Inspection on 07/08/07 for Seven Arches

This inspection was carried out on 7th 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

Seven Arches 24/07/08

Seven Arches 06/09/06

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 Ann Davey Unannounced Inspection 7th August 2007 08:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Seven Arches DS0000015560.V343867.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.V343867.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 gillbezzina@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) of places Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care Home with Nursing - Code N to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: `Old age, not falling within any other category - Code OP` The maximum number of service users who can be accommodated is: 30 6th September 2006 2. Date of last inspection 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. Communal areas and service facilities i.e. laundry and kitchen, are on the ground floor. Residents have access to extensive well maintained external grounds and the home is decorated and maintained to a good standard. The manager said that the current scale of charges at the home ranges between £550.00 - £665.00 per week. The actual fee depends on the source of funding, assessed nursing needs and /or type of accommodation available i.e. with or without an ensuite. The home’s current Statement of Purpose and Service User’s Guide are available upon requested. Both documents need to be reviewed and amended to bring them in line with regulatory requirements. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced site visit which stated at 8.15am, and finished at 4.45pm. The last key inspection took place on 6th September 2006. The manager, staff, residents and visitors were spoken with during the course of the visit. The Commission sent surveys to the home for residents to complete. Five were returned and the comments arising from them have been referenced within the report. The home has submitted an Annual Quality Assessment (AQAA) to the Commission. The day was pleasant and the home co-operative and helpful. A partial tour of the home was made. Care practices were observed and a random selection of records viewed. A notice advising any visitors to the home that an inspection was taking place was displayed in the main entrance hallway. The notice extended an invitation to anyone who may like to speak with the inspector to make themselves known. Three visitors were spoken with and their comments have been reflected within the report. All matters relating to the outcome of this inspection were discussed with the manager. It was suggested that the manager took notes for future reference. Full opportunity was given for discussion and/or clarification both during and at the end of the report. The manager said he was satisfied with the inspection process. In view of the shortfalls noted as a result of this inspection, a request for an Improvement Plan (Regulation 24A) will be made to the home. What the service does well: What has improved since the last inspection? Residents’ case records seen contained the Terms & Conditions of the home and the home now maintains a complaints logbook. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 6 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. Seven Arches DS0000015560.V343867.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 Seven Arches DS0000015560.V343867.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 (standard 6 is not applicable in this home) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their care needs assessed by the home to ensure that a proposed placement is suitable, but cannot be assured that the written information about the home is current. EVIDENCE: The record of one of the most recently admitted residents was assessed. The admission assessment was in place and the assessed care/nursing needs were documented. An important risk assessment concerning the use of bedrails had not been completed and reference to an injury had not been adequately managed or reported in the accident book. Both these matters were addressed during the inspection. It is important that more attention is given to recording residents wishes and preferences on the assessment document. This matter was raised at the last inspection. It is the home’s practice to invite a prospective resident to spend time in the home before any decision about their future is made. The manager described a Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 9 current proposed admission where although the resident is unable to visit the home, arrangements are being made for the relative to do so. A visitor told the inspector that they had visited the home prior to their relative being admitted and felt that the home had been very helpful and understanding during this time. The Statement of Purpose and Service User’s Guide was brief and not detailed enough to cover the aspects required by regulation. For example, details of the accommodation available and the management structure were not noted. The Service User’s Guide was not dated and the manager did not know when it was last reviewed. The manager was shown what was required by regulation and agreed that both documents needed to be developed. The manager said that the home did not have a copy of the Residential Care Home Regulations 2001 and was therefore unaware of these requirements. It is important that both these documents are current so that all interested parties have up to date information about the home available to them. A statement of the Terms & Conditions of the home was on the files of those seen. Seven Arches DS0000015560.V343867.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a plan of care drawn up by the home that details their assessed needs and to receive the services of health care professions. Residents cannot be assured that the home manages the storage of their medication safely. EVIDENCE: Four care plan records and other associated care/health documentation were selected and assessed. Records included health care multi-disciplinary records, daily notes and risk assessments. Care plans and risk assessment tend to be brief and not comprehensive. The home should consider developing the various elements of both documents. The home should ensure that residents’ wishes and preferences are also recorded. These matters were spoken about at the last inspection. The home was able to demonstrate that care plans are reviewed on a regular basis. The home has a key worker system, which means that each resident (and their family) can relate on a more personal basis to one member of staff. Staff said Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 11 that the system works well for the home. Two records contained ‘end of life’ information that had been sensitively recorded. Care practices were observed during the course of the day. Staff were attentive to residents needs. On arrival the majority of residents were still in bed and staff were seen to be around going in and out of rooms. Call bells were accessible in those rooms seen. During the day, there was at least one member of staff in close proximately in the communal areas at all times. One resident said ‘there’s always someone here to take me to the toilet’, whilst another resident overhearing this conversation nodded in agreement. Residents spoken with and able to voice an opinion said that their needs were met by the home. Three visitors spoken with all said that they were very satisfied with the care provided by the home and confirmed that they are involved with the care of their respective relative and spoke positively about the attention given. This view was reflected within the returned and completed surveys. Individual members of staff spoken with had a good understanding of residents assessed needs. There was a sense of humour around the home and some residents at the dining table at lunchtime were enjoying some banter about ‘chocolate biscuits’. Staff were overheard to speak to residents in a kind manner and the words ‘would you like’ or ‘is this, or that ok?’ were frequently heard. Residents cared for in bed looked comfortable and all residents were dressed (or clothed in bed) in keeping with their age and gender. Residents are registered with one of the two local GP practices. The manager said that the home has an excellent working relationship with all heath care professions. The home maintains a current record of all multi health care professional input received by residents. Residents said that their clothing is looked after. Visitors spoken with said that they were satisfied with the laundry service within the home. During a tour of the home in the morning the door to the room on the 1st floor which houses stock medication, oxygen cylinders and dressings was wide open. The fridge within the room which contains other prescribed medication was unlocked with the key still in the lock. Prescribed medication (due to be returned to the chemist) in boxes and bottles was left on the side and there were unlocked cupboards containing stock prescribed medication. The matter was brought to the manager’s attention who said that it was an oversight and had only been left for a short while and would address the situation. During the afternoon whilst accompanied by a nurse, the room was still open and the situation as found six hours earlier had not changed. The nurse locked the door as we left. The manager was immediately informed. The manager said that no resident would go into the room and he trusted his staff. The manager was informed that this practice is totally unacceptable as residents, Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 12 staff and visitors to the home use the area and was a clear breach of regulation. The manager was told to take immediate action to address the situation to ensure that all medication is stored in a secure environment. All medication within the home is managed and administered by a nurse. A selection of medication administration (MAR) and medication storage arrangements within the ‘trolley’ (medication that this used on a regular basis and kept on the ground floor) was assessed. Records and storage within this area was in good order. PRN (as/when necessary) medication protocols were available. One resident is able to administer their own medication and an appropriate risk assessment was in place. Seven Arches DS0000015560.V343867.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 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive a balanced diet and to be assisted in maintaining family/friend/community contact. Residents cannot be assured of a meaningful activity/recreational programme. EVIDENCE: Some care plans record residents personal interests. On a corporate level, some residents spoke of a ‘piano player’ who visits the home periodically and a ‘sing song’, but of nothing else. This aspect of care was spoken about at the last inspection and the home was required to develop a suitable and meaningful programme. At this inspection the home provided a folder indicating that a weekly one-hour activity takes place such a ‘sing a long’, ‘bingo’ and ‘nostalgic cards’. Records with the ‘activity folder’ were patchy and the home could not demonstrate that there is a consistent approach to this important aspect of care. There was nothing recorded for May and June. The manager said that due to the frailty of most residents, putting together an activity/recreational programme would be difficult. However, when speaking to Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 14 residents, a number demonstrated to the inspector that they had the ability and capability to respond positively to a suitable and meaningful programme. This view was reflected with the completed surveys. It was suggested to the manager that a positive attempt is made to speak to residents about what they would like to do would be a proactive step towards demonstrating that the home acknowledges this aspect of care. The manager said that the home was looking to employ an activities co-ordinator but was not able to be precise about any detail of this appointment. The home could not demonstrate that there has been any significant improvement on the outcome on this aspect of care since the last inspection. Through documentation and observation the home was able to demonstrate that it acknowledges and responds appropriately to assessed cultural and religious needs. Opportunity was taken to speak to one visitor about this aspect of care who was satisfied in the way the home manages the specific care needs of their relative. Visitors spoken with said that they are always made to feel welcome and that staff are friendly. They confirmed that tea and coffee is made available and one visitor said that they always stay for a cooked tea. This arrangement means a great deal to this visitor as it means that more time can be spent with their respective relative. The home does not have a designated visitors room but a smaller and generally unused lounge can be used if a private meeting needs to take place. The manager said that the majority of residents have active family/friend involvement to varying degrees. The home needs to develop the detail on care plans to demonstrate that resident wishes, choices and preferences have been sought and recorded. Residents spoken with said that staff do ask about their preferences and examples were given i.e. a choice of food is made by each resident and where they would like to eat their breakfast. The home operates a four-week rotation menu system. The system demonstrated that residents are offered a choice and variety at each meal. Records relating to breakfast were viewed and seen to offer cornflakes, grapefruit, ‘wheetabix’, toast and fresh fruit. This choice was confirmed when the inspector observed breakfast routines in the morning. Breakfast was being taking to residents in their bedrooms on a tray. One resident spoken with while they were enjoying breakfast said it was their choice to have breakfast in their room. Lunchtime routines were observed. Tables were nicely laid and residents wore linen tabards to protect their clothing. The atmosphere within the dining area was pleasant and residents spoken very positively of the choice and quantity of food provided. One resident said that if they didn’t like what was served to them, there would be no hesitation in asking for an alternative. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 15 Residents being assisted with feeding by staff were cared for in a dignified manger. Staff sat along side of residents and dialogue was warm and natural. Some residents require their food blended or pureed and the presentation of these dishes was appetising. The day was very hot and uncomfortable. There was a selection of cold drinks available in the dining and lounge areas and staff were observed to be ensuring that all residents were being provided with liquid at regular intervals. There were no negative comments about food within the completed surveys. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their complaints taken seriously but cannot be assured that that they will be protected by the home’s ‘safeguarding adults from harm’ procedures. EVIDENCE: Residents and visitors said that they were aware that they could make a complaint and said that they had confidence in the home to address any issues. The complaints procedure is displayed. The content should be amended to reflect current guidance issued by the Commission. The home maintains a complaints record book that demonstrated that complaints are managed appropriately. The manager said that the home would contact the local social services office should any resident not have a family member or friend to act on their behalf and an important decision has to be made. The home understands that residents have the right to an independent advocate should a situation present itself when a resident’s rights and interests have to be protected. The manager was not able to demonstrate that the home understands the correct procedure should a suspected ‘safe guarding adults from harm’ situation present itself. The home has the local authority guidance issued in 2005, but there was no evidence of any review or update. The home did not have the contact number of the local authority to report a suspected incident. The manager said that neither he nor any of the staff have undertaken Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 17 ‘safeguarding adults from harm’ training sessions. The manager acknowledged the home’s inability to manage any incident according to laid down guidance issued by the local authority and assured that immediate action would be taken to make urgent enquiries in order to attended training. The levels of training were explained i.e. what training might be appropriate for care staff, whilst the manager and any staff left ‘in charge’ and have responsibility for the home at anyone time, must receive a higher level of training assuring that the situation is managed properly. It was explained that there is currently a potential risk to residents because the home could not demonstrate that it knows how to or is competent to manage a suspected incident according to current guidance issued by the local authority. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a clean comfortable environment. EVIDENCE: A partial tour of the home was made. Bedrooms seen were personalised. Communal areas were appropriately furnished and decorated. Residents have safe ‘user friendly’ access to well maintained garden and patio areas. There were no unpleasant odours in the home. Corridors and communal areas were free from obstruction and hazards. The kitchen and laundry areas were clean and orderly. All equipment within these areas was in good working order. Cupboards and rooms containing COSHH, cleaning products and electrical equipment were secure. The door to the room that contained medication was left open twice and this is referenced Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 19 under standard 9. The manager said that since the last inspection 10 new nursing beds and 2 hoists have been purchased. Residents said that the home was pleasant to live in. Relatives said that the home was always clean and there was never any smell. One relative said that staff are very quick to clean up any spills and to keep the place looking nice. The home has equipment such as lifting hoists, wheelchairs and pressure relieving mattress and cushions to meet the assessed needs of residents. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by an adequate number of staff on each shift. Residents cannot be assured that records will be able to demonstrate that the home has followed robust recruitment and employment procedures. EVIDENCE: Rotas demonstrate that there is a minimum of one nurse and five care staff on duty during the day and a minimum of one nurse and two care staff on duty at night. The manager’s hours are supernumery to these levels. Domestic, laundry, kitchen and gardener/maintenance staff provide adequate cover in the home. The home also employs the services of a secretary five days a week. The home current has two full time care staff vacancies and these hours are currently covered by existing staff. It is not normal practice for the home to employ agency staff. The manager said that staff retention is good, sickness levels are low and some of the staff have work in the home since it opened in 1999. Staff said that the home was a nice place to work in and their fellow colleagues were friendly and pleasant to work with. Staff enjoy their working conditions and said that they felt supported. Staff said that team meetings take place from time to time. A nurse explained how verbal communication and ‘handover’ sessions work in the home and other staff confirmed that the system works well. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 21 Staff looked clean and smart in their uniforms. Residents able to express said that they thought staff were kind and attentive. This was reflected within the completed surveys. Relatives thought that staff were caring people and they demonstrated a good understanding of individual care needs. Three records belonging to recently recruited members of staff were requested. One file could not be located and there were shortfalls on the other two. Records relating to one file were in a ring binder and the records belonging to the other file were in a folder. Neither file had any order about it and information was difficult to find and understand. Induction records were incomplete and the format and content did not comply with the current Skills for Care criteria. Later, the manager found additional (unnamed) information in another location regarding both these induction records. The home could not demonstrate a structured approach to the management of staff induction. One set of records indicated that the member of staff started work in the home before the POVA 1st clearance check had been received and on the other file there was no clear initial indication that a cleared Criminal Records Bureau check had been requested or received. The manager located this record later. There were no job descriptions in place. The home could not demonstrate that it has a structured approach to formal staff supervision. Staff supervision and ‘in-house’ training is recorded on the same piece of paper. Records available were in no order and the home could not demonstrate that it has a tracking system to identify what has taken place, what is due and what is planned for the future. The manager said that all staff training is completed ‘in house’. There were no competency assessments of the ‘in house’ trainers and the home could not evidence the syllabus or criteria used for staff training issues. The home could not produce a staff training matrix and could not identify outstanding training needs, how training needs are identified, how statutory training is updated and how by or how any training needs are/would be met by the home in a competent manner. Staff were spoken with about their training needs. It was clear the ‘supervision’ training is given to staff and the nurses/manager ‘tell us about things’. There was no evidence to indicate that staff attend structured external training courses. At the previous two inspections concern was raised with the home about staff recruitment and employment records. At the last inspection it was recorded that major shortfalls were evident and some documentation was incomplete and/or missing. At this inspection there was little evidence to indicate that Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 22 significant improvements have been made in order to meet regulatory requirements. The manager said that two staff have achieved NVQ level 4 qualification, 3 staff have achieved NVQ level 2 and 3 qualifications with 8 more staff coming to the end of the training. Records were not requested to confirm this. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,37 & 38 (standard 35 was not assessed as the home does not safeguard, manage or keep residents personal monies) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a home where the management of care is good but residents cannot be assured of adequate administration management. EVIDENCE: The home demonstrated that verbal communication is effective in the home. The manager has an ‘open door’ policy and staff said that management was approachable and supportive. All staff had a clear understanding of their roles and responsibilities. Visitors said that management was helpful and very approachable. One visitor said that the manager is regularly seen working with staff. Residents able to express a view said that individual members of staff ask them periodically about daily routines in the home. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 24 The manager said that the home has recently asked residents to complete surveys and was in the process of looking through them. The manager was advised that surveys should also go to all stakeholders i.e. GP’s and social services. The manager thought that this exercise would not be productive but was advised that the home needs to evidence that opportunity has been given. The manager was not aware of the regulatory requirement to produce an Annual Quality Assurance report (regulation 24). Residents said that they could talk freely to the manager. There was no evidence of any formal resident meetings. Accident records were seen and maintained in good order. Documentation on individual residents case records reflected the information in the accident book. A random selection of service and maintenance records were requested and sampled. Initially it was difficult to locate current records within the file. The manager explained that this was because there is no systematic method of filing such records. The maintenance person checks the emergency lighting system, fire alarms and fire fighting equipment on a regular basis. Certificates were available to demonstrate that the passenger lift, gas boiler and lifting apparatus equipment have been recently serviced. At the last inspection it was recorded that environmental risk assessments and safe working practice assessments had not been formulated or were not current. At this inspection, some documentation was in place, but there was no evidence that consultation had taken place with the relevant authorities i.e. health & safety to ensure that the information followed good practice guidance and/or regulation. The manager said that he was not sure about what was required. The inspector provided advice and guidance. The home must obtain professional guidance from the relevant authorities and ensure that adequate guidance and documentation is in place. The home did not have a copy of the Care Homes Regulations 2001. The inspector also made reference to other guidance sent by the Commission to all homes concerning information with the complaints procedure and safeguarding adults from harm procedures. This guidance had not been acted upon. The manager acknowledged that the management of administration and documentation within the home is a weakness. Seven Arches DS0000015560.V343867.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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 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 2 X 2 X N/A X 2 2 Seven Arches DS0000015560.V343867.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 OP1 Regulation 4,5 & 6 Requirement The home must have a Statement of Purpose and Service User’s Guide that reflects current practice and the content complies with regulatory requirements. Amended documents must be sent to the Commission. Without these documents residents, relatives and all interested parties will not have current information to make an informed decision about whether they would like to live in the home. 2 OP9 13 Current medication storage practices must be reviewed to ensure practice is in line with legislation and guidance. All medication must be stored in a secure environment at all times. This was with immediate effect. 3 OP12 16 The current DS0000015560.V343867.R01.S.doc Timescale for action 30/09/07 07/08/07 15/10/07 Version 5.2 Page 27 Seven Arches social/recreational/occupational programme must be reviewed, developed and implemented to ensure and demonstrate that all residents are consulted about what they would like to do and have the opportunity to participate according to ability and choice. The previous timescale set by the Commission for the home to meet this required has not been achieved. This was 17/10/06. 4 OP18 13 All staff (including the manager) employed in the home must undertake ‘Safeguarding Adults from Harm’ training. Staff must be assessed as being competent and able to follow local authority guidance and procedure. The process to access training sessions must take place with immediate effect. This is reflected within the timescale. 5 OP29 18 & 19 For the protection and wellbeing of residents, the home must maintain staff recruitment and employment records as required by regulation. All staff must receive a documented structured induction that is compliant with ‘Skill for Care’ current guidance. The process of reviewing current records and documentation already held by the home must take place with immediate effect. All records must be compliant with legislation within the given timescale. No further staff should be Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 28 07/08/07 30/09/07 employed without the home being able to demonstrate that the required documentation being in place. The two previous timescales set by the Commission to meet with this requirement have not been achieved. These were 1/4/06 and 4/10/06. 6 OP30 18 The home must be able to demonstrate through documentation that all staff have attended statutory and other training courses as required by regulation and guidance. Training should be appropriate to members of staff individual roles and responsibilities. Staff must also be assessed as being competent. Statutory and other related care training is necessary to ensure that staff know how to provide care for residents in an appropriate manner within the boundaries of their personal job descriptions. 7 OP31 OP37 OP38 4,5,6,13, 16,18,19 & 24 Management and administration systems must be in place to demonstrate that all matters relating to the requirements of regulation are in place. Details of the shortfalls are within the report. Some aspects such as the management and administration of staff recruitment/employment records and environmental risk assessments have not been addressed since the last inspection. Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 29 30/09/07 31/10/07 The review of all systems must take place with immediate effect and compliance achieved within the stated timescale. The previous timescale set by the Commission for the home to meet with these requirements has not been achieved. This was 17/10/06. 8 OP33 24 The requirements of producing a Quality Assurance Plan must be understood and implemented. The home must be able to demonstrate that a system is in place to collate the information required to produce a plan within the stated timescale. 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Seven Arches DS0000015560.V343867.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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