Care Home: Alver Bank

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CARE HOMES FOR OLDER PEOPLE Alver Bank 17 West Road Clapham London SW4 7DH Lead Inspector David Pennells Unannounced Inspection 30th September 2008 10:20 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 Alver Bank DS0000022717.V373505.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. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alver Bank Address 17 West Road Clapham London SW4 7DH 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) 0207 627 8061 0207 720 2150 jean.adams@salvationarmy.org.uk The Salvation Army Ms Jean Adams Care Home 27 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (22) of places Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2007 (SOFI) Brief Description of the Service: Alver Bank is a home for older people owned by the Salvation Army Housing Association and managed by the Salvation Army Social Services. It is located in an historic listed building set in large, landscaped grounds. The home is situated between Brixton and Clapham and has good transport links. It offers some parking at the front and side of the home and on street parking. Within the same grounds there is a community centre building, and - adjoining the home - there is a sheltered housing complex. There is a good amount of communal space, and the both home & grounds are fully wheelchair accessible. Accommodation is provided in single rooms for 27 older people, of whom some may have Alzheimer’s or a similar dementia condition. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection visit took place over two days within the same week; the initial visit day was spent meeting people using the service, some relatives, staff and the management of the home. The second visit - two days later - was undertaken primarily as an opportunity to attend an afternoon residents & relatives meeting which had been called by the manager and her senior managers to introduce themselves and address issues arising in the home, not least of which was plans for substantial improvement of the premises especially the public spaces. Alongside the registered manager of the home Jean Adams, the representatives of the senior management of the Salvation Army attending the meeting were: the Director of Older People’s Services - Mrs Elaine Cobb, and the Assistant Director of Older People’s Services - Major Doreen Bland. The manager was in the home on both days, and facilitated the inspection. The inspector was able to check documentation and care plans, toured the building, and spoke to many involved with Alver Bank, including the Communities Service Officer who has been helping out since the establishment has been without the assistance of an administrator. Some concerns had previously been raised by staff about the general conduct of the home, and this inspection was intended to assess the situation, especially with regard to the quality of care outcomes for people using the service. Questionnaires were felt to be an important way of gaining honest feedback, and papers were distributed to relatives, to people using the service, and to staff members. Eleven, seven and eight surveys were returned respectively, with a varied response from each sector of the Alver Bank community. Qualitative comments offered in the responses are directly quoted in the various sections that follow. In summary, over 90 of relatives / friends felt that their loved one’s needs were always or usually met, in accordance to the care plan. A similar proportion felt that staff members were suitably skilled to provide appropriate care, and that they respected the individuality and diversity of each person. Some of those who did not visit very regularly felt that the home could improve on making regular contact with them. About two-thirds confirmed they were contacted with important issues relating to their relative / friend. Only one relative was not aware of the home’s complaints procedure, whilst the majority stated that issues raised were appropriately responded to. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 6 Of the people actually using the service (of mixed ages and genders) responding to the questionnaire, all stated that they had received a contract, most saying they had enough information about the home before moving in. Opinion was split over whether people using the service thought they individually received the support they needed, whilst confirming that staff members do listen and act on what they ask - with staff members ‘usually’ available when they are wanted. All respondents ‘always’ or ‘usually’ also received any medical care they needed. Activities are appreciated, and the home is fresh and clean in their opinion. Meals were liked ‘usually’ or ‘sometimes’ - indicating there is ‘room for improvement here’ - a comment made by one person; whilst another reflected that it “depends on which Chef is on”. Only one person was not clear how to lodge a complaint, with everyone indicating they knew who to speak to if they were unhappy with something at the home. Staff responding to the questionnaire felt that the recruitment process undertaken was rigorous, though thought that the induction process needed improvement, as did training with regard to their role, to diversity issues and to developing best practice ways of working. Care Plans were not felt to be providing enough information about individuals, and it was felt that the differing needs of the people using the service were ‘sometimes’ met (- as opposed to ‘usually’ or ‘always’). The level of staffing was questioned for adequacy, as was the effectiveness of staff communication within the home. Staff also mentioned their concerns about the food service provided; choice and presentation being mentioned. Some questionnaires contained other comments, which, sadly - as contact details were not provided - the inspector was not able to follow up. What the service does well: The home deals well generally with the process of assessing and welcoming new service users and supplies them with all information needed. The staff group work hard to support the health care and personal care needs of service users, within an improving and comfortable environment. People using the service are protected by the home’s complaints and vulnerable adults policies and also by the recruitment procedures. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Two requirements are set: that of the home assessing the banister height of the main staircase, and staffing issues raised particularly the need to ensure that a thorough and properly recorded induction process was put into place. Recommendations range from a suggestion that cooked breakfasts be provided seven days a week to that of a variety of hot and cold puddings being introduced alongside the fresh fruits alternative - and that the dining room is opened out into an activity function in the hours it is not being directly used as a dining area. From reflecting a need for greater contact with relatives, especially those who are not able to visit the home on a very regular basis, to ensuring that staff starting on a certain level of CRB check are clear about their need to be supervised continually within the home. Finally, Regulation 26 reports did not fully reflect the visits by the ‘people in control’, and it is suggested that the support for the home from senior managers should be more fully recorded - though the inspector sensed a change in the approach of senior managers, having met them on the second day of the inspection. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 8 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. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has information available for people considering using the service, and full assessments of applicants including home information visits are made prior to admission, giving the individual every opportunity to consider and make sure they wish to live at Alver Bank. The home does not provide intermediate care. EVIDENCE: The home has a detailed Statement of Purpose and Service User Guide, which contain all relevant information for prospective service users and their relatives. The manager confirmed that all prospective service users are assessed before admission and only after the home has full assessments from relevant social and health care professionals. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 11 The home aims to invite all prospective service users to visit the home before admission, and the manager confirmed that the majority of prospective people do so. Some people - e.g. if in hospital, sometimes do not manage a visit to the home prior to admission, in which case a Principal Care Worker would undertake an assessment and introductory visit to the hospital. All people living at the home come on a ‘trial’ basis as far, at least, as the first review. The home provides a service generally to older people and also - within the main home itself - to a smaller specific number (5) of people who have Alzheimer’s or a similar dementia condition. Staff training is being developed to address the individual needs of people with dementia. The home does not accept people for intermediate care, so this standard was not assessed. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service can expect to have a care plan in place, which fully describes the individual and the specific needs of that individual. Health care needs are well managed and people using the service can expect appropriate services when required, as well as medication being dealt with in an appropriate and controlled manner. People using the service can expect to receive a service that respects their individuality and responds to their diverse needs. EVIDENCE: All service users have a care plan - using a newly introduced format - and there was evidence that these are drawn up with the individual involved. A relative confirmed that she had also been invited to, and attended reviews of the care plans - which are now held regularly. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 13 Relatives confirmed they were aware of care plans held for each individual: “The Care plan book is much better than the last one….”, and they also stated they had been asked for further details about their relative’s history / background; emphasising the stronger focus on personalised care and ‘life history’ work - an important element especially for people with dementia. Some relatives and friends commented that they felt that contact with them could be improved; this relates especially to specific incidents (where a couple of reports of incidents of omission in the past were recalled). It is recommended that, for those relatives who are not able to visit so often - and where a service user cannot communicate so well (and with that individual’s permission) - a ‘courtesy call’ could perhaps be arranged to ‘update’ them on a regular basis. People at the service said that they received good care, and all appeared well cared for and generally cheerful. The inspector spoke to a District Nurse who was visiting the home - who said that she had no worries about service users’ health care, and found the staff helpful. The system for administering medication and subsequent recording was checked and found to be consistent and in order. Staff administering / dealing with medication were knowledgeable and organised in their approach. All service users have a risk assessment undertaken on admission to see if they wished, and / or were able, to keep charge of their own medication. Staff members interacted warmly and familiarly with people at the service and questionnaires from the people resident at the home suggested that they felt their dignity was respected, and that their individuality was recognised by the staff at the home. Comments such as: “the home is very friendly and caring”, “level of care is very good”, and: “a good standard of care achieved and staff are friendly to residents” and “The staff seem genuinely caring and approachable and the manner in which they deal with the clients” showed the generally positive stance and opinion that relatives took to the care provided. Alver Bank DS0000022717.V373505.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 - 15. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service are helped to live as they so choose, including the spiritual aspects of their life, and visitors are welcomed into the premises. People using the service may now gain a clearer focus on activities they enjoy, as the home now employs a worker to focus on this area, leading to more person-centred outcomes. People enjoy a varied and nutritious diet, though the menu could be expanded and made more accessible - thus providing a greater opportunity for choice. EVIDENCE: Spiritual support for people at the home is provided through a short daily Morning Service, held each morning either by external volunteers or by the senior staff. Attended by most, the session covered a Scripture reading, prayers and hymns. An Anglican Priest also visits the home once a week to provide Holy Communion. Sadly, the post of Chaplain to the home (a voluntary role) had been vacant since July 2008. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 15 The home provides a variety of social activities including board games, arts and crafts, Sing-a-longs and one-to-one activities. These generally occur each afternoon and are a timetable is displayed on a board in the hall. There are also day trips arranged and special activities. People using the service stated they enjoyed these activities. Service users’ past interests and present wishes for recreational activity are now more fully assessed by the Activities Organiser - and group work or 1:1 work is being more strongly focused on and being built into the process of care planning. Themed events are being held to mark significant calendar days and close neighbours are invited to join the home for these events. One person who gets out to the shops with staff has been observed by their relative to have gained “greater confidence” and a greater sense of self-worth being encouraged to be “in control of his personal finances” when out shopping. People using the service are generally encouraged to keep up contacts with friends and relatives; visitor said that they are always made welcome. Some of those who did not visit so regularly felt that the home could improve on making regular contact with them. This is a recommendation of this report. ‘Arrowmark’ provides catering services independently. Service users are offered a varied and nutritious menu with a choice for the main meal and - for the desert - an option of fresh fruit is offered as an alternative. Cold drinks are available on each table, with a hot drink offered after the meal. AfricanCaribbean food is available, and special diets are provided for, where needed. The breakfast menu was observed to somewhat restricted, with some days just ‘cereal and milk’ or ‘boiled egg’ appearing. ‘Proper’ cooked breakfasts were served on Saturdays and Sundays. The general menu was also reviewed, with the unclear dishes of ‘Chef’s Special’ and ‘Roast of the day’ be challenged, as they are not specific enough to promote choice or interest. Service users confirmed that they could get snacks and drinks outside of mealtimes. Additional to breakfast, lunch and supper, residents are also offered drinks and a snack mid-morning, mid-afternoon and in the evening. An issue arising from the social/catering aspect within the home was an observation that the dining room appears to be wholly used for dining only; the doors were firmly ‘closed’ outside of mealtimes, with people being removed if they strayed into that area. This very spacious and pleasant space could be used during the day for other activities - and as additional quiet accommodation for people living at the home. A recommendation from this report is that use of this dining space is reviewed to maximise the opportunities within the home. Alver Bank DS0000022717.V373505.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. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Policies and ongoing training show that effort is made to respond to both complaints and allegations - to protect service users from abuse. EVIDENCE: The home has a complaints procedure that is given to all service users and displayed in the hall. Almost all relatives and people using the service stated they knew who to approach / how to register a complaint if they so wished. Interestingly, it was staff who indicated some lack of understanding about making complaints / logging concerns about the service, and the management are ensuring that training in Whistleblowing, the Complaints Procedure and Safeguarding is promoted to give staff confidence to handle any allegations or comments which may come their way. Training in Safeguarding and the new Mental Capacity Act is planned for all staff members in the months up to and beyond December 2008. The home has a safeguarding / vulnerable adults policy and other necessary documentation. Allegations relating to safeguarding had arisen twice during this past year; they were investigated and the allegations were not found. Alver Bank DS0000022717.V373505.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 & 26. People using this service experience increasingly good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People residing at Alver Bank live in a safe, accessible and homely surrounding with appropriate personal and communal space. EVIDENCE: The ‘scoring’ for this section is based on the committed / projected work due to be completed within about two months from the date of the inspection visits. Service users all have single bedrooms, which are well furnished and decorated and populated according to the individual’s taste. It is the responsibility of the local maintenance staff to maintain / redecorate these areas. All areas of the home are accessible, including the grounds. Equipment and adaptations are provided throughout the home as needed. There are ample Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 18 modern bathrooms areas and work is going forward on making the toilet areas more congenial. There are large communal areas with two lounges and a dining room - which space the manager should review in order to give maximum flexibility of space. The main lobby outside the lounges should be made more ‘homely’ - too many notices present a muddle of messages - some for people living at the home and some for staff. A careful rationalisation of such display areas - to ensure they maintain a homely approach - should be undertaken. The communal space’s furnishings were noted to be in reasonable repair, and new furniture, carpeting and soft furnishings were expected to be in place by the end of the year, alongside the redecoration of the entrance hall and corridors. Adequate supplies of side tables for use in the lounges were also due for delivery imminently. People who use the service were involved in deciding on the colourway for the main rooms at the residents and relatives’ meeting. All areas seen were generally safe, but the inspector questioned whether the main staircase’s banister height was appropriate for the people who use the service, and whether an additional heightening balustrade might be needed. The manager agreed that this would be explored, reflecting at the same time that the ‘listing’ of the building might restrict adaptation. CCTV cameras are available to watch the external areas of the building and lighting in these areas has been improved. The ‘horseshoe’ at the front of the building is being resurfaced, and the flagstones are being replaced by a [probably] safer tarmacadam. On the two days of inspection visit, the home was clean, odour-free and generally found to be hygienic throughout. Alver Bank DS0000022717.V373505.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 - 30. People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users are supported and cared for by well-trained staff deployed in sufficient numbers. The recruitment process is a good one, which with small changes will fully protect service users. EVIDENCE: Staff numbers on all shifts were assessed as suitable by the manager and appropriate for the number and needs of people using the service. There are three Principal care workers under the manager’s post, with care assistants managed by the Principals. An Activities Coordinator post (20 hours) has been established, and a worker is in post in this vital area. There are two night staff members on duty awake each night. There is an Administrator’s post - which was vacant, and a combined Domestic maintenance worker and Driver post. Domestic cleaners (76 hours pw) and a laundry staff member (25 hours pw) complete the staff team. Catering is contracted out to ‘Arrowmark’. The percentage of staff trained or training to NVQ Level 2 is nearing 75 with ten out of the fourteen permanent staff qualified, and three staff currently in the process of gaining the qualification. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 20 The manager described a good process for recruitment; staff independently confirmed that the processes were appropriate and thorough. Documentation for two newly recruited staff was checked. This was mostly in order, but one staff member who started on a PoVA First check should have had clearer criteria agreed with regard to the concept of ‘supervised’ working. Other necessary checks are all being undertaken. From staff questionnaires, the home’s induction training was described variously as anything but ‘very well’ when asked if the induction process covered the areas staff members needed to know. This is clearly an area that requires development. Staff members’ training needs are identified through annual appraisals and a training programme is in place, though staff responding to the questionnaire clearly felt that training is a deficit that still needs addressing. Training in First Aid is provided at a level that all shifts are covered with a qualified practitioner. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 21 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 & 38. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the Service users benefit from good developing management input, and views on the service being sought and taken into account. Financial and Accounting Procedures and Health & Safety systems work to protect those using the service. EVIDENCE: The Registered Manager, Jean Adams, is completing her Registered Manager’s Award at NVQ Level 4, and all the management team have begun the NVQ in Care Management at the same level. Mrs Adams has been in post since January 2008. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 22 Jean Adams completed and sent us the CSCI’s Annual Quality Assurance Assessment (AQAA) when we asked for it. It was clear and gave us all the information we asked for - which has informed this inspection. Positive comments were received about Mrs Adams: “The manager is very good - as far as I’m aware everyone is treated the same regardless of ethnicity, gender and faith.” And: “Since the new manager has been appointed the concerns I raised before have been addressed.” The records of the visits of the Director of Older People’s Services and the Assistant Director of Older People’s Services in line with the statutory Regulation 26 visits to the home showed some gaps and the inspector recommends that all visits to the home are recorded and that the manager is accorded additional support during her early months in dealing with the issues she is facing in the establishment of a new approach to Alver Bank. There continue to be good methods for finding out and learning from the views of people using the service and other interested parties. An annual report is compiled from these surveys and questionnaires. The Salvation Army Quality Standards Manual underpins both quality assurance and consultation focuses. The Communities Service Officer - who has been regularly helping out since the establishment has been without the assistance of an administrator - was maintaining and managing financial issues and fees for people who lived at the home. Clearly such areas of the home are currently being focused on well, and were in good order. All health and safety systems are regularly checked, and were found to be in order on this visit. Training in First Aid is provided at a level that all shifts are covered with a qualified practitioner. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 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 3 X 3 X 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 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 24 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 OP19 Regulation 13(4) Requirement A Risk Assessment must be conducted of the height of the banister on the main staircase, and remedial action undertaken if this proves to be a risk. The Staff Induction process must be developed and provided to all staff [even retrospectively] to ensure that they have a full professional and local introduction to Alver Bank. Timescale for action 30/03/09 2. OP30 18 (1)(c)(i) 30/03/09 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 OP13 Good Practice Recommendations That a policy of ensuring contact with relatives is established to ensure all are regularly kept ‘in touch’. Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 25 2. OP15 That the menu should be more specific - rather than e.g. ‘roast of the day’ or ‘chef’s special’, to facilitate active interest and choice in the food provided. That a variety of hot and cold puddings be introduced alongside the fresh fruit alternative. That the breakfast menu is reviewed with the aim of providing a variety of cooked items each day. That the dining room is opened out into an broader activity room function in the hours it is not being directly used as a dining area. That, to promote the homely feel of the home, the areas that are principally dedicated to people living at the home should be kept as such - and all staff notices and posters etc should be kept in discrete ‘staff’ areas. That clear criteria be put in place to ensure that staff working on a ‘PoVA first’ basis before the CRB check is completed are appraised in writing of their responsibilities to be supervised at all times. That the frequency of Regulation 26 visits to the home by the registered provider or a representative should be reviewed to ensure positive support for the new manager as she settles into the service. 3. 4. 5. OP15 OP15 OP15 6. OP19 7. OP29 8. OP31 Alver Bank DS0000022717.V373505.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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