S.doc Timescale for action 10/12/07 2. OP16 22.3 10/12/07 3 OP4 12 10/12/07 4. 5. OP12 OP18 16 13 10/12/07 10/12/07 Rowena Version 5.2 Page 27 regular updated training in the Protection of Vulnerable Adults. 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 OP29 Good Practice Recommendations The Registered Manager should ensure that a audit of personnel files be undertaken and that the files should be reorganised to make them more user friendly. The Registered Person should ensure that training providers are approached to provide specialist training relating to the care of older people with dementia and challenging behaviour. The Registered Person should undertake an annual survey of residents, relatives, staff and healthcare professionals and communicate the outcome of the survey to those who have taken part and to the CSCI 2 OP30 3. OP33 Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Rowena DS0000006965.V345139.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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