Inspection on 20/10/06 for Summerdale Care Home

This inspection was carried out on 20th October 2006.

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

Summerdale Care Home 09/02/09

Summerdale Care Home 21/04/08

Summerdale Care Home 28/11/07

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

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

CARE HOMES FOR OLDER PEOPLE Summerdale Court Care Centre 73 Butchers Road London E16 1PH Lead Inspector Seka Graovac Unannounced Inspection 20th October 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Summerdale Court Care Centre DS0000068286.V354104.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. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summerdale Court Care Centre Address 73 Butchers Road London E16 1PH 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 7540 2200 020 7540 2201 Summerdale Court Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Rosalind Mbaki Care Home 72 Category(ies) of Dementia (15), Mental disorder, excluding registration, with number learning disability or dementia (21), Old age, of places not falling within any other category (36) Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. MINIMUM STAFFING NOTICE The home can provide accommodation for one (1) named service user under the age of 60 years. The home can admit anyone under the above category from the age of 60 years or older. 13th April 2006 Date of last inspection Brief Description of the Service: Summerdale Court is owned and operated by the Four Seasons Health Care group. It is registered as a nursing care home providing care to 72 older people and is divided into three units. Oak unit provides care to frail elderly (36 beds), Beech unit to older people with enduring mental health problems (21), and Ash unit provides care to people suffering from dementia (15). The home has a manager (matron), a deputy manager and two unit managers that support and manage staff team. The premises were purpose built and the home was opened in 1997. All bedrooms have en-suite facilities. Units are self-contained, but catering, laundry and parking facilities are shared. In addition to the above-mentioned units, Willow unit (45 beds) is leased to NHS Trust. Summerdale Court Care Centre DS0000068286.V354104.R01.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 lasted approximately nine and a half hours. The previous inspection that was conducted in April 2006 highlighted some improvements in care services offered at Summerdale Court Care Centre as judged against the National Minimum Standards and the Care Homes Regulations. This came after years of the service provision that had been noncompliant with legislation in many aspects. Ten requirements and two recommendations were made on that occasion. Prior to this inspection, the Lead Inspector had attended two meetings with the provider and the Newham Social Services following high incidence of potential safeguarding matters (occurrence of unexpected bruising and undetected fracture). She had also visited the home on the registered manager’s suggestion to speak to staff. The main aim of this inspection was to monitor the outcomes of implementation of the improvement plan that was agreed amongst the provider, Newham Social Services and the Commission for Social care Inspection as the way forward. The inspector viewed numerous records, such as: staff files, service users’ files, medication records, health and safety records, etc. She also spoke in private with two service users and had conversations with many others. She had her lunch with the service users from the Oak Unit. She also spoke to many staff members and gave feedback at the end of the inspection to the registered manager, her deputy and three staff nurses (one from the each unit). What the service does well: The management and the staff expressed their motivation and commitment to improve the care offered at Summerdale Court Care Centre in their conversations with the inspector. The registered manager is a registered nurse with over thirty years of postqualifying experience. She also has a management qualification and has been managing the Summerdale Court Care Centre for many years. She continued to attend training in various relevant subjects, such as: fire-warden training, POVA (Protection of Vulnerable People) for managers, end of life care, stoma care, medication, peg-feed, etc. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 6 The home was subject to Team Audit Process and the inspector was shown a copy of the home’s improvement plan for October 2006. The home was slowly turning around towards individually tailored customer quality care. The report on quality survey analysis that was based on the service users’ and relatives’ satisfaction with the service was published in March 2006. The inspector was also shown a copy of the minutes of the home’s meeting with relatives of service users that was conducted in September 2006. The home assessed prospective service users’ needs and kept related records. The service users who spoke to the inspector said that the food was good in the home and they enjoyed it. The staffing levels were appropriate. It was evident that the manager kept them under review and booked additional staff when it was needed. The home was committed to training its staff well. The training that was on offer included: POVA, infection control, dementia, customer care, fire safety, manual handling, challenging behaviour and dementia, etc. In addition to external and internal training, the home also organised reflective sessions on the care practices. All health and safety related records that the inspector checked (for example: electrical installations certificate, lifting equipment certificates, etc) were in date. The fire-safety log was also appropriately kept indicating that fire-alarm tests took place on a weekly basis as required. What has improved since the last inspection? The home’s ability to meet the National Minimum Standards for Care Homes for Older People and be more responsive to what service users, relatives and social workers wanted, has increased over the years of intense management of change and training for all staff. Out of ten requirements that were made at the previous inspection, the home has successfully dealt with six of them. These related to the following: • • All the bedroom doors have been fitted with the appropriate locks. An appropriate complaints procedure was fully implemented. Complaints raised were appropriately dealt with and the records were available to evidence the process. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 7 • An appropriate Safeguarding Adults procedure was fully implemented. Potential protection issues were referred to Newham’s Adult Safeguarding coordinators and the findings of the investigations were followed by the actions agreed as required. Service Users were enabled to use the nurse-call system in accordance with their needs and abilities. The home conducted a fire-drill. The home updated their risk assessments and the hazards were appropriately controlled at the time of the inspection. • • • New arm-chairs and dinning room chairs for the whole home were delivered on the day of the inspection. The inspector also noted that two new fridges still in their original packaging were in the office. What they could do better: Four requirements made at the previous inspection had to be restated. These related to: • the home’s record-keeping (not reaching the National Minimum Standards on a number of occasions such as: care plans, individual assessment, medication records, information about relatives, etc), fire safety (fire-doors being propped open with heavy items) health and personal care provision (see bellow). • • Although the service users had care plans in place, the inspector noted that more detailed guidance as part of the care planning process was needed in some instances such as: how the home was going to facilitate communication with the service user whose mother tongue was not English (the staff nurse was unsure what was his first language as this was not documented in his notes), how the home was going to enable him to practice his religion, how the staff will monitor and manage alcohol intake of one service user who suffered from alcohol induced psychosis and the staff sometimes gave him alcoholic drinks as incentive or reward, etc. Although the inspector noted some improvement in the home’s care planning process, the requirement in relation to them had to be restated once more time. The previous targets expired in July and March 2006 and prior to that in May 2005 (statutory notice). The inspector also noted that there were gaps in the Medication Administration Record Charts (MARS) making it unclear if the service users did not receive their medicines as prescribed or if some staff did not always sign for the medicine given and taken. For example one service user was prescribed shortcourse of a drug five times a day in a tablet form and also as a cream. In six Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 8 days that the inspector checked, there were eight gaps for the tablets and seven gaps for the cream in his MARS. In addition to the above, the same service user did not receive any of his prescribed medicines on one morning. When the inspector asked about it, she was explained that this person’s medicine was not available in the home on that morning due to the pharmacist’s stock shortages. However, this and the action taken by the staff at the time were not recorded anywhere. The related requirement regarding full implementation of the medication procedure at all times was restated. In addition to the restated requirements, three new requirements were made at this inspection, totalling seven requirements. The new requirements related to: • • • The air temperature at which the medicine was stored in the home (must not exceed 25 degrees Celsius). Enabling service users to maintain contact and communicate with their families and friends. Maximising service users’ capacity to exercise personal autonomy and choice in accordance with their needs and the risks involved (risk assessments must take place when considering issuing the keys to service users and the appropriate records must be kept). In order to safeguard service users in their care, the registered person(s) for the home must ensure that all the issues and breaches of legislation identified in this report are rectified within the agreed timescales. 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. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 9 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 Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 not applicable for the service). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home assessed prospective service users’ needs and kept related records. EVIDENCE: The inspector viewed individual files for four service users: two from the Beech unit and two from the Oak unit. All files contained completed pre-admission assessments carried out by the home in addition to the information obtained by external agencies such as: social and psychiatric services. Further detailed assessments in relation to mobility, nutrition, continence, pressure sore risks, oral care, falls risk assessment and general dependence were also available on the files. Those assessments formed the basis for the individual care plans and were monthly evaluated. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 11 The registered manager was in discussion with the commission in order to obtain necessary variations and admit two service users who were bellow the current registered age for the service. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users had current individual care plans. However, some of them were not comprehensive and there were issues with medication. EVIDENCE: The inspector viewed individual care plans for four service users. She crossreferenced them with the information available in the other documentation such as: assessments, body-maps and health visitor’s notes. She also spoke to some of these service users and observed them and the others while they were engaging in the activities of daily living. The inspector also spoke to the staff about these people’s needs and how the home was helping them to maintain and improve the quality of their lives. All the care plans were in date and were regularly evaluated on a monthly basis. However, on one occasion the evaluation written in October 2006 contradicted the care plan and also what the staff nurse told the inspector about this service user’s needs in relation to maintaining his independence and Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 13 leaving the home unescorted. The inspector also noted that more detailed guidance as part of the care planning process was needed in some other instances such as: how the home was going to facilitate communication with the service user whose mother tongue was not English (the staff nurse was unsure what was his first language as this was not documented in his notes), how the home was going to enable him to practice his religion, how the staff will monitor and manage alcohol intake of one service user who suffered from alcohol induced psychosis and the staff sometimes gave him alcoholic drinks as incentive or reward, etc. The registered manager also stated that the Newham Social Services reviewed all their placements in the recent months and reopened referrals to the Summerdale Court Care Centre. The viewed care plans agreements were signed by the service users or their representatives. Although the inspector noted some improvement in the home’s care planning process, the requirement in relation to them had to be restated once more time. The previous targets expired in July and March 2006 and prior to that in May 2005 (statutory notice). The registered persons must ensure that each service user has a comprehensive care plan that is based on detailed care and support needs assessments and that the plan is agreed and signed by all involved parties. Some of the health monitoring documentation that the inspector saw was confusing. For example some blood-sugar results that were taken were written in a weekly BM form, while the others for the same person were written in a monthly blood-pressure (BP) form. Also some staff wrote health related information into relatives contact sheet, although there was nothing written to indicate the relatives’ involvement on these particular matters. One staff nurse was not aware that one of the service users in her care was due to have a surgery until she checked his nursing notes kept separately from this person’s individual file. The requirement related to record keeping in the home was restated (see later in this report). The service users’ files contained health information and evidence of correspondence with other health care professionals that indicated that the home in liaison with them, appropriately supported the service users to maintain their health. One service user told the inspector about his podiatry treatment that he had on the day of the inspection and also about the pending dental treatment he worried about. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 14 Two major issues were identified regarding medication in the home. The treatment room on the ground floor that was used for storage of medicines kept on behalf of the service users was very hot. The thermometer on the wall showed 28 degrees Celsius when the inspector entered this room. The monitoring records that the home kept showed that this was not unusual. All the medicines that the inspector checked had labels stating that they must be stored at the temperature not exceeding 25 degrees. The treatment room upstairs that the inspector checked was appropriately cool. The registered person(s) must ensure that all medicine in the care home is stored at the appropriate temperatures. The inspector also noted that there were gaps in the Medication Administration Record Charts (MARS) making it unclear if the service users did not receive their medicines as prescribed or if some staff did not always sign for the medicine given and taken. For example one service user was prescribed shortcourse of a drug five times a day in a tablet form and also as a cream. In six days that the inspector checked, there were eight gaps for the tablets and seven gaps for the cream in his MARS. In addition to the above, the same service user did not receive any of his prescribed medicines on one morning. When the inspector asked about it, she was explained that his medicine was not available in the home due to the pharmacist’s stock shortages. However, this and the action taken were not recorded anywhere. There were only gaps left in his MARS. The related requirement regarding full implementation of the medicines procedure at all times was restated. The inspector also checked the home’s Controlled drugs-log on the ground floor and found that it was appropriately kept. The registered manager stated that all the bedroom doors were fitted with locks that were accessible to staff in emergencies as required at the previous inspections. Some service users who spoke to the inspector confirmed that they had the key and were able to use it. Please see later in this report identified related issues regarding autonomy and choice. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The activities coordinator supported service users to engage in various activities either individually or in a group setting. Service users enjoyed their food. EVIDENCE: The registered manager stated that the home had an activities co-ordinator. Her purpose of work was to organise activities and encourage service users to engage. While spending time on the units, the inspector did not see any group activities taking place. Service users were sitting in the lounges with televisions on, but it did not seem that they were actually watching it. The activities records that the inspector saw had entries such as: “had a smile on her face” repeated many times and did not always state what activities the service users engaged in. One service user told the inspector that he enjoyed the trip to South-end that was organised by the home. However, this was not noted in his activities monitoring chart. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 16 The inspector was told that some service users went to Day-centres. The staff also told the inspector that ministers of Christian religion visited the home on a regular basis. The home organised two barbeque parties in summer 2006. One service from the Oak-unit loved plants and he showed his green house in the garden to the inspector. He also enjoyed making model-ships. One person from the Beech-unit was knitting when the inspector came to her room. She wore clothes that she herself had sawn from torn-pieces of material. Please refer to the issues identified earlier in this report in relation to care planning and cultural and religious needs of service users and also recordkeeping. The inspector was concerned to discover that the information about one person’s family (three sisters, one of whom was the Next of Kin) got lost while being transferred from the social worker’s notes into the home’s records. The staff nurse told the inspector that this service user did not have a close family. She said that the home did not have any contact with the NoK who she believed was not related. The social worker’s notes stated that the sisters visited the previous placement several times a year. They could not come more often due to their own frailty but were in letter-correspondence with this service user. The registered manager confirmed that she spoke to one of the sisters over the phone. The registered person(s) must ensure that the home enables service users to maintain contact or communicate with their families and friends. The visitor’s book was kept and it seemed that the home had many visitors. None of them were on the units while the inspector was there. As mentioned earlier in this report, the inspector saw some service users having the keys for their bedrooms. No associated individual written riskassessments were available. The manager told the inspector that keys were not offered to service users but were given only to people who asked for them. The registered person(s) must ensure that the home maximise service users’ capacity to exercise personal autonomy and choice in accordance with their needs and the risks involved. Written evidence must be available to confirm that individual risk assessments took place when considering issuing the keys to service users. The inspector had lunch with the service users on the Oak-unit. The home had a traditional Friday menu: fish and chips served with peas and corn. Some service users had boiled potatoes or mash depending on what they liked and what they were able to eat. The other option was minced meat. The inspector Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 17 was told that there were no vegetarians living in the home at the time of the inspection. The inspector was also told that some service ate halal meat and also that special Caribbean and Indian dishes were made for some service users on their request. The service users were appropriately encouraged to eat and assistance was offered to them in accordance with their needs. The person who was sharing the dining table with the inspector had poor appetite. This was identified in his care plan. He chose to drink several cups of milk instead of having his liquidised meal. The staff told the inspector that he had a nutritious supplement drink in the morning. The service users who spoke to the inspector said that the food was good in the home and they enjoyed it. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users were safeguarded by the home’s policies and procedures on how to deal with complaints and potential protection issues. EVIDENCE: The inspector reviewed the home’s complaints and safeguarding adults log with the registered manager. The documentation kept indicated that the management took the issues brought to their attention either by the home’s staff, service users themselves or visitors, seriously, undertook rigorous investigations and implemented appropriate actions. Appropriate referrals were made to Newham’s Safeguarding Adults Co-ordinators and the notifications were sent to the commission as required. The commission was also made aware that one registered nurse was referred to POVA (Protection of Vulnerable Adults) list questioning her ability to safeguard adult people in her care. This was due to the investigation finding that it was likely that she altered the records relating to the fall of one service user. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The environment was generally fit for its purpose. Maintenance and improvement work was planned. EVIDENCE: The premises were purpose built in 1997. All bedrooms have en-suite facilities. Units are self-contained, but catering, laundry and parking facilities are shared. The areas that the inspector saw were tidy and clean but some walls had dirty marks and some carpets showed signs of overuse. The registered manager stated that all the communal flooring was due to be replaced and the bedrooms were painted when vacant. New assisted baths were on order and the home considered changing some bathrooms into shower-rooms. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 20 New arm-chairs and dinning room chairs for the whole home were delivered on the day of the inspection. The inspector also noted that two new fridges still in their original packaging were in the office. The manager stated that the home had a contract for clinical waste collection that worked well. Each unit had their own outside container and they were kept locked as required. Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff were trained and many of them were qualified. Some issues were identified regarding recruitment. EVIDENCE: The registered manager stated that the home had fifteen permanent qualified nurses, six senior care assistants and twenty five care assistants. Out of thirty one, eighteen care assistants (58 ) were qualified. In addition to the permanent staff, the home also used five qualified nurses and five care assistants as bank staff. At the time of the inspection, the home had fifty seven service users and fifteen vacancies. The manager stated that in addition to herself and her deputy there were six registered nurses and eight care assistants on duty. She explained that one additional registered nurse was booked for that day due to two recent admissions to the home. The staffing levels were appropriate. It was evident that the manager kept them under review and booked additional staff when it was needed. The inspector randomly selected files for four staff, one of whom has been employed since the previous inspection. All the viewed files contained all the required staff records, such as: references, identity checks, Criminal Records Bureau disclosures, etc. However, scrutiny of the records revealed that in Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 22 some instances the information about the previous employment provided in the application forms did not match the references. The manager stated that she mainly focused on the content of the references that related to the prospective staff ability to do the work. The inspector recommended that the references were always checked against the information provided in the employment application form and that all inconsistencies were followed up. The seen individual staff files and the central training log indicated that the home was committed to training the staff well. The training that was on offer included: POVA, infection control, dementia, customer care, fire safety, manual handling, challenging behaviour and dementia, peg-feed, etc. In addition to the external and internal training, the home also organised reflective sessions on the care practices. One staff said to the inspector: “Caring for people is source of my happiness”. She also told the inspector that apart from having regular supervision meetings, her work was sometimes observed by the manager and subsequently she would receive the feedback that was helpful. Summerdale Court Care Centre DS0000068286.V354104.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management and the staff were motivated and committed to improve the care for service users. Record-keeping was still inadequate at times. EVIDENCE: The registered manager is a registered nurse with over thirty years of postqualifying experience. She also has a management qualification and has been managing the Summerdale Court Care Centre for many years. She continued to attend training in various relevant subjects, such as: fire-warden training, manual handling, POVA for managers, end of life care, stoma care, medication, peg-feed, etc. The manager and the staff confirmed that one-to-one meetings were happening on a regular basis (two monthly), but not all minutes of the Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 24 meetings held were available on the day. The inspector was told that some of them were archived and would have taken a while to retrieve them. The inspector recommended that staff supervision records were kept in the way that would make it easy for the home to evidence that all staff had at least six one-to-one meetings a year. The inspector also restated the recommendation from the previous inspection regarding encompassing the information about the service user’s money into the care planning process. The inspector recommended that individual service users’ records were further improved by adding a note in their personal files explaining who was responsible for their money and how they would be supported in this aspect of their lives. This recommendation was restated as the manager who had not been present at the previous inspection was not clear what outcome the inspector was seeking and the reasons for it. This was clarified at this inspection. The inspector checked the personal money records for one service user that were held by the home’s administrator and found them consistent and satisfactory. This service user was able to sign when receiving money. The inspector also checked health and safety related records such as: risk assessments, electrical installations certificate, lifting equipment certificates, etc and found them all to be in date. The fire-safety log was also appropriately kept indicating that fire-alarm tests took place on a weekly basis as required. The home conducted a fire-drill in April 2006 and the other one was due. However, the inspector noted that the fire door between the dining room and the reception area was propped open with a heavy item (at first with a chair and later with a food-trolley). The requirement to keep the fire-doors free to shut was restated. The management and the staff expressed their commitment to improve the service in their conversations with the inspector. The home was subject to Team Audit Process and the inspector was shown a copy of the home’s improvement plan for October 2006. The manager also received management account statement on a monthly basis. The regional manager for Four Seasons Health Care Ltd visited the home regularly and reports in accordance with the Regulation 26. The report on quality survey analysis that was based on the service users’ and relatives’ satisfaction with the service was published in March 2006. The inspector was also shown a copy of the minutes of the home’s meeting with relatives of service users that was conducted in September 2006. The home’s ability to meet the National Minimum Standards for Care Homes for Older People and be more responsive to what service users, relatives and Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 25 social workers wanted has increased over the years of intense management of change and training for all staff. However, the record-keeping in the home still did not reach the National Minimum Standards on a number of occasions. See the rest of the report (i.e. care plans, individual assessment, medication records, information about relatives, etc…) Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 26 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X 3 X X N/A X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 2 2 Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES, Four 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 persons must ensure that each service user has a comprehensive care plan that is based on detailed care and support needs assessments and that the plan is agreed and signed by all involved parties. The previous target expired on 31/07/06 and the other previous on 31/03/06. This requirement also formed a part of the previously served statutory notice with the target expired on 31/05/05. The registered person(s) must ensure that all medicine in the care home is stored at the appropriate temperatures (not exceeding 28 degrees Celsius). The registered person(s) must ensure that the appropriate procedures for handling service users’ medication are fully implemented at all times. The previous target expired on 30/04/06. The registered person(s) must ensure that the home enables service users to maintain contact DS0000068286.V354104.R01.S.doc Timescale for action 31/01/07 2. OP9 13 (2) 31/12/06 3. OP9 13 (2) 31/10/06 4. OP13 16 (m) 31/12/06 Summerdale Court Care Centre Version 5.2 Page 28 5. OP14 12 6. OP37 17 7. OP38 23 or communicate with their families and friends. The registered person(s) must ensure that the home maximise service users’ capacity to exercise personal autonomy and choice in accordance with their needs and the risks involved. Written evidence must be available to confirm that individual risk assessments took place when considering issuing the keys to service users. The registered persons must ensure that service users’ rights and interests are safeguarded by the home’s record keeping procedures. The previous target expired on 31/07/06 and the one before that on 31/03/06. The registered persons must ensure that the fire-doors are free to shut in case of the firealarm being raised. The previous target expired on 20/04/06 31/01/07 31/01/07 26/10/06 Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29 Good Practice Recommendations The inspector recommended that the references were always checked against the information provided in the employment application form and that all inconsistencies were followed up. The inspector recommended that individual service users’ records were further improved by adding a note in their personal files explaining who was responsible for their money and how they would be supported in this aspect of their lives. The inspector recommended that staff supervision records are kept in the way that would make it easy for the home to evidence that all staff had at least six one-to-one meetings a year. 2. OP35 3. OP36 Summerdale Court Care Centre DS0000068286.V354104.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Summerdale Court Care Centre DS0000068286.V354104.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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