Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 31/07/07 for Welcome Care Home Ltd

Also see our care home review for Welcome Care Home Ltd for more information

This inspection was carried out on 31st July 2007.

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

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

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 is small and provides a homely and friendly atmosphere for residents. Management work well with the Commission and make efforts to address requirements and recommendations made following inspections. All of the Requirements made at the last inspection were dealt with. There is a stable staff team in post who know the residents well and no agency staff are currently being used. Residents are relaxed and comfortable and in their interactions with staff, and relatives and residents say that staff are very kind and caring and they feel that they can ask the for anything they need. Residents know the manager and said they would speak to her if they had any concerns. Resident`s Religious needs are being well catered for and the manager often takes residents to church and to coffee gathering afterwards. Four residents said that there are a good amount of activities to do and they really enjoyed the regular singing sessions.Residents were supported to be independent and a number went out alone or with staff to access local facilities. One resident said that he could go out every day and be as independent as he wants. All said that they are happy living at the home.

What has improved since the last inspection?

Care plans are now being reviewed monthly and kept up to date using a new system for recording information, which is easily readable. Records of Medicines brought into the home are now being better recorded and storage of these medicines is better. A variety of meals are being offered and there is flexibility for residents to have food other than what is on the menu if they wish. All residents interviewed said that they get good meals and are asked what they would like to eat. There is now a maintenance plan in place to make sure the home is in a good state of repair. There is a cleaner employed and there is a cleaning schedule for them to follow. The home is clean and well maintained. The flooring in bathrooms and some rooms have been replaced. Net curtains have been replaced. Covers have been installed on some radiators t and hot water temperatures are being checked regularly to prevent accidental burning. Staff recruitment and employment information is now up to date and the information on the rotas about who is to be on shift is clearer so that staff and residents now know who to expect to provide support and when the manager is available.

CARE HOMES FOR OLDER PEOPLE Welcome Care Home Ltd 26-28 Fordel Road Catford London SE6 1XP Lead Inspector Sean Healy Unannounced Inspection 31st July 2007 11:00 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 Welcome Care Home Ltd DS0000025650.V344890.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. Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welcome Care Home Ltd Address 26-28 Fordel Road Catford London SE6 1XP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8697 5024 0208 698 8287 welcomecarehomelimted@hotmail.com Mrs Margaret Newland Mrs Margaret Newland Care Home 15 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0) Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 15 persons whose primary needs are old age and dementia 11th December 2006 Date of last inspection Brief Description of the Service: The Welcome Care Home is registered to provide personal care and accommodation to a maximum of 15 older people suffering from dementia. The overall aim of the home is to provide care and support in a homely environment with a relaxed family atmosphere. The underlying philosophy, stated in the home’s brochure, is that of a holistic approach to care. The registered provider is a company belonging to Mrs Margaret Newland, who is also the registered manager for the service. The staff team comprised of a registered manager, a deputy manager, care staff and some domestic hours. The home was opened in 1993 and consists of two semi-detached Victorian houses, which have been joined into one. There is a rear garden with a patio, a fishpond and a lawn area, which is well maintained. Thirteen of the home’s bedrooms are single with en-suite toilet facilities. There is one shared room, which has a wash hand basin only, but exclusive use of a nearby toilet. There is a passenger lift and a short stair lift to ensure access to all parts of the house. The property is situated in a residential road in the Catford area, with some local shops nearby and is close to Catford town, public transport and local amenities and shops. The provider’s email address is: welcomecare@hotmail.com Information about the service provided is made available to current and potential residents in the homes Statement of Purpose and Service Users Guide, which are given to all service users. The recent CSCI report is kept in the office area in the home, and it is recommended that this be kept in a more accessible area and that all residents are informed. The current fees ranged from £435 - £450 per week and residents pay privately for items such as toiletries, newspapers and personal purchases. Welcome Care Home Ltd DS0000025650.V344890.R01.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 as a visit to the home on 31/7/07 and ended on 3/8/07 following receipt of information regarding health and safety. The home provided an Annual Quality Audit Assessment (AQAA), which was also used to inform the inspection. The registered care manager facilitated the visit. Four care staff had discussion with me and two of these were interviewed by me about their employment and understanding of job. Four staff employment files were examined to check that they had been properly recruited, trained and supervised. Two separate relatives of service users contributed their views of the home. Four service users gave their views on the home and four service users files were examined including assessments and care plans. The inspection involved a tour of the premises and examination of a range of management documentation. The home currently has one vacancy What the service does well: The home is small and provides a homely and friendly atmosphere for residents. Management work well with the Commission and make efforts to address requirements and recommendations made following inspections. All of the Requirements made at the last inspection were dealt with. There is a stable staff team in post who know the residents well and no agency staff are currently being used. Residents are relaxed and comfortable and in their interactions with staff, and relatives and residents say that staff are very kind and caring and they feel that they can ask the for anything they need. Residents know the manager and said they would speak to her if they had any concerns. Resident’s Religious needs are being well catered for and the manager often takes residents to church and to coffee gathering afterwards. Four residents said that there are a good amount of activities to do and they really enjoyed the regular singing sessions. Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 6 Residents were supported to be independent and a number went out alone or with staff to access local facilities. One resident said that he could go out every day and be as independent as he wants. All said that they are happy living at the home. What has improved since the last inspection? What they could do better: The home must ensure that residents are informed about the fees paid by them or by the local authority and make sure that the up to date fees are written into any contracts. The staff and cleaners need to make sure that the toilet/bathroom area adjacent to the dining room is always kept clean and free from strong smells The manager must make sure that there is a written agreement on file authorising the home to manage finances and benefits for any residents who receive this support The registered provider and manager must ensure that all care staff receives supervision with their line manager at least every three months so that they are kept up to date and are working safely. Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 7 The manager must check that there is a current electrical and wiring certificate available showing the home to be safe and free from electrical hazards It is recommended that clearer records of staff training planned and agreed as part of individual staff annual appraisal are maintained, and that staff receive a copy of this plan. Staff should also get at least three days paid training per year. 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. Welcome Care Home Ltd DS0000025650.V344890.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 Welcome Care Home Ltd DS0000025650.V344890.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): 2,3,4 and 6 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Residents have a Conract or Statement of Terms and Conditions, and an assessment of need completed prior to admission. Residents have received confirmation that based on assessment the service was suited to meeting their needs. EVIDENCE: All four residents files examined showed that they have a contract with the relevant Borough local authority in place, showing all of the required information. The fees paid by the local authorities for the care provided have recently changed, and have increased from £379 to up to £450. This needs to be reflected in all contracts. (Refer to Requirement OP2) As at the last inspection, the registered manager together with the deputy manager completed an assessment of resident needs before accepting their referral to the home. The manager said that care managers also completed Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 10 resident assessments. A long-term assessment of resident needs was completed at the time of admission. Residents were invited to have a ‘trial visit’ to the home before accepting a placement. The registered person had not confirmed in writing to residents that based on assessment the service was suited to meting their needs. There was a requirement at the last inspection for the home to confirm to residents in writing that they can meet the needs of new residents, before admission to the home. The home has now got a standard letter, which is used for this purpose. This requirement is now met. The home does not provide intermediate care for residents and therefore a standard six does not apply to this. Welcome Care Home Ltd DS0000025650.V344890.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are prepared for residents and these are based on a single social services assessment. Residents are supported to access healthcare services. Systems to manage medicines are satisfactory and improvements have been made. Resident’s rights are respected by the staff and they are treated with dignity and respect. EVIDENCE: There was a requirement at the last inspection for the home to ensure that care is staff have access to the most up-to-date information on residents care plans, and to ensure care plans be updated and not to use correction fluid when making amendments. This has now been done and the requirement is met. The home has a good care planning system, (The up-to-date Standex system) which includes health and social care interests and activities, relationships, medication, mobility, and a range of support guidance for staff. Care plans are consistently reviewed monthly. Staff interviewed were knowledgeable about residents needs and four residents said that staff are Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 12 very good at helping the personal care, and are very sensitive, and ask questions about how they should do it. All for residents files examined showed good inclusion of a range of health care needs. Some mental health, dementia, mild physical disabilities and moving and handling support needs featured amongst the health care needs listed. GP visits happen by request, and the residents and the manager said that the GP is quick to come out when needed. The GP normally visits fortnightly, the Chiropodist this visits three monthly, the Oral Hygienist visits monthly with the Dentist visiting at least once a year, or when a new resident comes to the home. None of the residents have tissue viability issues, as this is very well managed by the home. Medication is well managed by the home and none of the current residents manage their own medication. There was a Requirement at the last inspection for the home to ensure that records are kept of all medicines brought into the home, to include administration and disposal of homely remedies. It was also required that the temperatures of the storage area be monitored, and that internal and external medicines be stored separately. All of these requirements are now been met and good records are being kept. The home carries out an assessment of the residence wishes and abilities to self-medication as part of the referral and moving in process. All residents spoken to said they are very happy for the home to look after their medication. There was a recommendation made at the last inspection for the home to remove some personal information that was been displayed on a notice board, in order to preserve the dignity and respect are some residents. This is now been done and a recommendation is met. Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with their lifestyle and are supported to maintain contact with family and friends. Residents are involved with making decisions about their life and are given a choice of good and wholesome food. EVIDENCE: There was a requirement made at the last inspection for the home to keep upto-date records of activities for residents, to reflect the activities offered, and the take-up by residents. This has now been done and care plans include a comprehensive list of activities offered a daily basis, which are recorded on a daily activities chart. This chart was examined and was seen to be consistently completed by staff. Activities included are: a visiting musician who comes on a weekly basis to do a performance in the home, cinema, hairdressing, manicure, quiz evenings, reminiscence sessions, story reading, dancing, shopping, café, and visits to the Kingdom Hall for one residents religious support needs. Other residents said that they are supported to go to church by the manager. Four residents said that these activities happen regularly and they go out whenever they want, and will get to support from staff if they need Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 14 it. Some summer outings planned included a trip to Brighton and to Eastbourne. The home welcomes visitors at any time according to the wishes of the each resident. Visiting relatives said that the home is extremely welcoming and ”always welcomes us with a cup of tea and a smile”. They said that staff are very friendly and always include them in discussions and events taking place. On the day of inspection an opera singer was performing in the conservatory and family have been invited to attend. The relative said that these musical events happen regularly and he has attended every two weeks when visiting his mother. All of the residents with the exception of two manage their own financial affairs. The home has been requested by two local authorities to manage the finances for to residents. Good records are being kept of all financial transactions, however the home must ensure that there is a full written agreement for them to do this on behalf of these residents from social services. (Refer to Requirement under Standard 35 of this report) There was a requirement at the last inspection for the home to ensure that residents have a choice of meal at lunchtime, their special dietary needs are catered for, the kitchen is kept clean and that the food and fridge temperatures are monitored and recorded. This requirement has now been met. The manager said that they have changed the menus to reflect residents preferred meals, and that the residents can now have what they want on each day. Residents are asked the day before about the food that they want to eat the next day, and residents said that on each day they could change their minds and get something else if they really wanted. All residents spoken to confirmed that they are asked about the food and said that the food is “very nice”. I sampled the food and found it to be well presented and tasted very nice. Menu records are kept in a menu book. The kitchen was seen to be clean and well maintained, with fridge temperatures being recorded at least daily and these records are kept a logbook. Staff in the kitchen confirmed that they had been given direction by the manager on how to do this. Specialist dietary needs mainly consist of the management of diabetes and cholesterol. Two residents explained that they are aware of how to look after their cholesterol by avoiding too many sweet things and too much fat in the diet. They said that there is always a range of fruit available. Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 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. 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. Satisfactory systems are in place to manage complaints and the protection of vulnerable adults. EVIDENCE: A complaints policy and procedure was provided and included timescales for investigating complaints made about the service. Residents and relatives spoken with said they knew how to make a complaint and indicated they would feel comfortable doing this. There have been no complaints made since the last inspection. There have been no ellegations of abuse or POVA referrals made since the last inspection. The home has a written policy and procedure in relation to Adult Protection. The procedure should state clearly that all suspicions or allegations of abuse must be referred to the local authority for investigation under their procedures. At the last inspection it was recommended that a copy of the local authority’s Adult Protection procedures should be available to staff in the home in addition to the home’s own policy. This is being done and the home has a copy of this policy available at the home. The Adult Protection policy was last reviewed in March 2007 and shows clearly how to report suspicion of allegations of abuse. There is now flow chart showing clearly how to make reports quickly and efficiently. Staff interviewed had a good awareness of adult protection and how to manage an allegation or suspicion of abuse. Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 16 Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 21,24 and 26 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well-maintained home, with sufficient toilets and washing facilities. Some improvements are needed to ensure that all toilets are maintained to an adequate level of cleanliness. Resident’s bedrooms are safe and comfortable reflecting their own individual needs. EVIDENCE: There was a requirement made at the last inspection for the home to ensure maintenance and refurbishment programme is in place. Specific mention was made of the need to carry out repairs to some parts of the home, and replace some furniture. This has now been done and this requirement is met. The lounge and conservatory chairs and some bedroom chairs have now been replaced. Various areas such as the dining area, corridors and some bedrooms have been repainted, and the entrance of the home has been repainted also. Loose floorboards have been secured. There is a maintenance and refurbishment programme in place and future planned improvements include; Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 18 continued decoration of bedrooms, maintenance of the garden and improvement of the design, air conditioning for the conservatory area. There was a requirement made at the last inspection for the home to ensure that bathrooms and toilets are kept clean and in a good state of repair. Specific mention was made of repairing flooring in a first floor bathroom and fitting a protective cover on a radiator in a shower room. This has now been done, and the home was found to be generally in a good state of repair and maintained to an adequate level of cleanliness. Bathrooms and toilets now have new lino on the floor and the radiator in a shower room has had a cover fitted. The hall employs contract cleaners to clean the home thoroughly throughout each week. However the toilet and bathroom next to the dining room area was found to be a bit soiled, with the bin lid for continence materials having been left open, with used continence pads left inside. The manager explained that a few residents were more independent in personal care, and sometimes leave this bathroom in this condition with staff knowledge. While this is an issue which is unlikely to be sorted easily it is the responsibility of the home to address this problem. It is required that the manager discussed this issue would staff and with cleaners and decide on the best way to manage this problem. The home should also produce some written guidance for staff and for cleaners to sensitively support residents and to ensure that this bathroom area is consistently maintained to an acceptable level of cleanliness. (Refer to Requirement OP21) There was a requirement at the last inspection for the home to review the decision not to restrict windows openings above the ground floor area. This has now been done and all windows above the ground floor have had restrictor devices fitted to prevent them being opened to an unsafe safe level. Resident’s rooms were seen to be well equipped with comfortable beds, easy chairs, storage for clothing, and were generally clean and bright. Residents said that they are happy with their bedrooms and that staff are helpful when there is a need to clean or replace items in the room. There were requirements made at last inspection to keep the home clean and to wash the net curtains is in room seven. This has now been done and bedrooms were seen to be a good state of cleanliness. Contract cleaners employed to clean the home six days a week, and there are adequate facilities in place for the collection and disposal of waste materials. The home was generally found to be well cleaned are maintained, with the exception of comments regarding the need to be more consistent in maintaining a hygiene in the bathroom area beside the dining room. (Refer to Requirement OP21) Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As at the last inspection the staff team is made up of a registered manager who is an experienced manager and qualified nurse, a deputy manager, 14 care staff on various part time and full time contracts, and contract cleaners who come to the home six days a week. A written staff roster was kept to show which staff were on duty at any time. There are 3 staff on duty between 8am and 2pm and 2 staff on duty from 2pm to 9pm, with additional support provided by the manager. At night one waking and one sleeping member of staff are on duty. No agency staff or others who do not know residents are used which is a good achievement and helps maintain a consistent service. The homes staff are made up of one male and 14 female staff supporting 10 female and three male residents. The cultural backgrounds of residents are 10 White English residents and three Caribbean residents, supported by a staff team who are predominately either Afro-Caribbean or Black British. The manager has in place management of diversity training to try to ensure that the resident’s cultural needs are understood and are being met by staff. Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 20 At the last inspection the staff roster did not include the full name of the employee, did not show when the manager was on duty and did not show which employee slept over at night. There was a requirement made to have full names of staff included on the roster and to show the times when the manager is available at the home. This has now been done and this requirement is met. The home provides work experience for care students who are completing NVQ training. When on duty the students are supervised by the person in charge of the shift. Volunteers are sometimes used to provide additional support but not as part of the minimum staffing levels. The manager checks that all students and volunteers had up to date CRB and POVA checks before working in the home. Residents and relatives said that they felt there were adequate numbers of staff on duty and that all were quick to provide help when needed. The manager and deputy manager were both qualified nurses and nine out of fourteen care staff had achieved NVQ level 2, which was over 50 of care staff. The deputy manager is undergoing an NVQ level 4 course in care and management. Recruitment policies and procedures are in place. No new staff had been employed since the last inspection. Four employee personnel files were viewed. These were generally well kept and included all of the information required by regulation. This is now being done and this requirement is met. All the missing information has been collected and included in staff files. There is now a good file index being used on each of the staff personnel files showing how the information is collected, and this helps to monitor that staff are being recruited safely and in a fair manner. Recruitment records have much improved. There is a good induction in place for new staff, which is in line with the Skills for Care requirements. The home has a training schedule, which includes; equal opportunities, dementia, diversity, health and safety, fire safety, moving and handling, infection control, medication and food hygiene. It was confirmed that not all of the staff training time is paid for, and that staff sometimes attend training in their own time. It was also suggested that staff attendance at training might not be consistent. It may be the case that a minimum of three days paid training per year for each member staff is not being allocated. It is recommended that the home plan for all care staff to receive at least three paid days training per year, and that clear records are kept of attendance/nonattendance to allow management to follow this up with individual staff. (Refer to Recommendation OP30) It is recommended that the home record more clearly the training planned for staff as part of their Annual Appraisal. (Refer to Recommendations OP30) Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 21 Welcome Care Home Ltd DS0000025650.V344890.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 and 38 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s manager was registered with the Commission and had the experience and qualifications needed to manage the service. The manager was a registered nurse, had achieved NVQ 4 qualification in care and management and was supported by a deputy manager who was also a registered nurse and who has worked in the home over a number of years. Residents spoken with said they were happy with how the home was run. Two visitors commented that they were very happy with the homes management Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 23 and that their relative was very happy living there. They said they were fully consulted about the move to the home, and are “confident that we can speak with the manager who is quick to put things straight. There was a recommendation made at the last inspection for the home to ensure minutes of meetings with staff and residents are maintained, and an action plan is developed to improve the service based on the outcome of a quality assurance audit. Minutes of these meetings are now being kept and the home has developed an action plan based on the outcome of an annual service user/relatives survey. This constitutes the basis of a development plan for the home, which the manager is doing more work on to provide a more robust annual quality audit system. It is recommended that this process is further developed to produce a clear annual audit system for the home. (Refer to Recommendations OP33) All of the residents, with the exception of two, are in control their own finances. Social services have asked the home to manage the DSS and bank arrangements for these two residents, and good financial records are being kept of all transactions. However there is not a written agreement from social services authorising the home to do this, and it is required at this written agreement for each of these individual residents be agreed and placed on their care plans. (Refer to Requirement OP35) All for staff files examined showed supervision to the generally happening well with good notes being kept. However the regularity of three monthly supervision is not always adhered to, and some files showed that the frequency is sometimes more than four months between supervisions. Staff interviewed confirmed that they receive regular supervision and that the content address care of residents, and their own employment and training and development issues. However it is required that the home ensures that all staff receive supervision at least every three months. (Refer to Requirement OP36) Health and safety records were examined and these included fire safety, bath hoist, gas safety, electricity and accident records. Fire drills were held at regular intervals. As at last inspection an environmental health inspection was completed in January 2006 and the manager said that all the issues raised had been addressed. There was a requirement made at the last inspection for the home to ensure that there is a system in place to monitor a hot water temperatures, and that all radiators accessible to residents have protective covers fitted. These requirements are now met and the water temperature records are being maintained. Covers have been fitted to radiators identified as posing a risk. Almost all health and safety issues including documentation were seen to be in order. However the homes five-year electrical certificate was not Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 24 available at inspection, and it was not clear whether this had expired. It is required that the home ensures that there is an up-to-date five-year electrical certificate in place. (Refer to Requirement OP38) Welcome Care Home Ltd DS0000025650.V344890.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 X 2 3 3 X 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 2 X 2 Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation 5.1 Requirement Timescale for action 31/10/07 2 OP21 23.2 d 16.2 k 3 OP35 20.3 4 OP36 18.2 The registered provider and manager must ensure that the local authority fees paid for the service provided are as written in residents contracts or statements of terms and conditions are up to date as discussed in this report under Standard 2 The registered provider and 31/10/07 manager must ensure that in liaison with staff and cleaners that the toilet/bathroom area adjacent to the dining room is maintained to an adequate level of cleanliness and free from odours. Guidance in how staff should achieve this in a sensitive manner must be put in place. The registered provider and 31/10/07 manager must ensure that there is a written agreement on file authorising the home to manage finances and benefits for any residents who receive this support The registered provider and 31/10/07 manager must ensure that all care staff receive supervision DS0000025650.V344890.R01.S.doc Version 5.2 Welcome Care Home Ltd Page 27 5 OP38 23.2 with their line manager at least every three months and that formal notes are always kept The registered provider and manager must ensure that there is a current electrical and wiring certificate available showing the home to be safe and free from electrical hazards 30/09/07 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 OP30 Good Practice Recommendations It is recommended that clearer records of staff training planned and agreed as part of individual staff annual appraisal are maintained, and that staff receive a copy of this plan It is recommended that all care staff receive a minimum of three paid days training per annum and that clear records of planning this training and staff attendance are maintained It is recommended that further work is done to develop the current Annual Quality Audit system to include a greater range of checking of systems used in care planning, implementation and intervention such as care planning, complaints and adult protection and staff management 2 OP30 3 OP33 Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup 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 Welcome Care Home Ltd DS0000025650.V344890.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!