Inspection on 23/11/06 for St Josephs Rest Home

This inspection was carried out on 23rd November 2006.

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

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

Other inspections for this house

St Josephs Rest Home 08/11/05

St Josephs Rest Home 08/09/05

St Josephs Rest Home 09/12/04

St Josephs Rest Home 08/06/04

St Josephs Rest Home 28/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Spring Lane Care Home

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

CARE HOMES FOR OLDER PEOPLE St Josephs Rest Home 16 The Drive Ilford Essex IG1 3HT Lead Inspector Ms Harina Morzeria Key Unannounced Inspection 10:00 23 & 28th November 2006 rd 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 DS0000025925.V318006.R03.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. DS0000025925.V318006.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Josephs Rest Home Address 16 The Drive Ilford Essex IG1 3HT 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 8554 3755 Mr Avtar Sandhu Mr Ajvinder Sandhu Ms Louise Kane Care Home 26 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (16) DS0000025925.V318006.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th November 2005 Brief Description of the Service: St Josephs Rest Home is registered to care for 26 elderly residents and includes 10 beds for people with dementia. It is located in the London Borough of Redbridge and is situated close to the centre of Ilford. The home is within walking distance of a park and a bus route for easy access into the town centre. There are 24 single rooms and 2 double rooms, all of which have a wash basin. The rooms are situated on the ground and first floor which is served by a lift and stairs. Bathing and toilet facilities are suitable for the needs of older people. There are two lounges plus a separate dining area and a large well-kept garden. There is also a multi-sensory room (snoezelen) in place for all service users. The external grounds and premises are well maintained and secure. The home employs sufficient numbers of experienced and skilled staff to meet the needs of the residents. Personal care is provided on a 24-hour basis, with health needs being met by visiting professionals or by staff accompanying service users to hospital appointments and other healthcare specialists as required. A large variety of activities and entertainment are enjoyed by the residents provided by the activities co-ordinator as well as inhouse entertainment and outings. A Statement of Purpose is available upon request and a Service Users Guide is given to each prospective service user, which details the service the home can provide. The home will display a copy of the Commission for Social Care Inspection report in the foyer and make it available at the request of the service user or their relative/representative. The scale of fees charged by the home is between £410 - £484 per week. DS0000025925.V318006.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 1 1/2 days. The acting manager and general manager were both interviewed and assisted with the inspection. A tour of the home was made and about 12 of the 28 residents were spoken to. Relatives and friends of five of the residents were interviewed to get their views and 14 relatives/visitors comment cards were received. A variety of records, including care plans, staff files and health and safety documents were looked at. The inspector attended a staff meeting on the second day and following the meeting spoke to staff members as a group to get their views of the home. What the service does well: What has improved since the last inspection? A wide range of social and daytime activities are being provided by the activities coordinator some of which are also suitable for people with challenging needs. Staff confirmed that they have received training from specialist agencies and have received specific training in order to enable them to deal with people with specific needs. DS0000025925.V318006.R03.S.doc Version 5.2 Page 6 All staff confirmed that they received good support from the current management team and have developed a positive team spirit. 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. DS0000025925.V318006.R03.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 DS0000025925.V318006.R03.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1,2, 3,4,5, 6 A detailed Statement of Purpose and Service Users Guide are available to prospective residents to help them make an informed choice about where to live. Residents have an opportunity to visit the home and assess the quality and facilities and how the home will meet their needs. An accurate and comprehensive pre-admission assessment must be undertaken for all prospective residents prior to their admission to the home. Residents and their representatives know that all their care needs are understood and can be met by the home. DS0000025925.V318006.R03.S.doc Version 5.2 Page 9 EVIDENCE: The Statement of Purpose and Service Users Guide include detailed information about the service provided by the home, in order to enable other prospective residents and their representatives to make an informed choice about where to live. Evidence was seen that prospective residents and their relatives/representatives are encouraged to visit the home, talk to the residents and staff about the service prior to making a decision to live there. The home has a standard format for assessing prospective residents. However this needs to be further developed and adapted so that the person carrying out a pre - admission assessment is aware of all of the prospective resident’s needs and is able to make an informed decision about whether the home can meet individual residents’ needs effectively. The inspector noted that one resident has been referred back to the referring agency for a reassessment as she has been inappropriately placed in the home. Assessments by social workers are received by the home together with referrals. However the quality of the assessments and accompanying care plans were varied. The information and care needs assessments received from some Boroughs were more comprehensive than others. Consistency must be maintained by the referring agency about the information provided to the providers in order to enable them to make informed decisions about whether the home can meet the needs of prospective residents. This must be brought to the attention of the referring agencies by the providers via other forums. The residents spoken to said that they enjoyed living at the home and thought that their needs were met. Feedback received via the relatives/visitors comment cards said that, “ I am more than happy with the care my mother receives at St Josephs. The staff and carers there are brilliant.” Another comment received was “Ive always found all the staff wonderful in their duty”. The files checked for two of the most recently admitted residents had a preadmission assessment form, as well as an assessment by the social worker of the needs and wishes of the resident. The above comments must be borne in mind when future placements are being made by both the referrer and the provider. Privately funded residents have a contract and a statement of terms and conditions with the home. A separate contract exists with residents placed by the local authorities. The home does not provide intermediate care. DS0000025925.V318006.R03.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 7, 8, 9, 10 Close attention is paid by staff are to meet residents’ health, personal and social care needs. The standard of care planning is not consistent for all residents and must be improved. All care plans must be reviewed and updated regularly to reflect residents’ changing needs. Residents medication is administered safely and regularly. Personal support in this home is offered in a way which promotes and protects residents privacy, dignity and independence. EVIDENCE: Feedback from both residents and relatives was very positive about the commitment of the home to keeping residents as well as possible. Records confirmed residents are seen by a dentist, opticians, chiropodist, district nurses and doctors. Residents said that they able to see their GP on a weekly basis upon request. Action is also taken by the PCT community matron, to whom DS0000025925.V318006.R03.S.doc Version 5.2 Page 11 health concerns regarding individuals in hospitals are communicated. The inspector was informed that the matron liaises quickly with the hospitals regarding care issues whilst residents are in hospital which are dealt with by hospital staff enabling the residents to return to the home quickly rather than having to stay in hospital for long periods of time which has a detrimental effect on their overall mobility and well-being. The home is committed to enabling residents to return home and are willing and able to assist them to achieve full recovery via consistency of care provided by the staff in the home. Feedback from residents and relatives was positive about the commitment of the staff to keep residents as healthy as possible. A monthly health check routine is established as well as nutritional and weight charts being kept. Residents also appreciated the weekly visits by the hairdresser to the home. The records for four residents were looked at and indicated that for each one there was a current plan of care which set out the basic needs of the residents and how they were to be met by the staff. However, the inspector noted that there was inconsistent practice in some areas, in that the specific needs of some of the residents were not being identified in the care plans. However, discussions with the staff and the acting manager indicated that residents’ needs are being identified verbally and are met by the staff. The inspector is concerned that service users are at risk of not having their health care needs met if communication between staff fails. Staff must be provided with sufficient information to ensure that all the specific care needs of the residents are identified and included in the care plans in order to enable the staff to meet these needs. A requirement has been made that clear, consistent care plans must be drawn up which are specific for the individual, identifying their specific needs and how these are to be met by the staff. The care plans must be regularly reviewed and updated to reflect residents’ changing needs. Risk assessments must be attached to each individual care plan. The homes medication policy and procedure states that senior staff will be responsible for administering medication and have received medication administration training. None of the residents are responsible for administering their own medication. However on the day of the inspection, the inspector noted that although the majority of the residents had their medication administered by the senior on duty, one resident who had difficulty swallowing her medication and was reluctant to take it, was being given her liquid medication at the breakfast table by a student. This is not acceptable practice and a requirement has been made that all staff must adhere to the home’s policy and procedure regarding medication administration. DS0000025925.V318006.R03.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12, 13, 14, 15 There is a varied and suitable programme of activities available in the home for the residents. The home is a good at being able to meet the cultural and religious needs of people from different backgrounds living in the home. Visiting times are flexible and people are made to feel welcome in the home so that residents are able to maintain contact with their family and friends. A well-balanced and wholesome diet is provided to the residents in a pleasant environment. EVIDENCE: The inspector spoke to a number of residents to seek their views about living at the home. All the residents spoken to stated that they receive good care from the staff and all their needs are being met in a caring and professional manner. The visitor’s book showed that there is a steady stream of visitors to the home on most days. As well as friends and family, other visitors include the DS0000025925.V318006.R03.S.doc Version 5.2 Page 13 hairdresser, an entertainer, pets as therapy group, visits to the theatre and outings as well as shopping trips. There are a wide range of activities provided within the home by the activities co- ordinator. Plans are already in place for a Christmas party and lunch for the residents and their families, as well as an outing to see a pantomime. Residents confirmed they were consulted about activities and outings they wish to do. Residents are also encouraged to go out with relatives when possible. The activities coordinator also conducts a Jewish prayer service on a Friday evening for Sabbath and encourages the home to celebrate special Jewish festivals. The inspector was informed that any residents who wish to participate in church activities, go to the temple or the gurudwara will also be encouraged and enabled to do so. The care plans should contain information about preferred activities, including spiritual and cultural activities. There is also a visiting clothes shop available to the residents periodically where they can buy items of clothing. Residents have a choice of where to see their relatives, either in one of the lounges or in their own bedroom. Residents are encouraged to bring their own personal possessions with them when coming to live at the home and this was evident when the inspector visited some of the residents’ bedrooms. Meals are mostly served in the dining room, though some residents choose to eat on their own in the lounge or in their own bedroom. There were two choices of the main meal however the chef stated that she would cook something different if either of the choices were not to a resident’s liking. The meals observed on the day of the inspection looked appetising and nutritionally balanced and the residents were complimentary about the food. DS0000025925.V318006.R03.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 16,18 Quality in this outcome area is good. Residents and their relatives are confident that their complaints will be listened to and acted upon. Residents are protected from abuse by the policies, procedures and practices within the home. EVIDENCE: The complaints book was examined during the inspection and nine complaints have been recorded since the last inspection. The home has introduced a system for recording all complaints, expressions of concerns and issues of dissatisfaction with any part of the service. All complaints recorded are discussed to identify any trends and action to be taken to resolve them. The inspector noted that all the concerns and complaints recorded were dealt with appropriately by the staff and acting manager. The residents spoken to, on the day of the inspection, were asked if they were unhappy about anything in the home and if they knew who to make a complaint to. The residents said that they would talk to the staff or the acting manager. All the residents said that they felt confident that they would be listened to and their complaints would be acted upon. The accident book and was also examined and the inspector noted that 30 accidents had been logged. This is a high number of accidents and concern was expressed by the inspector about this. The accidents related to falls DS0000025925.V318006.R03.S.doc Version 5.2 Page 15 particularly in the mornings. This issue has been the dealt with by the acting manager by staggering the times people are brought down stairs for their breakfast. Residents are served breakfast as soon as they arrived downstairs and are not made to wait for their breakfast at a set time. This is good practice and must be maintained by the home in order to encourage choice and flexibility for the residents. The acting manager is aware that the residents must be supervised at all times by the care staff to prevent falls and accidents. The majority of the residents have relatives, friends or volunteers who can advocate on their behalf, if they so wished. The manager has ensured that an advocacy service is offered to residents who do not have any relatives/representatives to represent their views. The home follow the London Borough of Redbridge adult protection policy and procedure for dealing with allegations of abuse and whistle blowing. All the staff working in the home have completed adult protection training and new staff will be attending the course as part of their induction programme. Staff spoken to on the day of the team meeting, confirmed that they have attended adult protection training and were aware of the actions to be taken if there were any concerns about the welfare and safety of the residents. However the adult protection procedure needs to be clarified in order to ensure that the person in charge and staff know what action to take when an allegation is received. DS0000025925.V318006.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 19,20,21,22,23,24,25, and 26 The home has a welcoming atmosphere and provides the residents with a safe and well maintained environment. There need to be sufficient numbers of suitable toilets and bathrooms, for the number of residents accommodated. Residents bedrooms meet their needs and are furnished with their own personal possessions. Residents live in a home that is comfortable, clean and hygienic. EVIDENCE: The standard of the decor, furnishings and fittings in the home are maintained to a good standard. There is an ongoing programme of refurbishment and redecoration. A handyman has been employed to carry out any minor day to day maintenance to the home, which ensures that the residents live in a DS0000025925.V318006.R03.S.doc Version 5.2 Page 17 comfortable and safe home. There is an effective system in place for the staff to report items requiring repair or attention. The living area of the home consists of two large lounges and a dining area, which are appropriately furnished. There is a rear garden which is well maintained and planted with flower beddings for the residents’ enjoyment. All the bedrooms are single except two double bedrooms. All the rooms have hand wash basins and four bedrooms have en-suite facilities. The inspector noted that bedrooms are personalised by the residents and contained family photographs, ornaments, and small items of furnishings. On each floor there are sufficient bathrooms and toilets, however there is only one parker bath on the first floor and a low assistance parker bath on the ground floor. Most of the residents need assistance with bathing and use the parker bath. Although this standard is met the registered person should continue to assess whether there are sufficient suitable baths and toilets for the residents and provide these as required by regulation. The inspector noted that only one hoist is available in the home and suitable slings are not used to safely transfer residents. A requirement has been made that safe and suitable manual handling equipment is provided to enable staff to carry out their duties in line with Health and Safety Regulations and for the safety of the residents. A concern was raised about the safety of the residents and staff within the home due to an intruder into the home via a fire exit which was not kept shut as required. However this issue has now been addressed. This has improved safety around the home. Further measures also need to be implemented to improve residents’ and staff safety. The standard of cleanliness in the home is high and a cleaner is employed to maintain it to this standard. Staff have attended training on infection control and take all the necessary precautions to ensure that there is no spread of infection within the home. There are adequate control systems in place to ensure that the home is free from any offensive odours. The heating, lighting, water supply and ventilation of residents’ accommodation must meet the relevant environmental health and safety requirements and the needs of individual residents. Some bedrooms were very hot on the day of the inspection. Action must be taken to ensure that all the above issues are dealt with, especially that heating may be controlled in the residents’ own bedrooms. DS0000025925.V318006.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 27, 28, 29 and 30 Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. Residents benefit from a committed and experienced team of staff in the home who have the skills and training to meet the residents’ individual needs. The home follows a robust recruitment and selection procedure in order to ensure the residents’ safety and well-being. EVIDENCE: On the day of the inspection, staffing levels were observed to be sufficient to meet the needs of the residents. Staff rotas were examined and the rota correlated with the number of staff on duty to ensure the residents’ needs continued to be met. The home have a core group of stable staff who have worked there for a number of years and have built up a good knowledge and understanding of the needs of the residents. New staff are inducted and shadow other staff before commencing work. There is an ongoing programme of relevant training courses on offer to staff and evidence was the seen of various in house courses available to them, DS0000025925.V318006.R03.S.doc Version 5.2 Page 19 which they are encouraged to attend by the acting manager, in order to ensure that they develop the skills necessary to meet the needs of the residents. Staff files showed that they have done training in essential areas such as health and safety, adult protection, dementia awareness, assisted movement, fire safety, manual handling, infection control, complaints handling, equality and diversity, food hygiene, bereavement and loss, deaf and hard of hearing awareness, visual awareness, administering medication, dementia awareness. NVQ level 2 has been completed by 80 of the staff with a small number of staff completing NVQ Level 3 training. The home is also able to recognise when additional training is needed, and attempts to plan over time to provide this training. Staff are competent and trained to do their jobs in an efficient and professional manner. A good deal of positive verbal feedback about the staff at the home was received from the residents. They reported that staff working with them are able to meet their needs in a caring and sensitive manner and know what they are meant to do. Evidence was seen that newly recruited staff are receiving induction training, although the manager needs to use the induction book to show that staff received induction over a period of time and that their understanding was tested during supervision, to ensure that they clearly understood the information given to them. DS0000025925.V318006.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 31, 32, 33, 34, 35, 36, 37, and 38 Residents live in a home that is run in their best interests by an experienced and qualified acting manager. Residents financial interests are safeguarded by the policies, procedures and practices of the home. The staff team work well together to make sure that residents are safe and secure whilst living at St Josephs. Staff are appropriately supervised written evidence must be provided that this is taking place at regular intervals. Residents’ rights and best interests are safeguarded by the home’s recordkeeping policies and procedures. EVIDENCE: DS0000025925.V318006.R03.S.doc Version 5.2 Page 21 The acting manager has made an application to be registered by the CSCI. She has the competence and experience to run the home. The acting manager works closely with the general manager and the proprietor to achieve high standards for the home. Feedback from both the residents and staff was positive about the way in which the home is run. Regulation 26 visits (monthly monitoring) are undertaken by the service manager on a monthly basis and the reports are forwarded to the inspector promptly, showing that the registered providers are monitoring the service provided in the home. The inspector is also notified of any significant events and developments in the home. The home has an appropriate policy and procedures regarding safeguarding residents’ finances. If they wish and are able to, residents are helped to take responsibility for managing their own money. They are provided with facilities to keep their valuables and money safe. Where the home is responsible for residents’ money it maintains clear records that are routinely kept up-to-date and can be used to track individual resident’s finances. However, the inspector could not physically check individual resident’s finances because the person who administers the system was not present at the time of inspection, although the systems followed were checked. The acting manager is required to ensure that resident’s money is kept separately in order to offer protection to the residents. The service understands the need to meet external requirements where it acts as agent or appointee for residents. Staff files were checked and the inspector was informed by the acting manager that all staff receive supervision on a regular basis. However, some staff files checked did not contain up-to-date dates/records of supervision received. The acting manager must ensure that all supervision records are kept up-todate in order to evidence supervision received by staff. The inspector spoke to several staff members who confirmed that they receive regular supervision from the senior officers and the acting manager. The acting manager adheres to keeping records up to date. The home has carried out all health and safety checks. Fire drills and alarm testing are undertaken regularly. Residents files that were examined showed that not all risk assessments are being reviewed and updated on a regular basis or when a change in need is identified. A requirement regarding this has been made elsewhere in this report. DS0000025925.V318006.R03.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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 DS0000025925.V318006.R03.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person must ensure that clear and consistent care plans are drawn up which are specific for the individual, identifying their specific needs and how these are to be met by the staff. The registered person must ensure the risk assessments must be attached to each care plan and regularly reviewed according to the residents changing needs. The registered person must ensure that the adult protection procedure must be clarified in order to ensure that the person in charge and staff know what action to take when an allegation is received. The registered person must ensure that there are sufficient numbers of suitable toilets and bathrooms, for the number of residents accommodated. The registered person must ensure that safe and suitable manual handling equipment (hoist) is provided to enable staff DS0000025925.V318006.R03.S.doc Timescale for action 31/03/07 2. OP7 15 31/03/07 3. OP18 13 31/03/07 4. OP21 23 31/03/07 5. OP22 13(5) 31/03/07 Version 5.2 Page 24 6. OP36 18 to carry out their duties in line with Health and Safety Regulations and for the safety of the residents. The acting manager must ensure that all supervision records are kept up-to-date in order to evidence supervision received by staff. 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The inspector recommends that in order that care plans reflect the views and wishes of residents and their relative/representative, it is important that they are involved as much as possible in this process. DS0000025925.V318006.R03.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000025925.V318006.R03.S.doc Version 5.2 Page 26 - 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!