Care Home: Antokol

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What the care home does well The home is maintained in the Polish tradition and this ethos runs throughout the home, this enables residents to settle well into the home and it’s routines. All Polish holidays and celebrations are remembered and cherished. It was evident that residents have choice in their day and exercise their preferences in activities of daily living. Staff in the home enable residents to maintain a level of independence within a supportive environment without fostering dependency.AntokolDS0000006883.V375317.R01.S.docVersion 5.2The home is maintained in a clean tidy and hazard free manner. Bedrooms were personalised and ongoing upgrading has significantly improved the accommodation for residents to live in. The food is very good, freshly prepared and served in congenial surroundings. What has improved since the last inspection? The home had worked hard to address the requirements arising out of the last key inspection. It was evident that more information was obtained in respect of residents prior to admission; the care plans were more comprehensive and reflected physical, mental, and social and rehabilitation needs of the resident. Quality assurance measures had improved and the views of staff, residents and visitors to the home, had been obtained. Mr Novac has completed the process to become the Registered Manager and has started the NVQ in care. What the care home could do better: The home needs to develop further skills in dealing with those residents who have Dementia, in particular staff need to be aware of incapacity issues. Staff need to be alert to safety issues in the home and appropriate activities for Dementia residents need to be developed. Staff must be supplied in sufficient numbers to address residents increasing dependency. Efforts to ensure staff are competent in spoken and written English must continue to enable them to communicate effectively and get maximum benefit from training they attend. Key inspection report CARE HOMES FOR OLDER PEOPLE Antokol Antokol 45 Holbrook Lane Chislehurst Kent BR7 6PE Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 1st May 2009 10:00 DS0000006883.V375317.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Antokol Address Antokol 45 Holbrook Lane Chislehurst Kent BR7 6PE 020 8467 8102 020 8468 7190 antokolhome@btconnect.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) Polish Citizens Committee Housing Association Limited Peter Nowak Care Home 34 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 34 10th June 2008 Date of last inspection Brief Description of the Service: Antokol is a large detached house built in 1905. It was extended in 1986 and can now provide care to thirty-four elderly Polish people living in this country. The home maintains the Polish traditions, which the residents were accustomed to in their younger days. Stairs and a lift access all areas in the home. All the rooms have wash-hand basins. The bathrooms, shower room and toilets are located on both the ground floor and first floor. Some of these facilities have special adaptations and equipment to meet the needs of the residents. The ground floor provides spacious sitting areas a library, and a large dining area. Bedrooms are located through out the ground and first floors Residents may have telephones in their own rooms at their own expense. A pay phone is provided for both incoming and outgoing calls. There is a large garden to the rear of the building. There is parking to the front of the home and some off street parking available. In 2007 the home varied its registration categories to admit Dementia residents and frail elderly residents. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 5 Staff are provided throughout the day including waking night staff. The fees in this home range between £500.00 to £610.00 per week for care and accommodation. Extra costs are payable for items such as chiropody hairdressing personal toiletries. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 2 star. This means the people who use this service experience good. Prior to the inspection the Manager had filled in the AQAA and forwarded this to the CSCI. This had been well completed and provided good information on which to base the site visit. The inspection was conducted over one and a half-day period. The Manager facilitated the two site visits. Periods of observation were undertaken on the first visit. Twelve comment cards were provided and returned during the inspection including six from residents and six from staff. During the visit the inspector met with two relatives and several residents. Staff were interviewed as part of the site visit. All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans, staff personnel files as well as health and safety records. Feedback was provided to the Manager at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. What the service does well: The home is maintained in the Polish tradition and this ethos runs throughout the home, this enables residents to settle well into the home and it’s routines. All Polish holidays and celebrations are remembered and cherished. It was evident that residents have choice in their day and exercise their preferences in activities of daily living. Staff in the home enable residents to maintain a level of independence within a supportive environment without fostering dependency. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 7 The home is maintained in a clean tidy and hazard free manner. Bedrooms were personalised and ongoing upgrading has significantly improved the accommodation for residents to live in. The food is very good, freshly prepared and served in congenial surroundings. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 8 order line – 0870 240 7535. Antokol DS0000006883.V375317.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 Antokol DS0000006883.V375317.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. People using the 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 pre-admissions procedures provide residents with the information they require prior to any decision regarding placement being made, to establish whether the service is right for them. Staff have information to ensure they can meet individual residents’ needs and on which to base an initial care plan. EVIDENCE: At the time of the inspection there were 31 residents on site there were three bedrooms vacant. One resident was in hospital. We sampled admission procedures for two residents in the home. The two residents case tracked, included a new admission and a resident who was seen Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 11 at the previous visit. In the first file inspected there was information received prior to admission All residents are assessed by a Manager, unless exceptional circumstances occur. One residents who had been admitted from abroad, had not been seen prior to admission, although information on the residents health needs had been obtained prior to admission. The home has it’s own assessment form which outlines the activities of daily living information and includes details of all health issue including the residents weight and any allergies they may suffer. All residents are subject to a trial period of four weeks, which allows time for a fuller assessment and to see if, the resident settles. There is an admission checklist, which shows you at a glance whether things have been completed. Other information included personal details such as next of kin. Details of how the placement would be funded were retained on file, including the weekly fees and additional charges. The Manager advised us that Community Care Assessments were provided in advance of any Local Authority placement being made. Those admission records looked at were for residents who were self funding hence there was no local authority assessment information. Information included in resident surveys indicated that they had been provided with information regarding the home and had been issued with contracts. The AQAA indicated that residents are provided with information prior to admission and preliminary visits including over night stays are welcomed. Antokol DS0000006883.V375317.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 0. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that their care needs will be met by staff in the home supported by members of the multi disciplinary team. Care plans are in place, and reflective of residents needs and sufficiently detailed to enable staff to deliver the care. Medications were safely managed which provides protection to residents. EVIDENCE: Care plans are being completely redeveloped by the new Deputy Manager with assistance from the Manager of another home. Two care plans were selected for case tracking and included the latest admission. The first resident’s care plan, was that of a gentleman with whom we met. This gentleman was able to converse easily in English and was able to tell us what his care was like. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 13 His care plan was one, which had been done using the new format. The care plan was well organised and contained a clear photograph of the resident. It was to a much better standard and provided information on the resident’s identified needs, potential risks and other relevant information. The care plans and supporting risk assessments were written in Polish and English. Those problems, which were identified, had good interventions recorded, which is the information staff need to deliver the care. The mental health section included information on areas such as mood engagement and communication. The daily events were written in English only. This was introduced to encourage staff to use English and gain experience in writing it. A Polish translation sheet was available to assist staff in translation. Residents, or their advocate’s signatures were not recorded in the care plans, this need to be included as evidence that they have been involved in the development of them. The AQAA indicated that residents and their advocates were involved in developing the care plans. There was sheet for recording of visits made by members of the multidisciplinary team and a separate sheet for vast by the GP. Those care plans looked at had weight charts in place and nutritional risk assessments. The MAR charts were well completed with no gaps evident. Allergies were recorded on the charts. Records of medications received in to the home as well as those disposed of were retained. The homely medications, which staff can administer without a prescription, were confirmed by the G P. There were four residents in the home who self administer their own mediations. These residents are issued with a cassette on a weekly basis. The GP confirms that the resident is able to undertake self medicate. Secure storage is supplied in bedrooms. Staff monitor compliance by observation and checks on medications. There were risk assessments to address these procedures. There are six staff that administer medications and a signature list was on site. These staff have been assessed as competent to undertake the administration of medications have a good command of spoken and written English and have had additional training. The Primary Care Trust pharmacist had been in and done training with staff, she was planning to repeat this at some time in the near future. In addition the supplying pharmacist had done training with staff. The home felt that they received a good service from the chemist. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 14 The medication policy may need to be expanded upon to deal with the specific issues those Dementia residents present, such as refusal of medication and covert administration. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a lack of appropriate activities and engagement for some residents specifically those resident suffering from Dementia. Choices are provided which means residents are enabled to input into their day, although again greater understanding of Dementia would be of benefit to staff, to maximise resident’s independence. Meals are appetizing, provided in good portion size and reflect the resident’s choice and preferences. EVIDENCE: Periods of observation were undertaken during the first day of the key inspection. It was evident that choices were incorporated into every day lives. Staff in the main promoted independence even though this at times was very time consuming. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 16 There is a mix of dependency and varying levels of orientation amongst the residents. This is due to the two categories that the home admits, namely older people and those with Dementia. We observed that those residents with Dementia, although well cared for physically received less social interaction and engagement from staff, perhaps because of the resident’s limited abilities. More time and effort must be made to ensure all resident have sufficient social and leisure activities to maximise their well being. The home should look into group and 1: 1 activities that are beneficial with Dementia residents. The mid morning drink provided residents it a choice of hot or cold drinks with a selection of sweet and savoury snacks. Lunch was well presented, during the meal engagement between residents was good and signs of well-being were evident. Within the surveys cards the food received good comments. Food in this home is traditional Polish although other choices are available. All food is freshly prepared with the emphasis on using good quality produce. The kitchen was immaculately clean and well stocked with a wide variety of quality food and drinks including English and Polish food. Fresh fruit and vegetables were available. Mealtimes can be flexible to meet the resident’s needs. Drinks and food are provided on demand at any time. We met with one gentleman who on admission had been very unsettled. He had now settled well into the home and was enjoying his stay; he had made friends with other residents and admitted at first was very annoyed at being in the service. He stated that he enjoys staying in his bedroom for the majority of the day although goes to the dining room for meals. We met with several residents, all of whom expressed satisfaction with the service the staff and care that they received. The home has a chapel service every Friday and Sunday at 3pm. The presence of the religious sisters, who partly staff the home, were said to give a tranquil spiritual feeling to the home. Within the AQAA the home indicated that they need to provide more varied activities to include outside trips and complimentary therapies. This needs to be actioned. Please see requirement 1. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that any complaints will be actioned. Staff have sufficient knowledge and guidance to know how to action suspected abuse and raise concerns through whistle blowing. EVIDENCE: There have been new policies and procedures developed and put into general use since the last inspection to cover whistle blowing, POVA, codes of conduct and bulling. The policy for abuse needs to be clear in cases where abuse is suspected, an immediate referral to the Local Authority must be made prior to the home commencing it’s own investigation. All staff have been made aware that these are in place and need to be adhered to. Staff members met with us and were asked about adult protection whistle blowing and dealing with complaints. Although some staff did not have an in depth knowledge of the subjects they had sufficient knowledge to know that these must be reported on to senior people. One staff member had a very limited knowledge of whistle blowing although said that this was something she would report. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 18 Staff said that they had received training on the subject including training through Bromley Consortium. The home has purchased a video in relation to adult protection and use this as part of training on this subject. Any future training should incorporate scenarios of when it may be necessary to report issues through whistle blowing. Training on the” Deprivation of Liberty Act”, had been undertaken however this is a difficult subject and further training will need to be put in place particularly as the home has residents with Dementia. Within the complaints file the last one recorded was 18/4/09. There was good information retained relating to the investigation. The home needs to indicate if the complainant was satisfied with outcome and develop a complaints log to establish if there are any emerging themes within complaints. On the second site visit this had been addressed. The AQAA told us that residents were aware of their rights and the complaints procedures. In addition they added that the service receives low numbers of complaints. The CQC has been advised of one adult protection and no other complaints. There has been an ongoing Adult protection issue, which the Local Authority and CQC has been involved in. This has now been concluded and no further action will be taken. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the 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 is well maintained, in a domestic style and provides clean, comfortable and safe accommodation for residents to live in. EVIDENCE: Antokol is located in a quiet road in Chislehurst. There are buses, which run from the end of the road, although public transport is not ideal and it would be a long walk for residents to get to public transport. The home is an adapted building maintained in a domestic manner. All areas in the home were clean tidy and well maintained. The home was hazard free and equipment safely stored. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 20 Many areas in the home have benefited from refurbishment. The exterior of the building has been decorated. Several bedrooms have been upgraded and redecorated. At the time of the site visit the medical room was being enlarged. A new staff toilet had been located on the first floor. The laundry had been refurbished. Additional lighting has been installed and this means areas are well lit, to assist with the prevention of accidents. Bedrooms were personalised and many residents had items of furniture pictures and other items. In the bedrooms the windows have chains to act as restrictors – whilst these serve the purpose a more domestic style of restrictor should be investigated. In the first floor area, which is staff accommodation and easily accessible to residents, there was a window which was not restricted. This was addressed as the inspection progressed and a restrictor fitted. Equipment such as assisted baths, hoists and pressure relieving mattresses were in use. The garden is to the rear of the home and is well maintained. New fencing has made this are more secure. It is important that all areas are safe for residents to access, as those residents who suffer from dementia may not recognise dangers. Ramps into the garden and the front entrance make it easier for those with mobility difficulties. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,28 29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are provided in sufficient numbers to meet the minimum standards however with more dependent residents these need to be reviewed to reflect the residents needs. Staff are trained although more training around resident’s conditions and presenting problems would equip them with skills they need to fully address care. Recruitment procedures ensure staff are safe to work in the home. EVIDENCE: On the day of the inspection there were three managers on duty with seven care staff, two domestics and thee cooks. The off duty rotas indicated sufficient staff were employed. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 22 One ancillary staff that had worked in the home for several years felt that of late the home had settled down after a period of upheaval with changes to management and staff causing some discontentment. The comment cards received from resident all had comments about staff. One said, “ staff are trying to do their best but most important they are gentle, caring and understanding. All comment cards received, expressed concerns at the number of staff and the increased levels of resident’s dependency. The Manager must ensure that dependency levels are taken in to consideration when staffing rotas are drawn up. It must be remembered that dependency can change and this will affect how the home is staffed. The home has signed up to become a member of the Bromley Care Homes Training Consortium. This forum offers varied and regular training to staff in residential care homes on pertinent topics. Two staff have recently attended Dementia training in Guilford and more training on Dementia is being sought. Staff personnel files were sampled. Those selected were for Polish staff and they worked as carers. The information in the personnel files was well organised and easy to find. The files contained an application form, which detailed the applicant’s work history and education. The references were in the file and related to previous employment. There was confirmation of the employee’s identity including Polish ID cards, passport, National Insurance details and driving licences. Equal opportunities monitoring form is attached to the application form. Staff complete a self health declaration form. In the event that health issues were identified then a referral would be made for further investigations and reports. The inspector could not locate the POVA checks or CRB in some files as these are stored securely by the Manager and separate from the main personal file. The Manager needs to look at he current CRB guidance in respect to retaining CRB’s. There were documents in the file which outlined terms and conditions. Job description are issued, in English and the home must be satisfied that the staff members are able understand these as they may not have sufficient skills to read English. There was a record of the in house induction that the employees had undertaken, as well as certificates in relation to training attended. Induction includes the statutory topics as well as a tour of the home, routines and an introduction to policies and procedures. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 23 All staff are subject to a three month probationary period and during this time are supervision for at least one hour every fortnight. This is recorded and retained. Supervision has improved and the newly developed policy sets out specific guidance to address this including the frequency content and reasons for it. . Within the AQAA it was stated that the home are looking to recruit an additional male carer in order that gender care issues can be fully met. We met with staff and discussed topics, which related to their work, the type of resident in the home and adult protection. They confirmed that training was provided and lately supervision had been commenced. Please see requirement 2. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. People using the 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 sufficient management hours to ensure it is well run. Health and safety measure are in place to maintain the environment safely for residents. Quality assurance measures have been newly developed and incorporate the view of the resident’s staff and all stakeholders involved with the home. EVIDENCE: Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 25 Mr Nowac has completed the process to become the Registered Manager under what was the CSCI and now the CQC. He is now doing NVQ level 4 in care, which will enhance his skills in this field. The home’s management structure and personnel has changed, and it now includes the Manager, the Deputy and a Care Manager. This provides good management support and better opportunities for the management team to audit procedures, observe practises and supervise staff. The home is part of the National Care Homes Association and uses some of their documents as templates and publications to keep abreast of development in the care home sector. The Regulation 26 reports were on site, the home is using the format issued by the previous regulatory body the CSCI. The reports reflected that monthlyunannounced visits took place at different times of the day and these were satisfactory. A staff survey had been conducted April 2009. In addition a relatives and multidisciplinary team members survey had been sent out seeking their views on the service. The home is waiting the responses to the questionnaires and once received a report will be collated. Minutes indicting regular staff meetings were on file. They were recorded in Polish and English. Supervision has just started with staff. The standard supervision form was viewed and covered all items required. The home had commissioned a health and safety audit of the premises; the report arising from this was viewed. Generally the finding were satisfactory although did refer to the category and type of resident in the home and alerted staff to special precautions, which need to be in place to keep residents safe. The inspector sampled a number of health and safety records. There were a number of manuals relating to health and safety in care homes. Those certificates and service records seen were found to be satisfactory. The annual gas service had been conducted November 2008. Portable electrical appliances had been tested although the document was without electrician’s signature or stamp to validate it, this needs to be addressed. Fire equipment had been inspected January 09 and April09. Fire safety had been conducted frequently during 2008 and 2009 these had the staff signatures in place as proof as attendance. The employers liability insurance was on display and valid. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 26 Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 3 3 3 X 3 Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 28 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 OP12 2 OP27 18 Standard Regulation 12 Requirement Appropriate activities must be provided for residents in the home to enhance their well being. Staffing numbers need to be reflective of resident’s dependency to ensure they provide the best service for residents. Timescale for action 30/07/09 30/07/09 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 OP12 Good Practice Recommendations The Registered Manager should review the activities provision within the home in light of the varying abilities of the resident population. Antokol DS0000006883.V375317.R01.S.doc Version 5.2 Page 29 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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