Inspection on 06/09/06 for Seven Arches

This inspection was carried out on 6th September 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Seven Arches 24/07/08

Seven Arches 07/08/07

Seven Arches 29/03/06

Seven Arches 13/12/05

Seven Arches 22/03/05

Seven Arches 12/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Seven Arches Lea Rigg Cornsland Brentwood Essex CM14 4JN Lead Inspector Helen Laker Key Unannounced Inspection 6th September 2006 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 Seven Arches DS0000015560.V310684.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. Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seven Arches Address Lea Rigg Cornsland Brentwood Essex CM14 4JN 01277 263076 01277 216692 gillbezzing@aol.com 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) Brentwood Homes Limited Mr Lochan Kunkun Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Terminally ill (4) of places Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Nursing and personal care to be provided for up to 30 Older People. Nursing care for up to 4 Older People with a Terminal Illness. Maximum number to be cared for shall not exceed 30. Date of last inspection 29th March 2006 Brief Description of the Service: Seven Arches is a large purpose built two storey property situated in a quiet residential area close to Brentwood town centre and within approximately one mile from Brentwood rail station. The home provides single bedroom accommodation for up to a maximum of thirty older people, including up to a maximum of four people who have a diagnosed terminal illness. Residents have access to extensive well maintained external grounds and the home is decorated and maintained to a high standard. The home was first registered in August 2002. The Service User Guide and Statement of Purpose have been reviewed and when updated the residents and their representatives can be provided with this information and the manager stated that the home would provide them with Commission for Social Care Inspection reports too. These were on display on the day of inspection. At the time of this report the manager supplied a scale of the homes charges and fees these range from £595.00 to £665.00 per week Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection which took place over eight hours with two inspectors in the home, Lead Inspector for the home, Helen Laker and Carolyn Delaney. This unannounced inspection was undertaken on the 6th September 2006 with the assistance of the manager and nurse in charge. The inspection took place over two days, one spent in the home viewing records and files. There was a tour of the grounds and an inspection of records and documentation. Time was spent discussing the care of the service users. Further feedback was also received from service users and care staff through completed surveys, telephone contact and discussion. Survey responses have been included in the relevant sections of the report. A pre-inspection questionnaire and other reports and correspondence provided by the acting manager were also used as evidence to inform this report. The manager in charge of the day to day management of the home and staff were spoken with. Thirty seven National Minimum Standards were inspected on this occasion, twenty three overall outcomes were met and there were nine requirements and five recommendations detailed in the full report. Discussion of the inspection findings took place with the manager in charge of the day to day management of the home at the end and throughout the inspection, and guidance was given. Key standards as identified in the intended outcomes sections of this report are inspected at least once every twelve months during a key inspection. Where key standards have not been inspected on this occasion they will have been inspected at the previous inspection. Reports in respect of previous inspections may be accessed via the Commissions website www.csci.org.uk What the service does well: What has improved since the last inspection? Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 6 Seven Arches continues to provide good standards of nursing care for the people who live there. Information in respect of the homes arrangements for safe keeping of valuables can be provided to prospective residents. Nursing staff are now more aware of the need to ensure that records kept in relation to the medicines brought into the home and administered to residents are well maintained and that people receive medicines as prescribed for them. Although the requirements at this inspection have increased it should be noted that all standards were inspected on this occasion except one which was not applicable and this is a comprehensive report which details all areas which require actions to be taken. A system for obtaining the views of residents and their relatives regarding how the home is run was implemented at the last inspection so as to identify where people feel that the home provides a good service and where improvements could be made. Each relative has been contacted and offered the opportunity to complete a survey questionnaire. A meeting was been arranged so that relatives can meet with the manager to discuss the findings of the most recent questionnaire. A copy of these findings should be sent to the CSCI What they could do better: All service users must be provided with a contract and the terms and conditions of the home A detailed service user plan of care must be drawn up including consultation with service user families and significant multidisciplinary personnel, to be reflected in the care plan and be completed sufficiently and reviewed comprehensively monthly. The opportunities for stimulating activities, which are provided for the people living at the home, should be reviewed and residents should be consulted so as to find out how they would like to spend their days including how they would like to spend free time. Where activities are provided records could be better maintained. Records should be kept regarding any complaints made or concerns raised verbally or informally. These records should clearly indicate whether the complaint was upheld and what action was taken to address the issues raised. Service users must not be restricted with safety gates on doors intermittently or permanently for any reason or be subject to any form of restraint. The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice and that Records required by regulation for the protection of service users and for the effective and efficient running of the business must be maintained, up to date and accurate. People must only be employed at the home after all of the checks have been carried out so as to determine that the person is suitable to care for older people. A letter expressing serious concern The formation of environmental risk assessments must be undertaken and adequate precautions taken against the risk of fires with reference to evacuation procedures. All staff must be suitably trained and essential fire Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 7 has been issued to the home in respect of this at this inspection. drills undertaken and documented appropriately. (Fire Safety & Employers Guide) also refers 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. Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 8 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 Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4,5,6 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 Service User’s Guide. Present and prospective service users and their supporters are given adequate information about the home so that they can make informed choices. The admission procedure highlights some shortfalls but overall includes an adequate assessment, which ensures that service users needs can be met. EVIDENCE: The home has a Statement of Purpose and Service User’s Guide. Both documents generally incorporate all recommended criteria. The service user guide was discussed with reference to it being made more user friendly, in a relevant format and providing an overview of the home and services available. On inspection of the homes two most recent service user admissions, documentation a statement of terms, contract and conditions was found to be missing and COMM 5 documentation still awaited from the funding authorities. The majority of service users are admitted through social services and are accompanied by a full assessment and care plan. Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 10 The homes manager generally carries out pre- admission assessments and following this assessment a decision is made as to whether the home can meet their needs. Once people are admitted to the home a more detailed assessment is recorded from which care plans are developed. Attention should be paid to dating and signing documentation and assessments at the time of completion to ensure accurate information is maintained. It was noted that wherever it is possible that residents or their relatives were involved in the assessment process. Before staff visit prospective residents they request that the person or their representative view the home to see if they would be happy to move in should the home be capable of meeting their assessed needs. Seven Arches does not provide intermediate or rehabilitative care. Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan and service users are supported to take risks as part of an independent lifestyle via a process of assessment. While improvement has been made to the care planning process some further progress is required to ensure that service users needs are met. The health needs of service users are well met although better documentation would ensure clarity of needs. Medication administration and recording has improved since the last inspection. Personal support is provided in a way that promotes dignity. EVIDENCE: Evidence of five service user care plans indicated that their basic health, personal and social care needs are recorded within an individual plan of care. Instructions for staff to meet service users’ care needs were not on all occasions clear and comprehensive. Care plans did not always evidence service users’ or relatives’ involvement and those seen were reviewed on a regular basis. Daily recording requires improvement to ensure they detail the welfare of the service user, how they spend their day and the progress of the care plan. Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 12 Risk assessments were available for most service users but were also noted to require more detail in some areas and include potential complications of the risk. Care plans did not always include consultation on restraint agreements, likes and dislikes, evaluation of care needs though monthly reviews and have plans in place so as to minimise these risks and their impact on the lives of residents living at the home. The manager was advised of these issues during the inspection Care plans evidence that service users are enabled to access all community health services. The inspector was informed that only trained staff administer medication. Completed drug histories should still refer to dose changes on the form. All individual entries on the drug sheets should be signed by the transcriber and checked for accuracy. The dose form and strength of medication was generally clearly recorded on treatment charts. Minor shortfalls were noted with the maintenance of records in respect of the medicines received into the home and administered to people who live there. This issue was highlighted at the homes previous inspection but improvements were noted. The home also has an agreed contract for adequate disposal of waste medication. Two residents required oxygen therapy at the time of this inspection. The dose and frequency of this therapy was not clearly recorded at the last inspection and one service user stated that she did not use it. Staff were generally observed to treat residents and their visitors with respect and dignity. Staff are reminded to remember to knock on doors prior to entering and ensure communication is maintained during periods such as mealtimes. Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. However more prominence as appropriate should be based on ensuring service users views regarding afterlife issues are recorded in plans of care. Seven Arches DS0000015560.V310684.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A wider range of meaningful pastimes needs to be developed to promote the residents mental and physical wellbeing. Links with families are good and contacts are maintained. Choice in the routine of the day can be adapted to ensure residents rights are maintained. The home provided good food in ample quantities and is served in a congenial setting. EVIDENCE: There is information recorded for some but not all of the people who live at the home about how they wish to spend their days including their preferences for leisure. There are some activities provided such as entertainers, games and music. The home now does not employ a specific activities organiser. A member of admin staff provides activity cover from 2pm till 4pm from Monday to Thurs but no weekend cover. Activities need to be further developed in a planned way to meet all the service users needs. Individual one to ones should be planned and although an activities book with photos was available it had not been kept up to date since 2004. Seven Arches operates an open visiting policy where residents may receive visitors at any time they choose. Visitors who were spoken with during this inspection confirmed this and said that they were always made to feel welcomed when they visited the home. Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 14 Information about resident’s choices and preferences for activities of living are not consistently recorded for the people living at the home. It is accepted that a number of people living at the home may not wish to or be capable of participating in activities. However records in respect of meaningful occupational and stimulating activities are not consistently recorded and it was not clear what activities are planned on a day-to-day basis. More could be done in respect of the social and leisure activities provided by the home. Residents said that the food provided by the home was very good and that there were choices and a daily menu. Residents are weighed on a regular basis and are provided with nutritional supplements if required. It was positive to note that where residents required their meals to be blended or pureed that the reason for this was recorded and that they or their families were involved in this decision. Seven Arches DS0000015560.V310684.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy which informs complainants of their rights, in the event of any informal complaint documentation must be maintained appropriately or fully. Staff do receive relevant training relating to the protection of vulnerable adults. EVIDENCE: The home has a detailed complaints policy and procedure and people may raise concerns formally or discuss any issues in a more informal way with the homes manager. It was reported by the homes manager that there have been no complaints made since the previous inspection. It was noted that informal and verbal complaints are still not logged in a manner which recorded the outcomes and the home would benefit from this to avoid recurring issues and highlight areas where services could be improved. The inspector was advised that some service users have their own advocate or utilise an advocacy agency. Service users legal rights are protected by the home’s policies. Information on advocacy can be made available. The home has an Adult Abuse Policy and Whistle Blowing procedure, which have been updated previously. Most staff have now attended “Protection of Vulnerable Adults” training. The home must continue to ensure that all staff receive training in the protection of vulnerable adults and ensure through the home’s supervision procedures that all staff are fully aware of what is expected of them. Seven Arches DS0000015560.V310684.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): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Seven Arches was clean, bright and well maintained and provided the service users with safe, homely and comfortable surroundings. Not all staff were totally aware of the fundamental concepts of restraint. EVIDENCE: Each resident is provided with his or her own bedroom. Twenty-two rooms have ensuite facilities and there are sufficient bathrooms and toilet facilities to meet the assessed needs of residents. The home is maintained to a high standard in terms of general décor and cleanliness. There were no unpleasant odours detected during this or previous inspections. Residents have access to two lounge areas, one of which is used to hold birthday parties and to provide privacy for visitors as required, a dining room, a room for hairdressing and well-maintained attractive garden. The accommodation in terms of bedroom space meets the standards for homes registered before August 2002 Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 17 All service users’ bedrooms were seen to be personalised to individual tastes. The home provides beds, allocated by service user’s needs. The inspector noted on the day of inspection two service users were being restrained with safety gates on their doors with inadequate documentation in their plans of care and or no risk assessment. This was discussed with the manager at this inspection and the actions required therein as this is not considered good practice. The home has equipment such as lifting hoists, wheelchairs and pressure relieving mattresses and cushions to meet the assessed needs of the people who live at the home. Seven Arches DS0000015560.V310684.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): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels are currently maintained to meet the needs of service users. Recruitment practices currently are very poor and have major shortfalls which need addressing. Staff training needs more prominence in being appropriately developed and undertaken to provide a competent work force. EVIDENCE: The staff duty rota provided evidence that staff are employed in sufficient numbers to meet the needs of the people who live at the home. Staff do not work excessive hours without appropriate off duty time. Care staff are supported by experienced nursing staff some of whom provide regular in house training, supervision and support which covers how to manage illnesses and conditions associated with the ageing process, terminal illness etc. Of the staff records reviewed it was noted that some major shortfalls were evident and documentation was missing. The Inspector was informed that Criminal Record Bureau checks have been obtained but were not all available to inspect. There was little or no evidence of inductions or job descriptions and current contracts were noted to not be signed or dated or even in place in some cases. The process regarding agency and volunteer recruitment should the need arise, and CRB checks was discussed. Attention should be paid when recruiting, to addresses for references, incomplete application forms, comprehensive work history, permissions to work and proof of identity. The manager was advised that staff members must not start work at the home Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 19 until all relevant recruitment checks have been completed. The manager was also advised of current immigration requirements and regulations and the recruitment checks required. He was advised to inspect other staff personnel records to ensure that the home was compliant with legal requirements and because of the issues highlighted on the day of inspection the home was issued with a serious concerns letter. The home’s pre-inspection questionnaire evidenced that staff receive foundation and pertinent training. The Manager must ensure the home’s induction programme is to TOPSS standards. Records and certificates in respect of recruitment, training and supervision are not stored consistently so as to easily evidence training provided. The manager undertook to address this at the last inspection but more organisation is required. Seven Arches DS0000015560.V310684.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): 31,32,33,34,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is guidance and direction to staff and the home does overall have in place practices that will promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: Seven Arches is well managed with clear lines of accountability and residents and / or their relatives meet regularly with the manager and are consulted and kept up to date with changes to the day to day running of the home. The manager works at the home most days in a supernumerary capacity and oversees the day-to-day running and provision of care and treatment. Residents and their relatives can discuss care and any issues with the manager informally or formally when they visit. Competent and skilled nursing staff support the manager. Care staff are supervised and supported on a regular basis in the work environment. Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 21 At the last inspection the manager had contacted residents relatives for their views about the nursing care and services provided by the home. Following on from this, relatives have been invited to meet so as to discuss the findings of the survey. Relatives are invited to meet with management and staff twice yearly and these meetings generally coincide with planned parties such as the Christmas party so as to maximise attendance. People living at the home are discouraged from keeping monies and valuables however there is a safe should residents wish for their valuables to be kept on their behalf. The manager said that this arrangement suits residents and relatives. The manager was advised previously to include the homes arrangements for the safe keeping of valuable and monies in information provided to current and prospective residents. Supervision planning, forms and records were not all clear and up to date. Staff are aware of supervision. Induction programmes should be provided for all employees within the first six weeks. The inspector was informed that new staff are generally supervised and reviewed on a regular basis. The home does not have any volunteers but were made aware of the checks required if any are taken on in the future. It is recommended that all staff receive a minimum of six structured supervisions and one appraisal annually. Up to date appraisals were not seen for all staff. Records seen throughout the inspection were generally well kept but there were shortfalls in areas. Some have been commented on throughout this report. Health and safety checks are regularly carried out by the maintenance man. Safety certificates were available for gas, electric and fire, call systems, hoists and prevention equipment. Regular checks are done for hot water and fire equipment. Regular fire drills have not been maintained and only two had occurred in the preceding 7 months. It was noted that the last fire safety drill for staff was carried out in January 2006 and previous to that August 2005. This only included night staff working at the home at the one in January and no day staff in over one year. There were assessments recorded regarding the risk of outbreak of fire in key areas such as kitchen and laundry and assessments for other areas were being developed in accordance with guidance from Essex Fire & Rescue. General environmental risk assessments for the home were not formulated or up to date and the most recent were dated 1991. Up to date employers liability insurance was on display. Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 22 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 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 2 2 Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5 (1) Requirement All service users must be provided with a contract and the terms and conditions of the home A detailed service user plan of care must be drawn up including consultation with service user families and significant multidisciplinary personnel, to be reflected in the care plan and be completed sufficiently and reviewed comprehensively monthly. The routines of daily living and activities made available must be flexible and varied to suit service user’s expectations preferences and capacities. This with reference to the formulation of a formal activities plan in appropriate formats, with regard to differing service users needs. A comprehensive record must be kept of all complaints made and includes details of investigation and any action taken. Service users must not be restricted with safety gates on doors intermittently or DS0000015560.V310684.R01.S.doc Timescale for action 17/10/06 2 OP7 15(1)(2) 17(1)(a)( b) 17/10/06 3 OP12 16 (2) m &n 17/10/06 4 OP16 17(2)Sch 4 13 (7) & (8) 17/10/06 5. OP24 17/10/06 Seven Arches Version 5.2 Page 24 6. OP29 7, 9, 19 (1) to (7) Schedule 2 permanently for any reason or be subject to any form of restraint. Consideration must be given to the issue of formulating individual plans within a riskmanaged strategy. The registered person must operate a robust and thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. (Previous timescales of 1st April 2006 not met.) A serious concerns letter has been issued to the home in respect of this at this inspection 04/10/06 This must be addressed with immediate effect and within the 4 week time limit. 7 OP36 18(1&2) 19 (1) The registered person ensures 17/10/06 that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. Records required by regulation 17/10/06 for the protection of service users and for the effective and efficient running of the business must be maintained, up to date and accurate. The Registered Provider must 17/10/06 ensure that the home complies with all health and safety legislation, practice, policies, procedures and health and safety requirements, including the formation of environmental risk assessments. Also after consultation, with the Fire Authority, take adequate precautions against the risk of fires, and evacuation procedures. This is as well as ensuring staff are suitably trained and essential fire drills are undertaken and documented appropriately. (Fire DS0000015560.V310684.R01.S.doc Version 5.2 Page 25 8 OP37 17(1-3) 15(1-2)S4 9 OP38 12,13(4,5,6 ,7,8),17,23( 4) Seven Arches Safety & Employers Guide) also refers 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 OP3 Good Practice Recommendations The way in which information is recorded when pre admission assessments are carried out could be more clear and ordered and attention paid to dating and signing documentation. Where MAR charts are handwritten by staff these records should be checked, countersigned, correctly completed and regularly reviewed so as to minimise the risk of errors and omissions. Please also note that where residents receive oxygen therapy the dose and frequency should be recorded as part of the care and treatment plan and kept under regular review. Information about how people living at the home wish to spend their days and how staff can assist and support them in this should be recorded consistently. The records maintained in respect of staff training and supervision of staff would benefit from reorganisation so as to better evidence good practices at the home. It is recommended that where Monthly Regulation 26 auditing visits are undertaken that is on a consistent basis and specific dates and signatures are in place and filed appropriately. 2 OP9 3. 4. 5. OP14 OP30 OP33 Seven Arches DS0000015560.V310684.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Seven Arches DS0000015560.V310684.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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