Inspection on 11/07/07 for Swallows, The

This inspection was carried out on 11th 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

Swallows, The 18/05/06

Swallows, The 04/10/05

Swallows, The 28/04/05

Swallows, The 02/09/04

Swallows, The 11/05/04

Similar services:

Queen Elizabeth House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Swallows, The 318 Brownhill Road Catford London SE6 1AX Lead Inspector Sean Healy Unannounced Inspection 10:00 11th July 2007 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 DS0000025645.V340887.R02.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. DS0000025645.V340887.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swallows, The Address 318 Brownhill Road Catford London SE6 1AX 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) 0208 4613391 020 8461 1200 Mr Alan Wilde Mrs Susan Wilde Mrs Susan Wilde Care Home 19 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (19) of places DS0000025645.V340887.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 19 elderly persons of whom up to 12 may have dementia 18th May 2006 Date of last inspection Brief Description of the Service: The Swallows is a private care home managed by the same proprietors since opening in 1984. It is a large Victorian house situated between Lee and Catford, within walking distance of shops and public transport. It is registered for 19 older people and twelve of these may have dementia. The home is no longer registered for those who are physically disabled. There are 13 single rooms and 3 shared rooms. It is centrally heated and attractively decorated. Washing facilities are available in all bedrooms and there is a 24-hour nurse call system. There are two lounges, dining areas and a conservatory. There is a garden with a patio area for use in good weather. Residents are encouraged to bring in personal items of furniture and mementos to personalise their bedrooms. Bathrooms and toilets have aids and adaptations available. Visitors can be entertained in all of the communal areas and in private bedrooms. The home can provide information about their service through the service users guide and statement of purpose. There is also a folder with responses from a questionnaires completed by various health professional that visit the home. There is information on the notice board that a copy of the last CSCI inspection report is available in the information folder as well as a copy in resident rooms. Fees are set at £479.88 per week for all residents. There are additional charges for toiletries, hairdressing and newspapers. The homes email address is: swallowsrch@aol.com DS0000025645.V340887.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, and took place on a one-day site visit on the 11th July 2007, and ended on the 13th July 2007 after receipt of relevant information. The Registered provider and the registered manager facilitated the inspection. The inspection included a tour of the home and examination of records on care plans of five service users, building maintenance records and four staff training and recruitment records. Observations were made of staff working with residents in the living room/dining room area and while doing one to one activities. Three residents spoke with the inspector. Two staff contributed information, and there was a brief group discussion with a few residents present. Two visiting relatives also gave their views on how the home is run. The home had completed an Annual Quality Assurance Assessment, which was also used to provide information for the inspection. At the time of this inspection there was one resident vacancy. What the service does well: What has improved since the last inspection? DS0000025645.V340887.R02.S.doc Version 5.2 Page 6 There is now a strategy in place of the home to try to add an extra shower room in future. Although it is not possible to do this yet the management have said that they will try to get this done when there are less shared rooms in the home. Manager has now got the qualification NVQ level 4, which helps her to run the home better. There is now an assistant who helps her to manage the home, who is also studying for this qualification. Three staff said that they meet with the manager regularly, at least every eight weeks, for supervision, so that they will understand how to do their jobs better and to get the help they need. Residents plans are now being reviewed monthly, and the home has now reduced the number of shared places in bedrooms by one, and is hoping to reduce it by another one place in the future. 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. DS0000025645.V340887.R02.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 DS0000025645.V340887.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 and 6 Quality in this outcome area is good. This judgment is made using available evidence including a visit to the service. Residents have sufficient information to make an informed choice with regard to moving to the home, their needs are fully assessed and they have had a chance to view the home to be sure that it is suitable. EVIDENCE: There are clearly written Statement of Purpose and Service Users Guide, which give residents all is information they need to help them to decide whether to live at the home. These documents are made available to all residents during the resettlement process. One resident explained that the home’s owners had provided very good information to help her in her decision to move into the home. I examined five residents files and all of these had care assessments provided by social services, and the home had also done it’s own assessments for each one of these residents. The home has a policy of assessing all residents prior DS0000025645.V340887.R02.S.doc Version 5.2 Page 9 to admission, they receive a full assessment from the professional team involved with the prospective resident and the home will assess the person themselves. The manager has revised their own assessment tool to include further sections around behaviour and mental health issues, to ensure that all areas of need are fully explored prior to offering a place to the person. The home have a policy of inviting residents to visit the home prior to moving there, and residents spoken to confirmed that this was something that some of them had done. If they are not able to visit, which is an increasing issue for residents that are in hospital, then relatives will visit the home. All the residents files looked at had a contract of terms and conditions present on them. The registered manager is responsible for doing assessments, and routinely checks the accuracy of the assessments with the staff over the first week of admission, to ensure that information provided is correct. The home does not provide intermediate care. DS0000025645.V340887.R02.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 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from comprehensive and up to date care plans, their health needs are meet and they are treated with dignity and respect by the staff and management. EVIDENCE: Examination of five residents care plans showed that clear planning and recording is happening in resident’s individual files. There is a new Standex care planning system in place, which now includes sections for recording dates of care reviews and showing details of all the social and leisure interests, which enables residents to have a fuller and more personal service offered. As at the last inspection the manager felt that the new sections in the care plans detailed above have been helpful, and the home continues to develop life history records for residents so that staff will be able to know them better and have more meaningful conversations about past experiences. Five files showed that care plans were up to date and detailed resident’s needs, showing how DS0000025645.V340887.R02.S.doc Version 5.2 Page 11 these should be met. The care plans contain risk assessments, sections on weight, nutrition and skin care. Residents who need it have an individual plan for monitoring their weight, either monthly, 3 monthly or yearly as appropriate for their needs. Some residents receive a visit from the GP every two weeks, and the GP will on that visit see other residents if they need to see the doctor. However, the home manager said that they would usually make appointments for residents and take them to the GP in the normal way or arrange a home visit. The home liaises with other health professionals such as district nurse, opticians, dentist, chiropodist and the tissue viability nurse. The district nurse currently visits the home twice weekly. Previous comments from the GP and District nurse show the home provides them with good information and manages the health care needs of residents very well. The home is registered to support residents with dementia. Care plans have various sections to complete to ensure that mental health and behavioural issues are identified, and actions and objectives are monitored and recorded. There is a supportive routine within the home that whilst flexible, supports residents that have difficulties with memory and cognition. The keyworker now consistently reviews care plans monthly. As at the last inspection the manager has drawn up an information and guidance sheet for night staff around risk assessments, and the manager checks the risks identified and quickly acts to provide a safe service for the residents. The system for managing medication was examined and the storage and administration records were seen to be well managed. One resident who had managed her own medication no longer lives at the home and care plans showed that some residents have been asked whether they wish to manage their own medication. Currently none have taken up this opportunity. It is recommended that the home ensure that all residents are asked about their wishes and abilities to manage their own medication and that the findings are recorded on care plans and action is taken to help people to do this if they wish to. (Refer to Recommendations OP9) Observations of the interaction between residents and staff indicated that residents are treated with respect and their dignity upheld. The home discusses and records resident’s wishes and details with regard to their death and funeral arrangements on their care plan. Comments from residents included: “The home’s owners are very nice and are always available to speak with me. They are very competent and are quick to sort out any problems”. DS0000025645.V340887.R02.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): 12,13 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find their lifestyle experience in the home matches their expectation and preferences. They are able to maintain links with family and with the community. They benefit from being able to access a healthy and well balance diet. EVIDENCE: The home has a weekly programme of activities and all care plans looked at had an individual programme of weekly activities on them. These had been worked out between the resident and their keyworker. The keyworker enters the activities that resident take part in, in the home diary; the home finds this the most effective way of recording activities for individual residents. Residents are able to choose whether to spend time in their rooms or in communal areas and some residents choose to live fairly independent lives and not participate in communal activities other than on special occasions. As well as trips out to the local parks or further a field, which are discussed and agreed at residents meeting, the home will arrange fairly short local trips for residents e.g. short walks in the local area. The home have made links with the Pump House Museum and one of the staff have received training to do reminiscence work with residents. The home has purchased various photos and DS0000025645.V340887.R02.S.doc Version 5.2 Page 13 other equipment to support this work. The home has visiting entertainment on special occasions. They also have regular visits from representatives of different religions, which will depend on the individual needs of the residents; at present these are from the Church of England and the Roman Catholic Churches. In the past the home have had residents following other religions and have arranged visits where appropriate e.g. for the local mosque. Three residents commented that the home does provide daily activities in the home, which are enjoyable. The manager said that she would like to improve the level of organised outings for residents, which have dropped a bit, mainly due to not having been taken up by previous residents. It is recommended that the home survey resident’s opinions about their needs for these outings and to act accordingly in trying to meet people’s preferences. (Refer to Recommendations OP12) The home offers a healthy and balanced diet, with choices offered to residents. Meals are served in pleasant surroundings with attractively set tables. The atmosphere at lunchtime was observed to be pleasant with residents chatting and enjoying the social occasion. Three residents said that they are asked about the food they prefer to eat on a daily basis and that the food provided is very good. DS0000025645.V340887.R02.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the policies around safeguarding adults and there is an appropriate complaints procedure in place. EVIDENCE: The home have a complaints policy, a copy of which is make available to residents on admission and is also in a file of resident information in the conservatory. The home has investigated three complaints since the last inspection and these have been recorded in full detail at the home and investigated under the homes complaints policy. The first of these concerned a resident becoming upset during personal care, another was concerning a resident who had a bruise (both of which were investigated fully and found unsubstantiated) and the third was a complaint from a resident about the attitude of a staff member when supporting her but she later withdrew the complaint. Supporting residents with dementia is a prominent issue within the home. The manager agreed that there is a need to be clearer about issues that may need to be reported to the CSCI and to the Adult Protection Team, as some residents who have dementia support needs often complain, but then are not able to be clear about details such as what happened or the time of day or the people involved. It is recommended that the home identify residents for whom this applies to and contact the social worker involved to agree a strategy for recording and responding to these situations. DS0000025645.V340887.R02.S.doc Version 5.2 Page 15 (Refer to Recommendations OP16) The homes Adult protection policy was reviewed in June 2006. This policy meets the requirements of the local authority Adult Protection policy and procedures. All of the staff have had adult protection training as part of their induction. There have been no adult protection issues reported since last inspection. DS0000025645.V340887.R02.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): 19,22,23 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home offers a very pleasant and well-maintained environment, with a choice of communal and dining areas for residents. Resident’s rooms are well furnished and personalised. There is a well-maintained garden that is wheelchair accessible. The home is safe, comfortable, clean and hygienic. EVIDENCE: The home is situated in a residential street within walking distance of shops and public transport. The home has a large communal sitting room, a second small sitting room and a conservatory leading on to a pleasant and wellmaintained garden. There is ramp access and a paved area for wheelchairs and a grassed area. The home has two dining rooms and can provide a small dining area on the second smaller sitting room as well. Residents are able to smoke in the conservatory. The home is pleasantly decorated and well maintained throughout. There is lift access to the upper floors. DS0000025645.V340887.R02.S.doc Version 5.2 Page 17 There are 3-shared rooms at present. All had appropriate curtaining to ensure residents’ privacy. Residents’ rooms were pleasantly furnished and residents have brought personal belongings as well as items of furniture with them to the home. The home have a CCTV monitor, this is only used to monitor the exits for extra security. At the last inspection the home had an occupational therapist assessment report recommending that the home have additional shower room facilities, as there were no shower rooms at the home. There was a requirement made that the home ensures that a strategy is in place to action these recommendations. The owner now has a statement of intent to install a new shower room, which is linked to the reduction of shared rooms and to funding for placements. This requirement is now met and the home will do the work required when a vacancy arises. The home should ensure that this issue is clearly identified in the home’s development plan and reviewed when a vacancy arises. (Refer to Recommendations OP22) There is a target for the home to reach 80 single occupancy of bedrooms and a recommendation was made at the last inspection to consider how this could be achieved. The home’s stated intention is to achieve this when a vacancy arises which is suitable and agreeable to existing residents. Already one room which was being shared is now used as a single room and a further reduction of one bed space will achieve the 80 target for single occupancy. (Refer to Repeated Recommendation OP23) The home employs a cleaner from Monday to Friday. Three resident’s bedrooms were seen, in addition to the kitchen bathrooms, dining room, living room and all communal areas, and all of these were very clean, warm and well ventilated. Three residents said the home is always very clean and that their rooms are very comfortable. DS0000025645.V340887.R02.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): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is staffed by workers sufficiently experienced and trained to carry out their work and in sufficient number to need resident’s needs. The home has a recruitment policy that protects residents and staff are supported by ongoing training programme. EVIDENCE: The home has sufficient staff on duty to meet the needs of their residents. 16 care staff and the team manager provide the care and support residents. In addition to this there is a full-time cleaner, to cooks and the registered owner also tends the home on a daily basis providing maintenance support and sometimes helping the transport residents. Staff spoken to as well as resident said that they had time to spend with residents and support them with their care needs without feeling rushed or unable to give the residents the time they need. There are four staff on shift from 8 a.m. to 5 p.m., with the registered manager providing additional support during this time. Between 5 p.m. 8:30 p.m. there are three staff, and nighttime support is provided by two waking staff from 9 p.m. to 8 a.m. Normally the staff to residents ratio is one staff to five residents. DS0000025645.V340887.R02.S.doc Version 5.2 Page 19 Over 50 of the care staff have a level 2 NVQ in care and some staff are exploring to options with regard to future NVQ training. 11 of the current staff team of 16 staff have this qualification. Examination of five staff files showed evidence of an appropriate recruitment policy being put into practice. These files contained two references, evidence of interview, CRB check details, health check clearance, and all of these were in place before commencement of employment. All staff have contracts of employment. The home have an induction programme that is comprehensive, a new workbook has been introduced to support the induction programme. It is recommended that the home use an index for staff files, showing recruitment information, including dates when all information was received and the date of commencement employment. (Refer to Recommendation OP29) The home has a training programme in place and staff confirmed that they are able to access training. The home is registered with the Skills for Care organisation, and the manager has a training plan in place for all individual staff, especially focusing on medication, dementia, adult protection, moving and handling, and a range of other relevant areas. As there are some mental health issues associated with some residents who have dementia, it is recommended that the home consider including mental health training in its training programme. (Refer to Recommendation OP30) Staff were observed to be caring and supportive of residents. Residents and their family described staff that were “marvellous, couldn’t do enough, very patient and kind.” DS0000025645.V340887.R02.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. The home’s manager is fit to be in charge, is of good character and is able to fully discharge her responsibilities. The home is run in the best interests of residents, and their financial interests are safeguarded. The staff are regularly supervised, and health and safety is promoted. EVIDENCE: The registered manager is experienced and is qualified as Registered General Nurse. She has been managing the home since it opened in 1984 and is experienced in accessing the network of healthcare available in the area. She demonstrates an open and honest approach to managing the home, and is progressive in her attitude to managing the many challenges and changes within the home. DS0000025645.V340887.R02.S.doc Version 5.2 Page 21 There was a requirement made at the last inspection for the manager of the home to obtain an NVQ level 4 in management and care qualification. The Manager has now achieved the NVQ level 4 qualification, which helps her to run the home efficiently and effectively. There is now an assistant manager who helps her to manage the home, who is also studying for this qualification. The home completes a residents survey and has also undertaken a relatives and other visitor’s survey. The survey results are available to residents and visitors to look at. The home holds residents meeting every three months, and relatives are invited to these meetings as well. These are seen as a place to pass information to residents as well as hear from them and plan future events. These meetings are minuted. Residents and visitors to the home said that they are happy with the consultation by the owners about the care provided, saying that they are asked about care plan reviews when they happen. However, there is not a completely adequate Annual Quality Assurance System in place, neither is there a development planning system being used. The home must put these systems in place to ensure residents involvement in the development of the home. (Refer to Requirement OP33) All residents are responsible for their own finances, and three residents spoken to confirmed this. The home provides facilities for keeping small amounts of money for residents personal spending, for which good clear records and receipts are kept. There was a requirement made at the last inspection for the home to ensure that staff have supervision with their manager at least every two months. This requirement has now been met. Three staff said that they meet with the manager regularly, at least every eight weeks, for supervision, so that they will understand how to do their jobs better and to get the help they need. Examination of five staff files showed that good discussion is happening between the manager and staff about their job and their development within their work. The home has an up-to-date health and safety policy, which was last reviewed in June 2006. The health and safety responsibilities are shared between the registered manager and the registered owner/provider. The portable appliance tests have been done and certified, and electrical and gas certificates and are still up-to-date. Fire tests are done weekly with drills taking place every few months. This includes an evacuation drill and a contingency plan in for relocating residents in the event of damage to the home. Hoists and lifts are under maintenance contract, and all were done in November 2006. An annual maintenance of wheelchairs is also carried out. Health and safety issues are taken seriously by the home and excellent records are kept. DS0000025645.V340887.R02.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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 X X 3 3 X X 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 X 2 X 3 3 X 3 DS0000025645.V340887.R02.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 OP33 Regulation 24 Requirement The Registered Provider and manager must put in place an effective Annual Audit system and an Annual Development Plan to ensure that residents views are included in the homes development Timescale for action 30/11/07 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 OP9 Good Practice Recommendations The registered manager should ensure that all residents are asked about their wishes and abilities to manage their own medication and that the findings are recorded on care plans and action is taken to help people to do this if they wish to. The registered manager should survey resident’s opinions about their needs for organised outings and act accordingly in trying to meet people’s preferences as discussed in this report Standard 12. The registered manager should identify residents who are given raising very regular concerns and then not being DS0000025645.V340887.R02.S.doc Version 5.2 Page 24 2. OP12 3. OP16 4. OP22 5. OP23 6. OP29 7. OP30 able to provide information and contact the relevant social worker involved to agree a strategy for recording and responding to these situations. This is to better protect residents who are vulnerable. (Refer to this report St16 page 16) The registered manager should ensure that all residents are asked about their wishes and abilities to manage their own medication and that the findings are recorded on care plans and action is taken to help people to do this if they wish to. The registered provider should continue to work towards a final decision about how the home could offer at least 80 of its places in single rooms. Details of this financial planning should be included in the business plan for the home. The registered provider should consider using an index for staff files, showing recruitment information, including dates when all information was received and the date of commencement employment. The registered manager should consider inclusion of mental health training for staff in relation to also supporting people with dementia as discussed in this report. DS0000025645.V340887.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 DS0000025645.V340887.R02.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. 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