Inspection on 02/07/07 for St Ann`s Residential Home

This inspection was carried out on 2nd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Ann`s Residential Home 03/08/06

St Ann`s Residential Home 11/10/05

St Ann`s Residential Home 10/05/05

St Ann`s Residential Home 01/11/04

St Ann`s Residential Home 20/08/04

St Ann`s Residential Home 26/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Ann`s Residential Home 125 Chalkhill Road Wembley Park Middlesex HA9 9AL Lead Inspector Julie Schofield Key Unannounced Inspection 09:30 2nd July 2007 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 St Ann`s Residential Home DS0000017440.V338761.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. St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Ann`s Residential Home Address 125 Chalkhill Road Wembley Park Middlesex HA9 9AL 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 8908 2033 020 8904 2856 Capital Investments & Devlp Ltd Monica Aurelia Luca Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2006 Brief Description of the Service: The home is registered to provide personal care for up to 17 service users. At the time of the inspection there were 11 residents and 6 vacancies, although 2 more residents were to be admitted to the home, later in the week. St Ann’s is situated close to Wembley Park underground station and main bus routes. It is also close to a parade of shops and to a supermarket. At the front of the home there is a large paved area for off street parking. (There are parking restrictions in the road immediately outside the home). Service users are accommodated in bedrooms on both ground and first floors and there are bathing and toilet facilities on both floors. Eight of the bedrooms have en suite facilities. There is a passenger lift connecting ground and first floor. Staff accommodation is situated on the second floor. The office, open plan dining and lounge areas and kitchen are situated on the ground floor and the laundry room is situated on the first floor. Details of fees charged may be obtained, on request, from the manager of the home. St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Monday in July. It started at 9.30 am and finished at 6.15 pm. During the inspection discussions took place with the proprietor, the manager, deputy manager, members of staff and 6 residents. The serving of the midday meal and the preparation of the evening meal were observed. A tour of the premises and the garden took place. Records were examined and the care of 3 residents was case tracked. The Inspector would like to thank everyone that took part in the inspection for their assistance and comments. What the service does well: What has improved since the last inspection? Four statutory requirements were identified during the previous inspection and these have now been met. Lines have been painted on the parking area in front of the home marking out 2 parking spaces and they are clearly marked for visitors only. St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 6 The home requests references and now receives a response addressed to the manager of St Ann’s. Each staff file contains confirmation of right to work, if required. Staff appraisals and training profiles are now undertaken on an annual basis. The freezer is defrosted on a regular basis and bags of food items are tied securely after their initial opening. 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. St Ann`s Residential Home DS0000017440.V338761.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 St Ann`s Residential Home DS0000017440.V338761.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): 3, 5, 6 People who use this service experience good outcomes in this area. The resident is assured of a service tailored to their individual needs by a comprehensive assessment process being carried out prior to admission. Visiting the home prior to admission also assures the prospective resident that this is somewhere they would like to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were examined and these belonged to residents admitted to the home since the last inspection. The funding authority had provided information for each resident. Documents included a social worker’s report, a St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 9 local authority care plan and a FACE overview assessment. In addition one of the managers had completed the home’s own assessment form. There was evidence on file that the manager had either visited the prospective resident in hospital or in the community, prior to admission, or the prospective resident had visited the home prior to admission. This gave the prospective resident the opportunity to view the home, look at the bedroom that was being offered, have a meal and see what activities were taking place, meet members of staff and meet the current residents. The day prior to the inspection this opportunity had been taken by a prospective resident and their family members and during the inspection the family telephoned the home to express their satisfaction with the visit and to confirm that the placement would go ahead later in the week. The home does not offer an intermediate care service. St Ann`s Residential Home DS0000017440.V338761.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 People who use this service experience good outcomes in this area. Evaluating care plans on a regular basis ensures that changes in the needs of residents are identified and can be addressed and regular reviews of the placement confirm that the care home continues to be able to meet the individual needs of the resident. Residents’ health care needs are met through access to health care services in the community. The general well being of residents is promoted by assistance or support from staff in taking medication, as prescribed. Residents said that their privacy and dignity is respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were examined. Each contained an initial care plan that had been drawn up with the aid of the assessment documents. The care plan identified a need, the aims and objectives, the action required, how to St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 11 evaluate, a date for review and was signed by the home and by either the resident or their representative. Initial care plans were then replaced by an updated care plan that is drawn up after the resident has been given time to settle into the home. There was evidence that care plans were kept under regular review and there were up to date monthly care plan review outcomes/evaluations on file. These were very detailed and comprehensive and looked at health, nutrition, medication, sleep patterns, personal care, mobility, continence, day care activities, social/family contact and behaviour. In addition minutes of review meetings were kept on file. Initial review meetings were held approximately 6 weeks after admission and looked at the suitability of the placement. Detailed records of the six monthly review meetings were kept on file. These included an assessment of whether the action plan agreed at the last review meeting had been achieved. There were copies of letters sent to the funding authority after a review meeting had been convened by the home that included a progress report. There were also copies of the minutes of review meetings convened by the funding authorities. The home is to be commended for its informative and comprehensive assessments, care plans and system of reviews. Files contained risk assessments in respect of the prevention of falls, nutrition, mobility, attending out patient appointments, prevention of pressure sores etc. The risk assessment identified the hazard, the personal risk, the existing control measures and any further action required. These were subject to regular review, carried out at the time of the review meeting. All were signed and dated. Case files contained evidence of access to health care services in the community. Files contained a list of appointments in date order and then an individual sheet for each health care professional was kept so that the detail e.g. instructions or recommendations made, referral for further treatment etc could be noted. Appointments with the optician, dentist and chiropodist took place on a regular basis. Residents received support from the GP, district nurses and community nurses. When necessary requests are made for specialist equipment e.g. pressure-relieving mattress. Residents had access to preventative health care services and to routine screening. Files included consent forms for the flu vaccine. Residents were also supported when attending out patient appointments at the hospital. Weight charts are used on a monthly basis and were up to date. One resident has expressed a wish to stop smoking and is being supported by members of staff and by wearing patches. The storage of medication was safe and secure. The home uses a weekly nomad system, which is supplied by the pharmacist. Medication that is not dispensed in this way i.e. tubes of cream, sprays or bottles of medication are stored within the cupboard in plastic boxes that are labelled with the name of the resident to whom they belong. A note is made on each item of the date on St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 12 which it should be disposed of. The records were examined and were up to date and complete. Medication had been appropriately administered prior to the inspection according to the time of day and the day of the week when medication was inspected. Members of staff have received medication training. The Inspector spoke to 2 residents in the privacy of the residents’ rooms. They confirmed that they liked to spend time on their own and that the members of staff respected this. One of the residents confirmed that the members of staff always knocked on the door and waited to be invited in before entering. When assistance with toileting is required it was observed that it was offered discreetly. A resident said that when staff helped them with their personal care the staff made the resident feel at ease. All bedrooms are single bedrooms and when the resident sees their GP the consultation (and examination) take place in the resident’s room. A resident said that she prefers to be called by the name that she is known by to her family and friends and said that this is what she is called by members of staff. Residents are able to make and to receive telephone calls in private. It was observed that residents requiring assistance with feeding received help from members of staff in a relaxed and friendly manner that maintained the dignity of the resident. St Ann`s Residential Home DS0000017440.V338761.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 People who use this service experience good outcomes in this area. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. With staff support, residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected. Residents are offered a varied and wholesome diet to maintain their well-being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the manager and deputy managers have developed the activities programme in the home and displays of photographs record residents enjoying themselves. Some residents now go to a day centre on a Thursday (including the resident that is 106 years old) or attend computer sessions at Neasden library, or go with one of the carers to the local shops and the home is trying to increase the activities taking place outside the home. St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 14 Parties have been held in the home for Halloween, Christmas and St Patrick’s Day. There was an Easter egg hunt in the home and a St Valentine’s Day celebration. Children from a local school have entertained residents. Residents said that they could play board games, take part in craft sessions, use the exercise bike or relax in the garden or in the lounge. For residents that wish to spend time in their rooms rather than joining in activities they are free to do so and their privacy is respected. A priest calls each week to provide spiritual guidance and support and a resident said that the deputy manager had taken them to church. However one of the residents said that they were bored. It was noted at the start of the inspection that activities were already taking place e.g. a game of scrabble. Records are kept of what activities take place during the day and the names of residents taking part. The home is to be commended for the progress that it has made in providing residents with a more stimulating and enjoyable lifestyle. A statutory requirement was identified during the previous inspection that lines are painted on the parking area in front of the home marking out 2 parking spaces and that they are clearly marked for visitors only. This requirement is now met. The home encourages residents to maintain links with their families and friends and a resident confirmed that when their friend visits the members of staff on duty always make the person welcome. Relatives telephone the residents or visit and visits can take place in the privacy of the resident’s bedroom or in the lounge. The home writes to relatives or telephones them if the distance prevents regular visits and updates them with the resident’s progress. A resident confirmed that at their recent birthday party in the home all their family members were invited. Residents are encouraged to make decisions for themselves. When entering the home they are able to bring small items of personal possessions with them and some of the bedrooms reflect the personality of their occupant. One of the residents is responsible for feeding the cat and for ensuring that the home is active in recycling. Since the last inspection the menus have been reviewed and amended. Residents were consulted and menu request forms (used to record their wishes) were kept on file. Menus are discussed during residents’ meetings. Residents requested home made soup and more fresh vegetables. This has been put into action. The home uses a 3-week menu cycle and each day there is a choice of main meal. African-Caribbean food is prepared for AfricanCaribbean residents although the manager said that other residents also choose and enjoy rice and peas etc. A Polish resident has Polish dishes included on the menu and the meatballs are also a favourite of other residents. Daily food records were inspected and they demonstrated a varied and balanced diet. One of the case files examined included information on the likes and dislikes of the resident and noted that the resident enjoyed curries. Daily food records demonstrated that curries were served. During the morning of the inspection a homemade shepherd’s pie was prepared for lunch. When it St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 15 was served, with green beans, it looked and smelt appetising and portion sizes were generous. The preparation of the evening meal was observed and 9 different meals were being prepared, according to what residents had chosen. A bowl of fresh fruit and a bowl of toffees are left on the dining table during the day for residents to help themselves. There is a chilled water dispenser in the lounge for residents and visitors to use. During the day hot drinks and snacks are served. A resident said that the food was better now as they liked their food “spicy” and the staff do this for the resident. Other residents said that the food was good and that portions were large. St Ann`s Residential Home DS0000017440.V338761.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 People who use this service experience adequate outcomes in this area. A complaints procedure is in place to protect the rights of the residents. An adult protection procedure and training in protection of vulnerable adults procedures help to promote and protect the welfare and safety of residents but the lack of thoroughness in recruitment procedures compromise these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the complaints procedure is on display in the entrance hall, adjacent to the visitors’ book. The procedure is detailed and includes timescales for each stage of the process and refers the reader to agencies that may also have an interest e.g. the Commission for Social Care Inspection. There is a suggestions box in the entrance hall. A notice advises visitors to the home that a copy of the most recent inspection report is available. The complaints book was examined and 1 complaint had been recorded since the last inspection. The complaint had been resolved and the resident had received an apology after the matter had been investigated. A copy of the complaints procedure is placed in the bedroom of each new resident and a copy is given to their relative. Residents confirmed that if there was something that they were St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 17 not satisfied with they could talk to either a manager or a member of staff. One resident said that the proprietor of the home called in on a daily basis. The home has a protection of vulnerable adults policy in place and a copy of the local authority interagency guidelines in the office. The policy includes a link to the whistle blowing procedure. The manager and deputy manager confirmed that they had attended recent awareness sessions run by the local authority and that all staff had received training in protection of vulnerable adults procedures. Staff were able to describe their responsibilities in the event of a disclosure being made. The manager said that there have not been any incidents or allegations of abuse recorded since the last inspection and that restraint was not practiced in the home. There are policies and procedures in place to protect the financial affaires of residents. An examination of staff files identified a lack of 2 satisfactory references on each of the files examined and the lack of a pova first check before a member of staff started working in the home. St Ann`s Residential Home DS0000017440.V338761.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 People who use this service experience good outcomes in this area. Residents live in a home where the general standard of maintenance is good, although commencing a programme of refurbishment would assure residents of the continuation of pleasant and comfortable surroundings. Residents are assured of hygienic surroundings as standards of cleanliness are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection a tour of the premises took place. The home was originally refurbished after building works joined 125 and 127 together and as this was some time ago a programme of redecoration, replacement and refurbishment needs to be drawn up and commence. A resident said that the St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 19 home was not the most modern but there were to be some changes. The manager confirmed that the home has already secured funding for a number of projects. A new television is on its way, the ground floor communal areas and corridors are to be re-carpeted, new patio furniture is to be provided and new dining furniture is to be purchased. A resident that uses a wheelchair confirmed that the layout of the ground floor is suitable for their needs and that the home is accessible both at the front door and through the patio doors into the garden. A passenger lift linking ground and first floor assists residents with limited mobility. Heating and lighting was appropriate to the time of the year that the inspection took place. However it was noted that light fitments throughout the home, with energy saving light bulbs, lacked lampshades. In the kitchen a section of the work surface has been damaged. Residents have access to a pleasant garden area at the rear of the premises. It was noted during the inspection that all areas were clean and tidy and free from offensive odours. Laundry facilities are situated on the first floor, away from any areas where food is stored, prepared or consumed. Staff have received training in infection control procedures. At present some staff are undertaking a more detailed training course with a college in respect of infection control. St Ann`s Residential Home DS0000017440.V338761.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 People who use this service experience adequate outcomes in this area. The lack of catering staff means that carers are preparing and cooking meals and this reduces the time available to spend supporting residents. Residents are assured of competent members of staff supporting them by a programme of training for members of staff. A lack of thoroughness in recruitment practices compromises the welfare and safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the staff rota was available for inspection. Each member of staff was identified by their name and post title. The hours that they worked were recorded. It was noted that the deputy managers work some weekend shifts. On the day of the inspection the manager (9 am to 5 pm) and both deputy managers (9 am to 4 pm and 7 am to 3 pm) were working in the home. In the morning a carer was on duty (7 am to 3 pm) and in the afternoon/early evening 2 carers were on duty (3 am to 11 pm). One of the deputy managers was responsible for preparing the midday meal. There are no separate catering staff but a domestic is on duty for 4 hours each day. At night 2 carers St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 21 are on waking night duties with on call staff, asleep on the premises. A resident described the staff as “great”. A discussion took place with the manager in respect of NVQ training being undertaken by members of the staff team. Of the 16 members of staff named on the rota 6 members of staff hold an NVQ level 3 qualification. Four members of staff hold an NVQ level 2 qualification, 1 member of staff is a qualified nurse and 2 other members of staff are nursing students. Five members of staff are studying for their NVQ level 4 qualification. The target set in the National Minimum Standards is for 50 of the staff team holding an NVQ level 2 qualification, or equivalent. The home is to be commended for considerably exceeding this standard. A statutory requirement was identified during the previous inspection that the home requests references and receives a response addressed to the manager of St Ann’s and that each staff file contains confirmation of right to work, if required. During the inspection 6 staff files were examined. Files contained evidence of right to work, if necessary and so the statutory requirement is now met. It was noted that each file contained proof of identity with a photograph of the member of staff i.e. passport details, national identity card or photographic driving licence. There were copies of 2 satisfactory references being received on 5 of the files. The sixth file contained a note that the proprietor had followed up the references as he knew the referees but the references were not on file. Five files contained CRB disclosures. The sixth file was for a person employed on a work placement basis. Although the manager said that a CRB disclosure has been applied for it had returned for further information. A pova first check had not been obtained prior to the person starting work in the home. Files of members of staff that had recently joined the staff team contained evidence of induction training taking place. Staff files also contained attendance certificates for training courses. Certificates covered a range of topics including safe working practice topics i.e. first aid, food hygiene, fire safety and infection control. There were certificates for breakaway techniques, medication, pova, diversity and equalities, health and safety, communication, mental health awareness and dementia training. Staff files contained evidence of recent manual handling training. A statutory requirement was identified during the previous inspection that staff appraisals and training profiles are undertaken on an annual basis. Staff files examined of members of staff that had been employed in the home for over a year included evidence of a staff appraisal being undertaken in January or February 2007. This requirement is now met. St Ann`s Residential Home DS0000017440.V338761.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, 33, 35, 38 People who use this service experience good outcomes in this area. The manager demonstrates her competence and commitment to a quality service for residents by continuing to develop her understanding, skills and knowledge through further training. Systems are in place to gather feedback on the quality of the service provided to enable the service to develop in ways that meet the changing needs of the residents. Systems are in place to safeguard the financial interests of residents. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents and regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. This judgement has been made using available evidence including a visit to this service. St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has recently completed her NVQ level 4 qualification and is awaiting the certificate. She has started a university course in the Management of Social Care. (This is beyond a level 4 qualification). Since the last inspection she has undertaken refresher training in safe working practice topics and protection of vulnerable adults procedures. She has also attended dementia care and mental health awareness training. A discussion took place with the manager in regard to quality assurance systems in place in the home. A resident confirmed that residents’ meetings took place on a regular basis and that they were a chance to “say what you want”. This resident had requested more “crispy” vegetables and now their vegetables are not cooked as long and are served, as the resident prefers. Minutes were available. Residents can also give feedback directly to managers or the proprietor on a day-to-day basis. Residents, visitors or members of staff can use the suggestion box in the entrance hall. Staff confirmed that regular staff meetings also take place. Comments may be given by residents, relatives or representatives of the placing authority at review meetings or by completing an annual satisfaction survey, which are distributed in August. Completed survey forms from a social worker and family member were on file but generally the response rate is low. There was evidence that items raised by residents at their meetings have brought about change in the home e.g. in respect of the content of menus and in the activities offered. The manager said that only 1 resident receives assistance with their financial affaires from the home. Relatives support the other residents. The records relating to the assistance given to this resident were inspected. The resident chooses to draw their personal allowance on a weekly basis and signs a receipt to acknowledge this. The records were up to date. Records were kept in respect of relatives that leave small sums of money with the home to be spent on items e.g. clothing, toiletries or hairdressing. These were up to date and included a running total. Receipts were kept for items of expenditure, which were identified. There was evidence on staff files that training was given in relation to safe working practice topics. Manual handling training was updated on an annual basis. Health and safety issues are discussed at staff meetings and infection control measures were an agenda item in April. There were valid certificates in respect of the servicing/checking of the lift, the electrical installation, the gas supply, the fire extinguishers, the fire alarms and emergency lighting and the portable electrical appliances. The weekly testing of the fire alarms was up to date and the last fire drill to be held took place in June. A visit by the LFEPA in November 2006 identified some remedial work that needed to be undertaken. The manager confirmed that it had been carried out. St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 24 A statutory requirement was identified during the previous inspection that the freezer is defrosted and that bags of food items are tied securely after the initial opening. This has now been met. St Ann`s Residential Home DS0000017440.V338761.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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 16.2 & 23.2 Requirement The registered person must draw up a plan for the redecoration and refurbishment of the home so that residents can enjoy comfortable and smart surroundings. The registered person must ensure that lampshades are fitted where light fitments have energy saving light bulbs so that residents can enjoy attractive surroundings. The registered person must ensure that the work surface in the kitchen is intact so that hygienic conditions can be maintained. The registered person must employ a cook for the preparation and serving of the mid day meal so that more time can be available to support residents. The registered person must ensure that each staff file contains 2 satisfactory references so that there is confirmation of the integrity and suitability of the person to work DS0000017440.V338761.R01.S.doc Timescale for action 01/10/07 2 OP19 23.2 01/09/07 3 OP19 16.2 01/10/07 4 OP27 18.1 01/09/07 5 OP29 19.4 08/08/07 St Ann`s Residential Home Version 5.2 Page 27 6 OP29 19.4 as a carer with vulnerable adults. The registered person must 08/08/07 ensure that before a carer begins to work in the home an application for an enhanced CRB disclosure is made and that a pova first check has been received so that there is confirmation of the integrity and suitability of the person to work as a carer with 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 OP38 Good Practice Recommendations That the home provides the CSCI with a copy of the acknowledgement from the company carrying out the remedial work that it has been completed. St Ann`s Residential Home DS0000017440.V338761.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!