Inspection on 24/07/07 for The Close

This inspection was carried out on 24th July 2007.

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

The Close 19/06/09

The Close 23/07/08

The Close 25/07/06

The Close 29/09/05

The Close 26/04/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Close 53 Lynn Road Snettisham Kings Lynn Norfolk PE31 7PT Lead Inspector Mrs Geraldine Allen Unannounced Inspection 24th July 2007 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 Close DS0000064311.V347129.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. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Close Address 53 Lynn Road Snettisham Kings Lynn Norfolk PE31 7PT 01485 540041 01485 540041 rsiva91@hotmail.com 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) Norfolk Care Ltd Position Vacant Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 Brief Description of the Service: The Close is a care home providing personal care and accommodation for twenty-three older people. The home is privately owned by Norfolk Care Ltd. The home is located in the village of Snettisham. The coastal town of Hunstanton is approximately five miles away and King’s Lynn approximately ten miles. The Close is a large detached property and provides accommodation on the ground and first floors for up to twenty-three elderly people. Seventeen of the bedrooms are single and two are double. Nine of the bedrooms have en-suite facilities. Access to the first floor is gained by one of two staircases, one with a stair lift, or a passenger lift. There is a pleasant, well-maintained garden with lawns, trees and shrubs, which has a path all around the home, enabling residents to walk safely outside. The current fee range is £347.00 - £410.00. There are additional charges payable for hairdressing, private chiropody, newspapers and personal toiletries. People are advised verbally about the charge payable at the time of the initial enquiry. People only receive written confirmation of the amount payable when they receive their terms of residence contract. The Close DS0000064311.V347129.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 took place during the day of 24th July 2007. Information was obtained from various sources, including looking at records, speaking with residents, visitors to the home and staff and touring the premises. Time was also spent observing practice. All services are required to complete a document named the Annual Quality Assurance Assessment (AQAA) each year when requested by the Commission. Despite reminders, this had not been received by the time this inspection was carried out. Despite assurances from Mrs Siva that the AQAA would be forwarded, this document remains outstanding at the time of this report. Because the AQAA was not returned as required, it was not possible to write to residents, next of kin or health and social care professionals to find out their views of the service. Such views could only be obtained by speaking with people during this inspection and therefore opportunities were limited. Since the last full inspection was conducted on 25th July 2006, a further unannounced inspection was carried out on 13th February 2007 to assess compliance with the requirements made. In addition, a meeting was held with Mrs Siva on 2nd November 2006 to discuss the concerns held by the Commission about the lack of progress towards meeting requirements. It is disappointing to note that there remain areas where progress is still not good enough. On the day of the inspection visit, both Mrs Siva (representing the company which owns the Home) and Mrs Linnett (the Manager) were present. Overall, residents said that their experiences of living at this home are good. However, much of what they say cannot be supported, as record keeping needs to improve and monitoring by Mrs Siva is not good enough. As a result of this inspection, 10 requirements and 8 recommendations have been made. Four of the requirements are repeated from previous inspections. What the service does well: People who use the service speak about very positive experiences. One person said the service “could not be faulted”. Another referred to the food, describing their main meal as “a cracking good lunch”. People said they could The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 6 make choices about their daily living and were sure staff would respect their choices. People spoke warmly about the staff at the home, describing them as “kind, caring and thoughtful”. The interaction between residents and staff was observed throughout the day and was appropriate, warm and respectful. People at the home have access to all healthcare support when they need it. Visiting health professionals spoke about the competence of the manager and staff to provide good care and support to people living at the home. What has improved since the last inspection? What they could do better: It is a legal requirement that the home’s registration certificate is displayed prominently. When asked for its location, neither Mrs Siva nor Mrs Linnett knew. This must be found and displayed without delay. The information contained within the Statement of Purpose and Service User Guide remains inaccurate in some aspects. This needs to be improved so that people have full and up to date information to help they make an informed choice to live at the home. Care plans do not give staff sufficient information to ensure they provide the care and support needed for all people using the service. Some information kept about people is not maintained well enough and as a result privacy and confidentiality is compromised. The complaints procedure needs to be corrected so that the information is relevant and up to date and must be displayed prominently in the home. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 7 The guidance ns place for staff regarding safeguarding adults does not comply with the protocol agreed in Norfolk. This must be amended. The lighting in the dining room is very poor and needs to be increased so that people can use this area more and can move about in safety. Kitchen staff need to be employed over teatime, 7 days per week. At the moment, there are 2 days when care staff have to deal with the serving of food and the cleaning up after tea. This impinges on their ability to provide timely care and also has health and hygiene implications. The AQAA is a legally required document that must been provided when requested by the Commission. Despite reminders, this document has not been provided. As a result, the Commission cannot make informed judgements about the quality of this service or the appropriateness of any improvement plan set by the service provider. Monthly service provider visit reports are required to be made and sent to the Commission. This is not currently taking place. 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. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 8 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 Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 9 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 & 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are given a copy of the service’s Statement of Purpose and Service User Guide, however the information within these documents is not necessarily accurate. People have an assessment of their needs completed before they move into the home. The home does not provide intermediate care. EVIDENCE: A copy of the Service User Guide, Statement of Purpose and Resident Handbook were obtained. Mrs Siva stated these had been reviewed and updated so that they refer only to The Close. The Statement of Purpose and Service User Guide would benefit from the inclusion of sample menus and a blank copy of the terms of residence. Overall there is clear information about what services the home offers and what additional charges are made and how they are invoiced. Mrs Siva said the The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 10 home has a brochure but there were no copies available at the time of inspection. The Resident’s Handbook was last updated in September 2006. Unfortunately residents are asked to return this booklet to the office, although it would be beneficial for people to keep a copy of their own. The Service User Guide refers to a pre-admission assessment of needs taking place. This attached document feels incomplete. For example, section 10 is meant to contain comments made by existing or previous service users, but the page is blank. Section 7 states that there are useful addresses and telephone numbers at the end of the booklet but these were not in the copy provided. The Statement of Purpose contains the most information but this is a lengthy document of 27 pages long. There are some inaccuracies, for example the complaints procedure suggests people should only approach the Commission if they are dissatisfied with the way the home has dealt with a complaint. The document states also there is administrative support available however Mrs Linnett stated that administrative support is no longer employed at the home. In addition, amendments to the Care Homes Regulations 2001 in September 2006, mean that essential information regarding fees have not been complied with. Mrs Siva & Mrs Linnett were referred to these changes. A requirement regarding the Statement of Purpose and Service User Guide has been made in the past but was not repeated at the last inspection because some amendments had been acheived. These are not sufficient to ensure that prospective residents and their representatives can have complete confidence in the information provided. A further requirement has been made. Care plans showed that all prospective residents have an assessment of their needs before they move into the home. More detail is needed in the preadmission assessment so that this document can inform more detailed care plans at an early stage. Mrs Linnett also said people are admitted to the home on a trial basis. The home does not provide intermediate care. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have access to health care services both within the home and in the local community. Care plans did not provide sufficient information about the needs of people and how the care should be delivered. The care plans did not contain all the elements required. The service has a medication policy that is understood and implemented by staff. Staff were aware of the need to treat individuals with respect and to consider their dignity when providing personal care. EVIDENCE: Three care plans were looked at in detail. Each care plan followed a different format, although there were some areas that were consistent. Overall, the care plans provided insufficient information about the needs of people and how their care should be delivered. The care plans did not contain all the elements required. For example, there were no photographs of the The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 12 residents on file and religious/spiritual needs elements were not completed. The admission form needs to be completed in full to ensure all services are provided as required. The personal history for each resident should be completed as far as possible. All care plans need to be reviewed at least monthly with evidence of the involvement of the resident and/or their next of kin. The daily records need more information about the social and emotional elements of the person’s daily life. The care plans need to give clear and explicit information that describes the care needed and how it is to be delivered. Mrs Linnett said she is not satisfied with the care plans in use at the home and intends to review and redevelop them along better practice. She intends to introduce a new format that will be kept more accessible to staff in a locked cupboard on the ground floor. The daily records will also be kept in the care plan. The daily records were looked at and need more information about how the person spent their day and with whom. There was also a document called the shift handover summary. This document contained confidential information about people, their needs and care. Each page contained a list of residents’ names and was therefore not protecting their confidentiality. Further, the shift handover summary was left on a dining table in the dining room. A requirement regarding care plans has been outstanding since 31 October 2006 and is repeated. This matter now requires urgent action. A further requirement has been made regarding confidentiality. Other requirements made at the last inspection have been met or met in part. The dispensing of lunchtime medicines was observed. Good practice was seen. The carer checked the medicine administration record throughout and only signed once she had witnessed ingestion. She said she has attended medication training at King’s Lynn College and confirmed she had her competence checked by the manager. Mrs Linnett later confirmed that, although she is monitoring competence and also doing a fortnightly audit of medicines, these are not fully recorded. A recommendation has been made. No controlled medicines were in use at the time of inspection. No residents were self-medicating at the time of this inspection. During the course of this inspection, a resident had a fall in the dining room. Staff were seen immediately responding appropriately. The person was made comfortable and medical assistance was immediately requested. Paramedics responded to the call and made sure the person had no injuries. Staff reacted appropriately and quickly to the accident. A visiting district nurse was seen and spoken with in private. She said the care at the home had “really improved” since Mrs Linnett had been appointed. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 13 The nurse said that staff refer appropriately and follow advice and guidance given by the nursing team. She said she has done some training with staff that has been very well attended. During the course of this inspection, a visiting dentist attended and was seen visiting several people in private. The interaction between staff and residents was observed throughout the day. At all times, staff were heard speaking to people respectfully, and it was clear there was a warmth and friendliness between residents and staff. All personal care was given behind closed doors and staff made sure people’s dignity was protected. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to maintain important personal and family relationships. People have access to meaningful daytime activity of their own choice. Meals are balanced and nutritious. Staff are sensitive to the needs of people who find it difficult to eat. EVIDENCE: Two residents were spoken to together in the conservatory. Neither resident had lived at the home for very long but they felt they had settled very well. They said the food was “lovely” and there was plenty of it. They said the staff were “kind, caring and thoughtful”. One resident said the home “could not be faulted”. The residents then spoke about their rooms and described them as lovely. One resident said he enjoyed spending his time sitting with his newspaper and was not interested in joining in activities taking place in the home. Both residents said their visitors were always made to feel welcome and were offered refreshments by staff when they arrived. Both said they were “very happy” and had “absolutely no complaints”. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 15 Another resident was spoken to briefly in the corridor after lunch. He said he had enjoyed “a cracking good lunch” and was going back to his room to rest. During the afternoon, the activity organiser arranged table games in the dining room and several people attended. One resident was seen being brought into the dining room at 10:30 and given her breakfast. At this time, the resident was offered a choice for lunch and this was recorded by the member of staff. Lunchtime was observed discreetly. Each meal was plated up and immediately served by kitchen staff. The meal looked appetising and well presented. One resident was seen being assisted discreetly by staff, who sat beside the resident. This resident’s meal had however been dished up and left in front of the resident for some time before the member of staff was available to assist them to eat. Staff need to ensure that meals are only served when the person is ready to eat to prevent the meal going cold. No special or softened diets were seen. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that is not in line with best practice. The complaints procedure is not displayed in the home. The home has a policy about safeguarding adults but this does not accurately reflect the existing adult protection protocol. EVIDENCE: The complaints folder was looked at. The folder contained the complaints procedure but this was not in line with best practice. Mrs Linnett was referred to the relevant Regulation and the Commission website for guidance. The complaints procedure was not displayed in the home. People said they would speak with Mrs Linnett or a member of staff if they had any concerns. A Requirement has been made. There was a need to update the abuse awareness policy document. The policy refers to another home and does not provide explicit guidance to staff. The guidance that is provided is not in accordance with the existing protection of vulnerable adults protocol. A Requirement has been outstanding since 31 October 2006 and is repeated. Staff described training they had received that referred to safeguarding adults. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 17 The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides an environment that meets the needs of the people who live there. People said they can personalise their rooms. Some communal areas of the home were not well lit. There is a programme to improve the décor and fixtures. Generally, the home was clean and tidy. EVIDENCE: A tour of the premises was conducted with Mrs Linnett. All areas of the home were clean and there were no unpleasant odours detected. Most carpets were in a reasonable condition although there was sun fade of some bedroom carpets. Bedrooms were seen and contained varying degrees of personalisation depending on the choices of the resident. There was a damp problem in the corner of one bedroom. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 19 The bathrooms looked tired and dated. The floor tiles in the ground floor bathroom need to be replaced as some are broken and will make it difficult to keep the bathroom clean. Mrs Linnett said the floor will be replaced as part of the refurbishment planned to be completed by the end of the year. Curtains or blinds need to be placed at the bathroom windows to make them feel more homely. The lock to one communal toilet was very high up and would be out of reach for most people. Mrs Linnett said only one resident, who did not like to lock the door, used this toilet. It was therefore suggested that an “engaged” sign is placed on the door to help preserve dignity and privacy. Recommendations have been made. The lights in the dining room were very low, making the room gloomy and there is an urgent need to increase the wattage of bulbs in this area. A requirement has been made. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have confidence in the staff who care for them. There are enough qualified, competent and experienced staff to meet the needs of people using the service. The manager is aware there are some gaps in the timeliness of statutory training provision and she is dealing with this. EVIDENCE: The staff rota for the week of inspection was provided. This showed that sufficient staff are employed to meet the needs of people in a timely way. The staff rota shows that there is no teatime kitchen cover on Sunday and Mrs Linnett covers the kitchen on Monday teatime. This means that care staff are required to serve tea and clear up after, taking them away from their primary task of providing personal care. There are also health and hygiene implications for this practice. A requirement about this has been outstanding since 30/9/06 and is repeated. Urgent action is required. For the day of inspection, a second carer was scheduled to be on duty between 17:00 and 21:00 but was on leave. There was no record on the rota that this shift had been covered. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 21 Three staff files were looked at in detail. These showed that robust employment procedures are followed. There was also evidence that Criminal Records Bureau disclosures are obtained for all staff. All catering staff had completed food hygiene training. Mrs Linnett described some of the other training planned. These included moving & handling, food hygiene, emergency aid, fire safety, health & safety, falls and infection control. Mrs Linnett stated she has the documentation for the skills for care induction and one person is currently working through this. Mrs Linnett said that the home does not have any trained trainers for some statutory training and accepted that some statutory training is not necessarily available in a timely way. A recommendation has been made. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has the necessary experience to run the home. The service provider did not provide the Annual Quality Assurance Assessment (AQAA) as required by the Commission. The service has a quality assurance process but this does not give people sufficient opportunity to fully express their views. The service provider is not conducting monthly visit reports and sending a copy to the Commission as required. Staff are supported by a regular supervision process. The service has health and safety arrangements that generally meet requirements although some areas for improvement have been highlighted. EVIDENCE: The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 23 Mrs Linnett has completed NVQ4 but has not yet commenced the Registered Managers Award. The AQAA had not been received prior to this inspection despite 1 written reminder and 2 telephone reminders. Mrs Siva stated that this had been returned via email the week prior to inspection, however confirmation was obtained that the document had still not been received. Mrs Siva later provided a partly completed AQAA but what had been completed was of a poor standard. A requirement has been made. Monthly visit report are still not being completed and returned to the Commission as required. A requirement about this has been outstanding since 31/8/06 and is repeated. Urgent action is required to comply with this requirement. Regular assessments are done as part of the home’s Quality Assurance process. A copy of the homes quality assurance procedure was provided and this refers to the various activities undertaken to assess the quality outcome for people. These include annual questionnaires for residents and relatives. The questionnaires need to be developed to include all stakeholders. Questions need to be more open to ensure the home receives comments rather than just “yes/no” answers. A recommendation has been made Mrs Siva confirmed that no money is held on behalf of people living at the home as explained in the Statement of Purpose. She said that residents or their relatives are invoiced quarterly for any additional costs incurred such as for hairdressing, newspapers etc. Signed receipts support all transactions and these are attached to the invoice. Mrs Linnett was conducting staff supervision during the day of inspection. She confirmed that all formal supervision had been scheduled for the rest of the year. Some of the supervision will be conducted as group supervision. She said that records are now being kept. Various health & safety records were looked at during this inspection. A fire inspection had taken place on 19/4/07 and had resulted in an Enforcement Notice being issued by the Fire Service. The Notice was in respect of risk assessment, principles of prevention, fire safety arrangements, maintenance, training, emergency routes and exits, fire fighting and fire detection and provision of information to employees. A copy of the action plan was obtained and the work schedule was due to be complete by the end of September 2007. However, Mrs Siva later said she had been given a little further time to complete the work required. Accident records were looked at. These were cross-referred to accidents recorded in care plans. Where necessary, staff complete a falls diary and there was evidence of referral to the falls team as needed. There was no The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 24 accident analysis and the need to develop this in due course was discussed with Mrs Linnett. A recommendation has been made. Some service contracts were looked at and were up to date. The maintenance contract for the standing hoist needs to be checked to ensure servicing takes place every 6 months. A recommendation has been made about this. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X 3 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 2 2 The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? 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 Requirement All people considering using the service must receive a copy of the Statement of Purpose and also the Service User Guide that is up to date and accurate. This will ensure that people are confident about the information provided and that it can be used to help them make an informed decision about living at the home. All people must have a care plan that is clear and provides information and guidance to staff about how they wish to receive the care and support they need. The person should be involved in a monthly review of the plan wherever possible. This will mean that people receive the care they need that reflects their preferences. This requirement has been outstanding since 31/10/06. Consideration needs to be given as to how personal and private information about people living at the home is recorded and stored. This will ensure that people can be confident that DS0000064311.V347129.R01.S.doc Timescale for action 18/09/07 2 OP7 15 18/09/07 3 OP7 12 (1)(a) 21/08/07 The Close Version 5.2 Page 27 4 OP16 22 5 OP18 13 (6) 6 OP25 23 (2)(p) 7 OP27 18 (1) 8 OP37 17 (2) 9 OP33 26 10 The Close OP1 7 their privacy and right to confidentiality is not breached. The service needs to ensure that the complaints procedure is correct, up to date and clearly displayed in the home. This will mean that people visiting and using the service have the information they need if they wish to make a complaint. The service needs to amend the current procedural guidance about safeguarding adults so that it reflects the agreed Norfolk protocol. This requirement has been outstanding since 31/10/06 The lighting in the dining room needs to be improved so that the room is much brighter. This will help to ensure that people can see more clearly. Kitchen staff must be employed for the tea time period seven days a week. This will ensure care staff are available to provide personal care at all times and also that good standards of hygiene are maintained. This requirement has been outstanding since 30/09/06. The Annual Quality Assurance Assessment was not completed and returned to the Commission as required. This means that it has not been possible to assess the service’s plans for improvement. Monthly visit reports are not being completed and sent to the Commission as required. This means that there is no record of monitoring of quality by the service provider being kept. This requirement has been outstanding since 31/8/06. The service must display in a prominent place, the registration DS0000064311.V347129.R01.S.doc 21/08/07 21/08/07 18/09/07 21/08/07 18/09/07 21/08/07 21/08/07 Page 28 Version 5.2 certificate. This will mean that people can see the home is operating within its registration and that the information is current. 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 Regular audits of the medication practices and competence of staff need to be fully recorded. This will enable the manager to quickly identify any problems and to take remedial action where necessary. Staff need to make sure that meals are not dished up and served until the person is ready to eat. This will mean that they can enjoy their meal whilst it is still hot. The locks on toilet doors need to be fixed lower so that people can reach them with ease. Consideration also needs to be given to fixing “engaged” signs to doors for the use of people who prefer not to lock toilet and bathroom doors. This will help to protect their independence and privacy. Blinds or curtains need to be fitted to bathroom windows. This will make them feel warmer and more domestic. Efforts need to be made to ensure that all statutory training, required as part of the induction training process, is delivered in a timely way. This will ensure that staff have the skills needed to provide good and safe care. The quality assurance questionnaires developed by the service need to be improved so that the questions are not closed. The process also needs to include all people who visit the service. This will ensure that the service receives the views of people that can be used to develop and improve the care given. The manager needs to complete an accident analysis on a regular basis. This will help her to identify any remedial action needed in a timely way. The manager needs to check the servicing arrangements for the standing hoist currently on loan from another agency. This will help to ensure that it is serviced every 6 DS0000064311.V347129.R01.S.doc Version 5.2 Page 29 2 3 OP15 OP21 4 5 OP21 OP30 6 OP33 7 8 OP38 OP38 The Close months and kept in prime working order. The Close DS0000064311.V347129.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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