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Inspection on 21/09/05 for The Arches Residential Care Home

Also see our care home review for The Arches Residential Care Home for more information

This inspection was carried out on 21st September 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home encourages all staff to attain an NVQ award.

What has improved since the last inspection?

The service users at the home now have the choice of two lounges and fewer service users are sharing a bedroom. The home has applied for and gained a change to the registration category of service users living at the home. All the service users living in the home should now have a diagnosis of dementia. Although there are still some concerns around medication, the trolley is now secured to a wall when not in use and printed Medication Record Sheets are used.

What the care home could do better:

The policies and procedures and other related documents used in the home need to be reviewed at least annually and reflect changes in legislation etc. The staff at the home would benefit from regular supervision. The home has been asked to review the current staffing levels to ensure staff are able to meet the care needs of the service users. The home would benefit from a copy of The Royal Pharmaceutical Society Medication guide lines for care homes, asshortfalls were identified during this inspection. A risk assessment of the building is required with time scales for action. Staff morale is low and the reasons for this need to be identified and actions taken to improve matters.

CARE HOMES FOR OLDER PEOPLE The Arches Residential Home Mounts Road Greenhithe Kent DA9 9ND Lead Inspector Sally Hall Unannounced Inspection 21st September 2005 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 The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 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. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Arches Residential Home Address Mounts Road Greenhithe Kent DA9 9ND 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) 01322 370163 01322 381642 Arches Care Home Limited Mrs Joy Chapman Care Home 21 Category(ies) of Dementia - over 65 years of age (21) registration, with number of places The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only 18 beds can be used as Dementia Care beds until new extension is built and then the number can increase to 21. 26th April 2005 Date of last inspection Brief Description of the Service: The Arches is registered to accommodate 21 older persons, who have a diagnosis of dementia. However, only 17 beds are in use until the planned extension has been completed. The home’s accommodation is on 3 floors; a 5person lift serves all floors. There is a large lounge/dining room on the first floor and a smaller lounge/diner on the lower ground floor, the home also benefits from a large conservatory with extensive views over the valley. There is a small garden to the rear which is accessible to service users. The home is situated in a quiet residential area of Greenhithe with local shops and a post office close by. Bluewater shopping complex is approximately 1 mile away. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection at The Arches took place on 21st September at 10.15am and continued on the 22nd September 2005. The Inspector agreed and explained the inspection process with the Registered Manager. Documentation and records were read, including care plans. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. A tour of premises was also undertaken. The focus of the inspection was to assess The Arches in accordance with the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. What the service does well: What has improved since the last inspection? What they could do better: The policies and procedures and other related documents used in the home need to be reviewed at least annually and reflect changes in legislation etc. The staff at the home would benefit from regular supervision. The home has been asked to review the current staffing levels to ensure staff are able to meet the care needs of the service users. The home would benefit from a copy of The Royal Pharmaceutical Society Medication guide lines for care homes, as The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 6 shortfalls were identified during this inspection. A risk assessment of the building is required with time scales for action. Staff morale is low and the reasons for this need to be identified and actions taken to improve matters. 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 Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 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 The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-4 The Statement of Purpose and Service Users Guide do not give sufficient accurate information for prospective service users and their families to make an informed choice. Service users are issued with terms and conditions of their stay, however they do not contain all the required information. The pre-admission assessment, care planning system and staff training provided in the home ensures that the service users needs can be met. EVIDENCE: The Statement of Purpose and Service Users Guide has not been reviewed annually. Therefore it does not reflect the changes to the homes registration, which occurred earlier this year. The home is registered for people with dementia, not EMI (elderly mentally infirm). Other documents contained in these were also found to be out of date or in some cases did not contain the full information i.e. the complaint procedure did not show the time scales for action. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 9 The home does provide terms and conditions for the service users living in the home. The documents need to be reviewed to include the number of the room they will occupy and who is responsible for paying the fee and what that fee is. The manager has a pre assessment form that she completes when visiting prospective service users in their own home or hospital. A sample of these were seen and the manager had made detailed notes. The Manager explained that this information was then used to determine if the home could meet the service user’s needs. The home now only admits service users who suffer from dementia and therefore it is paramount that staff are all trained in the care of people with dementia. They would also benefit from accessing some training in the management and handling of challenging behaviour. The manager explained that all staff have undertaken a dementia course and gradually staff are being put forward for other associated courses. The plans of care seen described the care needed by individual service users. These plans accompany a full assessment that is recorded after the service user’s admission. These assessments and plans cover the physical and psychological needs of the service users. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, Service users can feel confident that their health, personal and social care needs are identified and this information forms part of their care plan The service users are not totally protected by a robust medication policy and procedure within the home. EVIDENCE: The manager explained that the plans of care have recently changed in format. Those sampled showed the assessment of the service user with the direction for staff to meet that assessed need. A place is provided on this care plan for staff to date and sign to indicate when reviews have taken place however, it did not allow space for the outcome of the review to be recorded. This was discussed with the manager, it was also noted that the plans were not being reviewed monthly. The manager was also reminded that a re-assessment of needs and a full care plan review for each service user was due every 6 months and that these should involve the family and care manager if possible. As the service users have dementia this does make it difficult for them to be The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 11 part of the care plan process, but their key workers should be able to make a valuable contribution on their behalf. The daily notes seen varied in detail, with some staff having a better understanding of what needs to be recorded. The staff need to ensure that their records cross reference with the plans of care, so that there is evidence that the identified needs are being met. The entries were dated but they did not record the timing of events or the care interventions; this was discussed with the manager. The service users all have the same GP, Dr Desai who is the owner of the home. A recently admitted service user was with another local doctor who suggested that they be moved onto the list of the owner. The manager explained that although they ring for the duty doctor from the surgery to visit it is always the owner who undertakes the call. This current practice is in need of an urgent review. Due to the owner carrying out a duel role as the service users’ Doctor and owner of the home this could lead to a possible conflict of interest. To show openness and transparency the home must show that any medical advice or treatment received by service users is wholly independent of it and its owner. Plus service users should be given the choice of retaining their existing G.P. when moving into the home and not persuaded to change practices. In the files sampled there was examples seen of health care needs being identified and followed up by staff. Staff spoken with understood the need for pressure area prevention and knew the signs that could indicate pressure and a breakdown in skin integrity. The plans of care also included details of the dietary needs of the service users. Staff also record the amount of food being eaten at each meal by some service users. Staff endeavour to weigh all service users monthly. Evidence was seen that the home arranges for visits from a chiropodist, dentist and optician when required. The home encourages the family to go to hospital appointments with their relative. An escort from the home can be arranged for a fee. The manager explained that they do try to offer a home for life but they are not a nursing home so if the service users develops an ongoing nursing need then an alternative home would have to be found. The home stores much of it’s medication in the trolley supplied to house the MDS system. This was seen secured to a wall while not in use. The Medication Record Sheets seen indicated the service users’ information and the medication they required. The sheets however, had not been completed to show what medication had been received into the home. Also medication from the previous month that was carried forward was also not recorded on the Medication Record Sheet. This meant that it was not possible to carry out an audit of the medication. The second point of storage was in the main office, the home does not have suitable storage for controlled medication. This and the correct recording of controlled medication was discussed with the manager The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 12 who is to purchase the correct ledger. Staff were observed giving out medication, this was seen to be done in a safe manner. The files showed that most service users identification photographs were with the Medication Record Sheets. Staff who can give out medication were listed with their signatures, the manager confirmed that these staff had received a certificated medication course at their local college. The manager was advised to get a copy of The Royal Pharmaceutical Society Medication guidelines for care homes. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Service users are given the opportunity to take part in activities suitable to their needs and follow their religious preferences within the home. Service users receive a wholesome, appealing and balanced diet in pleasant surroundings. EVIDENCE: The deputy manager has chosen to do a unit of her NVQ about activities. She has been looking into the types of activities that are suitable for service users with dementia. The home does not have an activities co-ordinator, all staff currently have an input in the devising and provision of activities. Staff spoken with said that they do their best to provide all service users with some sort of stimulation through the week but that activities have to be fitted in with the other tasks, i.e. laundry. Staff explained that they tried and do some activity morning and afternoon, whether on a one to one basis or in a small group. There were examples of activities carried out recorded in the daily records. The service users at the home do not have the opportunity for trips out into the community, the manager explained that staffing would be difficult and that the home did not have any transport. The manager also stated that when asked service users had refused to go out. The manager has been asked to The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 14 record this in future. The home does have church services that are held monthly. The staff said that visitors are made to feel welcome and can visit at anytime. The cook said that if the visitors arrived at lunch time then they were offered a meal. The cook explained that she has now gained her NVQ level 2, she stated that she had enjoyed undertaking the training course and felt she had learnt from it. The meal sampled on the day of inspection was tasty and well presented. The cook said that fresh produce was used as much as possible. The home offers a cooked breakfast every day as well as cereals etc, a cooked midday meal and a hot or cold choice at tea time. The service users partaking of the midday meal said “it was very nice”, they also had plenty of choice. The menu showed a varied and nutritious diet, the cook also caters for special diets. The home keeps a record of what meals are eaten by individual service users, the amounts they have eaten is recorded in the daily record. The menu was seen displayed in the dining areas. The dining rooms are pleasant and have been made to look homely. The meal times are unhurried and food is always available between meals if a service users requests something. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 15 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): 16-18 Service users and their relatives and friends can be sure their complaint will be listened too and acted upon, however there needs to be time scales to ensure their response is available within a reasonable time span. Service users’ legal rights are protected. Service users are not protected by the home’s policy or trained staff in relation to adult protection. EVIDENCE: The complaints procedure seen did not contain the time scales for action. This was discussed with the manager. No complaints had been recorded since the last inspection. The Statement of Purpose stated that service users would be taken to the polling station should they wish to vote. This has become more difficult as all the service users at the home now have dementia. Therefore, the manager said that postal votes would be sent for and the families would be asked to help their relative fill out the form if appropriate. The adult protection policy and procedure seen was out of date and did not reflect the changes in legislation. The home did have the new adult protection protocols received from the local authority. The manager said she would use these to adapt the home’s policy and procedure. The home has only three care staff who have undertaken the adult protection training. All staff must attend The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 16 this training and the manager has been asked to ensure that this training is facilitated. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 17 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): These standards have not been inspected during this inspection. EVIDENCE: The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 The numbers of staff currently on the rota are not enough to ensure the service users’ needs are fully met as they are also expected to carry out other duties. The home has shown a commitment to encouraging staff to do NVQ’s. The home has a robust recruitment procedure in place, however, it does need to ensure that all the require ID is on file. Staff would be more competent if they had completed all the required training EVIDENCE: The home’s accommodation is located over three floors with most service users being on two floors during the daytime hours. The home employs 3 care staff on the morning and afternoon shifts. The home has only one cleaner working six days a week. This means that the care staff are also responsible for bed making, laundry, activities etc. The staff forum for staffing hours indicates that the number of hours being employed is about right for the size of home. However, these are caring hours, they also do not take into account that the home is split on two levels during the day, that staff are helping with other duties such as cleaning and cooking during the evening. It is recommended that the staffing levels be reviewed. With consideration being given to the employment of a second cleaner and laundry personnel for example, particularly now many of the service users are incontinent. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 19 There are 18 care staff employed at the home, of these the manager confirmed that 10 have an NVQ level 2 or above. This is over the required 50 , to ensure this remains at a high level other staff are due to start the course soon. The manager confirmed that there were no new staff that would be eligible to go on the TOPPS induction and foundation course. Four staff files were sampled and found to contain the required application form, interview notes, proof of a satisfactory CRB, references and employment contract. It was apparent however, that only one person carries out the interviews and good practice suggests two people, both completing interview notes and recording why they did or did not employ the applicant. The files did not contain all of the required ID or photos and the manager was shown where to find the list of what is required. The manager said that the home does not have a copy of the GSCC code of conduct, they have also not been given out to staff. The staff training records show that many staff have been included on some of the required courses, but that refresher courses i.e. in moving and handling is still needed by some staff, as many are out of date. The course needs to be repeated yearly. A large number staff have not yet undertaken training in basic food hygiene, adult protection or infection control. All staff have undertaken fire training and courses are held six monthly. The staff are not being paid a minimum of three training days per year, as all staff are expected to do all training in their own time. The manager is to discuss this with the owner. Staff spoken with on the day commented on the training they have done and said they felt it was beneficial. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,38 Service users benefit from the home having a manager with a wealth of experience in elderly care. Service users’ care needs could be compromised by the low morale of the staff team. Service users could benefit from a good system of quality assurance. Staff would benefit from regular formal supervision. The health, safety and welfare of the service users would be promoted and protected if all staff received the required training and the necessary checks and risk assessments were completed. EVIDENCE: The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 21 The registered manager at the home has many years working in the caring industry, starting off in nursing and then becoming a social worker, having gained a SESW. The manager also has completed a diploma in management. As the manager is nearing retirement she has now chosen not to undertake the required Registered Manager’s Award. Having spoken with a number of staff over the two days of the inspection it was evident that staff morale is low generally in the home. Most said that they were well supported by the manager and her deputy, but did not feel the same way about the home’s owner. The staff felt that the other jobs they have to do such as all the laundry, elements of cleaning and cooking, take them away from the care of the service users. The manager said that the home has staff meetings about once every three months. The record of these was not seen on this occasion. While it is recognised that having residents meetings with service users who suffer from dementia is difficult, it is possible to canvas individuals. The manager confirmed that she had not sent out a questionnaire to seek the opinion of interested parties as to the quality of care provided. It was found that all policies and procedures seen during the inspection process were in need of reviewing as all had not been reviewed annually. The manager confirmed that all the required insurance policies are in place, the public liability certificate was seen displayed and was in date. The manager of the home is responsible for all the invoicing and also ensures that fees are banked on a regular basis. The manager confirmed that all transactions are recorded and audited. The manager had not got a copy of the financial or business plan at the home. None of the current service users are able to manage their own finances. All service users either have relatives or the local authority who are empowered to oversee their financial affairs. The manager explained how a small amount of personal money is left at the home for each service user; this money is used to pay for daily expenses i.e. hairdressing. The accounts were seen and checked against the cash kept in the home. The accounts reconciled and receipts for all the transactions are also kept. All the service users’ money and valuable items are kept individually in the safe. The manager confirmed that the safe and contents was insured. The staff at the home are not receiving the required formal supervision six times a year. There was evidence on the file that staff have had an annual appraisal. The practice of formal supervision although started, has not been completed for each member of staff. As detailed in earlier standards, training requirements need to be brought up to date. The home needs to ensure that staff have the required knowledge and The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 22 skills to meet the service users’ needs and comply with health and safety regulations. The manager still needs to complete a building risk assessment with the owner, prioritising any identified risks and giving time scales for action. The accident book is the old type and the manager was informed about the new format, which ensures the records comply with the data protection act. The maintenance certificates were seen for the hoists and lifts as required. Other certificates were seen and included the gas and electrical appliance testing. The manager however, was not able to find the home’s periodic electrical testing certificate. The manager is to send a copy to the Commission. The COSHH file was seen and the manager confirmed that it contained a sheet for every chemical used in the home. The fire log seen showed that the alarms are tested regularly on a weekly basis in the home and that staff had regular drills and training. The log however, did not record the required emergency lighting monthly testing or the monthly visual checks of extinguishers. Evidence was however, seen that the extinguishers are checked for pressure etc. on a yearly basis by an outside contractor. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 X X X X X X X X STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 2 3 1 X 2 The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,5, schedule 1 Requirement Timescale for action 30/11/05 2 OP7 15,13 The registered person produces and makes available to service users, an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the home’s service user’s guide A service user plan of care 30/10/05 generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. It is reviewed monthly by staff, with out comes recorded and a new assessment and review is held with family/care manager six monthly. All entries in the daily log have the time recorded of DS0000024030.V251804.R01.S.doc Version 5.0 The Arches Residential Home Page 25 3 OP8 12,13 4 OP9 13(2) 5 OP12 16.2 (m)(n 6 OP13 12(4)(a) 16.2 7 OP27 18 8 OP32 10,12 9 OP33 24 the care provision or event. The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs which are open and transparent. The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, following The Royal Pharmaceutical Society Medication guide lines for care homes The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. With activities and service users stimulation being facilitated as programmed The home needs to ensure Service users are able to develop and maintain links with the local community in accordance with service users’ preferences. Enabling service users to access safely the community with regular outings Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. The registered manager/owner ensures that the management approach of the home creates an open, positive and inclusive atmosphere. Effective quality assurance and quality monitoring systems, DS0000024030.V251804.R01.S.doc 30/11/05 30/10/05 30/11/05 31/01/06 30/10/05 30/10/05 30/11/05 Page 26 The Arches Residential Home Version 5.0 10 OP36 12,13,17, 23,25 11 OP38 25,41,sch edule 4.3 based on seeking the views of service users, family and health professionals are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. The registered person ensures 30/10/05 that the supervision arrangements are put into practice, and formal supervision takes place at a minimum of six times a year. The registered manager ensures 28/02/06 so far as is reasonably practicable the health, safety and welfare of service users and staff. Required training to be facilitated by the registered person. 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 OP2 Good Practice Recommendations Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately), which contains all the required information as per the standard. The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively and that is reviewed yearly The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies which are reviewed yearly and reflect changes in the regulations that under pin the DS0000024030.V251804.R01.S.doc Version 5.0 Page 27 2 OP16 3 OP18 The Arches Residential Home 4 OP31 standard. That any new manager employed when the current manager retires has the required qualifications including the RMA and a qualification in dementia care. The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 The Arches Residential Home DS0000024030.V251804.R01.S.doc Version 5.0 Page 29 - 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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