Care Home: Echelforde Resource Centre

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What the care home does well People who use the service are provided with the information they need to enable them to make a choice about living at the home. Assessment documentation is in place to ensure the individual needs of residents can be met. Care plans and risk assessments are in place that ensure the physical and health care needs of residents are met. Residents are protected by the home`s storage and administration of medication procedures. People who use the service are provided with opportunities to improve their lifestyle, and where possible they are able to maintain contact with family. Special dietary needs are catered for. Meals are varied and choices are offered ensuring that residents receive an appealing and balanced diet. Residents are protected by staff having training and an understanding of adult protection issues. Staff are provided with training required to ensure the residents` needs are met. People who use the service are protected by the organisation`s recruitment policy and procedures. The arrangements for management and administration ensure the home is run in the best interests of residents What has improved since the last inspection? A falls audit has been carried out for the home and a completed copy of this audit was sent to the Commission For Social Care Inspection. A review of staffing levels was undertaken and a copy of this was submitted to the CSCI. All areas in the home have adequate supplies of hot running water. The tap in the identified residents bedroom has been repaired. What the care home could do better: Risk assessments should include the action to be taken when residents become exposed to the identified risk. Staff should discuss the care plans with residents to ensure consultation has taken place. The manager should contact and encourage visits from local church leaders to the home to enable residents to practice their religious beliefs should they wish to. The home should display the menu to enable residents to see the meals that are on offer. The alarm call system must be replaced or repaired to ensure the health and safety of residents is maintained at all times. The registered person must attend to the identified areas in regard to the environment as detailed in the report. CARE HOMES FOR OLDER PEOPLE Echelforde Resource Centre Echelforde College Way Ashford Middlesex TW15 2XG Lead Inspector Joseph Croft Unannounced Inspection 26th March 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Echelforde Resource Centre DS0000013890.V359322.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. Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Echelforde Resource Centre Address Echelforde College Way Ashford Middlesex TW15 2XG 01784 255225 0178 442 3243 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) manager.burroughs@careuk.com Care UK Community Partnerships Ltd Mr Edwin Phillip Steyn Care Home 50 Category(ies) of Dementia - over 65 years of age (50), Old age, registration, with number not falling within any other category (50), of places Sensory impairment (3) Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Not exceeding 50 persons within the categories OP, DE(E) and MD(E). Of the registered Service Users, 3 (three) named service users may be within the category SI. 12th June 2006 Date of last inspection Brief Description of the Service: Echelforde Resource centre is a purpose built single storey home for older people with dementia and is conveniently located for all the local shops and community facilities. The home is organised into five units, each with ten bedrooms. All accommodation is offered in single rooms. Each unit has its own lounge, dining area and small kitchen. The home is situated in good-sized grounds with safe and well-maintained gardens. There is ample car parking facilities to the front and side of the home. The fees at the home range from £408.00 to £780.00 per week Echelforde Resource Centre DS0000013890.V359322.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 Star. This means the people who use this service experience good quality outcomes. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 26th March 2008 using the ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the registered manager assisted him throughout. This site visit took place over a period of seven hours, commencing at 10:00 and concluding at 17:10. People living at the home prefer to be known as residents, therefore this term of reference is used throughout this report. The inspection process included a tour of the premises, direct observation of practice and sampling of residents’ care plans and risk assessments. Other documents sampled included the menu, records of medication, training records, staff recruitment files and health and safety records. The Inspector had discussions with the manager, six members of staff, a trainer who was providing training in regard to Dementia on the day of the site visit, four residents and one relative who was present at the time of this site visit. Residents informed the Inspector that they were happy living at the home, and were complimentary about the care they receive from staff, stating that the staff look after them well. Residents informed the Inspector that the food was very good, and they are offered a choice of foods. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the manager of the care home has been used as a source of evidence in this report. At the time of writing this report the Inspector had not received completed surveys from residents or staff. The inspector would like to thank the manager, members of staff and residents for their cooperation during this visit. Feedback was provided to the registered manager the end of this site visit. Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A falls audit has been carried out for the home and a completed copy of this audit was sent to the Commission For Social Care Inspection. A review of staffing levels was undertaken and a copy of this was submitted to the CSCI. All areas in the home have adequate supplies of hot running water. The tap in the identified residents bedroom has been repaired. Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 7 What they could do better: 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. Echelforde Resource Centre DS0000013890.V359322.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 Echelforde Resource Centre DS0000013890.V359322.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): Standards 1, 3 and 6 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with the information they need to enable them to make a choice about living at the home. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide. These documents include information in regard to the aims and objectives, accommodation, staffing at the home and complaints procedure. Care files for the most recent admissions to the home were sampled as part of the case tracking process. These provided evidence that prospective residents Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 10 had a pre- admission assessment undertaken prior to admission to the home, which included personal, health and social care needs. It was noted that one of the assessments had not been signed or dated by the person undertaking the assessment. This was discussed with the manager who stated this would be attended to. The manager informed the Inspector that Health Care Needs Assessments are obtained for those placements that are funded. The manager or a senior member of staff would also visit the prospective resident to undertake an assessment of their needs. Relatives and residents are encouraged to visit the home to meet other residents and staff. This was confirmed during discussions with residents, and also a relative, who informed the Inspector that their relative had an assessment of their needs undertaken before moving into the home. All new admissions are reviewed after six weeks. Care plans are developed from the pre-admission assessments. The home follows the organisation’s Admission and Discharge policy and procedure that was last reviewed in March 2007. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). The manager stated the home does not offer intermediate care. Echelforde Resource Centre DS0000013890.V359322.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): Standards 7, 8, 9 and 10 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans and risk assessments in place that ensure their physical and health care needs are met. Residents are protected by the home’s storage and administration of medication procedures. EVIDENCE: Three care plans were sampled during the site visit. Care plans were appropriately maintained and included information in regard to meeting the personal, physical and health care needs of residents. Care plans had been reviewed on a monthly basis and are also maintained on the homes’ computer that all staff have access to. It was noted that one care plan had not been signed or dated by the resident or their relative. The manager informed the Inspector this would be attended to. Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 12 The home uses the key worker system. Staff were knowledgeable in regard to the contents of care plans, and stated that these are reviewed on a monthly basis by the Team Leaders. One visiting relative informed the Inspector that they were aware of the care plan, that they attend the annual reviews and are always kept informed of important events affecting their relative. Residents informed the Inspector that they were not aware of the care plan. Discussions took place with the manager in regard to ensuring that residents are made aware of the contents of their care plans. The manager informed the Inspector that this would be followed up with staff, and would be recorded in the key working notes maintained by staff. A good practice recommendation has been made in regard to this. Care plans sampled contained risk assessments that included falls, nutrition, pressure sores and moving and handling. Evidence was observed that risk assessments had been reviewed regularly. The home has complied with the requirement made at the previous inspection in regards to undertaking a falls risk audit in 2006. The manager has since undertaken another audit for 2007, and informed the Inspector that falls are continuously monitored. Other risk assessments were in place and included Bartel care, continence and weight. On the day of the site visit it was noted that one resident had been smoking in their bedroom. The manager and staff were aware this does happen, however, there was no risk assessment in place. The manager made arrangements for this risk assessment to be put in place during the site visit. Discussions also took place with the manager in regard to risk assessments, in that that one did not provide guidance to staff of the action to be taken when the resident becomes exposed to the identified risk. A good practice recommendation has been made in regard to this. From discussions with staff and residents, and from viewing records, it was clear that residents have access to all health care professionals as required. These include a General Practitioner, Dentist, Optician and Chiropodist. Staff informed the Inspector that records of monthly weights for residents are maintained and the General Practioner undertakes annual health care checks. During discussions, residents informed the Inspector that the GP visits the home, and sees them in the privacy of their bedrooms; they see all other health care professionals when they need to. One relative stated that the staff keeps him informed of any medical appointments for his relative, ‘staff let me know everything.’ The home follows the organisation’s medication policy and procedure that was last reviewed in March 2007. Medical Administration Record sheets (MARs) are used for the recording of administration of medicines. MARs sheets sampled Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 13 during the site visit were accurately maintained with no omissions identified. The manager and staff informed the Inspector that only the Team Leaders who have received the appropriate training administer the medication. The local Pharmacist provides training in regard to the safe administration of medication to the senior staff. The home maintains records of medicines received and returned to the Pharmacist. Medicines were appropriately stored and kept secure in locked medicine cabinets. Staff informed the Inspector that only one resident self-administers their medication, and that a risk assessment is in place. Creams and lotions are kept in locked metal cabinets in residents’ bedrooms. Controlled Drugs are stored in secure metal cabinets, and a Controlled Drug register, that is signed by two members of staff, is maintained at the home. This was viewed during the site visit. The Controlled Drug register balanced with the amount of Controlled Drugs kept at the home. Residents informed the Inspector that they always receive their medication on time. During discussions, the manager stated that he undertakes an audit of the medication every two weeks to ensure medication is being appropriately recorded and administered. Staff informed the Inspector that they respect residents’ privacy and dignity through knocking on bedroom doors, calling residents by their preferred names and providing personal care in the privacy of their bedrooms and bathrooms. Evidence of these practices was observed during this site visit. Residents stated that the staff look after them well, and that they are always treated with respect. Throughout the site visit staff were observed to be interacting with residents in a professional manner, and providing support as and when required. Information provided in the Annual Quality Assurance Assessment (AQAA) informs that all residents have individual care plans that include personal choice and preferences according to their assessed needs. The Home has a contract with the local GP Surgery through the PCT who provide medical cover and support. Residents’ individual wishes are recorded within their care plan. Echelforde Resource Centre DS0000013890.V359322.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): Standards 12, 13, 14 and 15 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with opportunities to improve their lifestyle, and where possible they are able to maintain contact with family. Special dietary needs are catered for. Meals are varied and choices are offered ensuring that residents receive an appealing and balanced diet. EVIDENCE: The home employs an activity co-ordinator who organises activities twice a day from Monday to Friday. Activities provided include bingo, art and craft, exercises, music and reminiscence. The activity co-ordinator showed some of the work residents had done, in particular the making of bird feeders that will be put into the garden. External activities are organised and there is a list of all events taking place throughout the year. These included trips to the seaside, local events, pub lunches and other seasonal celebrations. It was noted that daily activity lists are not available for residents to see which activity is taking place. This was discussed with the activity co-ordinator who informed the Inspector that this would be attended to. Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 15 The home also has a day centre that provides activities for residents every weekday. Photographs of birthdays and other celebrations that had taken place were displayed in the entrance to the home. During discussions residents informed the Inspector that the activities provided are good, and that they are able to choose whether or not to join in. One activity was observed during the site visit. During discussions, staff and residents informed the Inspector that there are no restrictions on visitors to the home. This was confirmed during discussions with one visiting relative during the site visit who stated they could visit the home at any time, and are able to see their relative in private. All but one resident living at the home are white British, and hold Christian beliefs. Residents informed the Inspector that religious leaders do not visit the home on a regular basis. This was discussed with the manager who stated that the Roman Catholic Priest occasionally visits, however, he was aware that the church leaders do not visit the home regularly. A good practice recommendation has been made that the manager should contact and encourage visits from local church leaders to the home to enable residents to practice their religious beliefs should they wish to. The home uses an external company who provide cooked and chilled food to the home. The home has a four-week rolling menu that includes meat, fish, pasta, rice, vegetables and desserts. Each meal provides a choice, and the cook has discussions with each resident every day to ascertain their views on the meals they have had. They are also asked for their choice of meal for the following day. Staff and residents informed the Inspector that the food provided is always good, and there is a choice of meal. Residents stated they could have a different meal to the day’s menus. It was noted that the menu is not on display for residents or visitors to see the meals that are on offer. A good practice recommendation has been made in regard to this. Residents stated they have snacks and drinks throughout the day. Information provided in the (AQAA) informs that records on admission provide details in relation to lifestyle and interests to facilitate individual activities and care planning. Those who are able are assisted to go out and use local facilities such as shopping, optician, church etc. to promote the feeling of Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 16 independence. The AQAA states that there is a four-week rotating menu that offers a variety of choice. Echelforde Resource Centre DS0000013890.V359322.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Residents are protected by staff having training and an understanding of adult protection issues. EVIDENCE: The Commission For Social Care Inspection has not received any complaints in regard to the care home during the last twelve months. The home has a Complaints Policy and Procedure that includes the timescales for responding to the complainant and the correct contact details for the local Commission For Social Care Inspection office. This document clearly informs that complainants can contact the Commission For Social Care Inspection at time during the process. Copies of the Complaints Procedure were in the bedrooms that were viewed by the Inspector during the site visit, and a copy is displayed in the entrance to the home. During discussions residents and one visitor informed the Inspector that they knew how to make a complaint, but have not had the need to do so. Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 18 From discussions with staff it was clear that the home are proactive in regard to responding to, and resolving complaints made. Staff at the home follows the organisation’s Protection of Vulnerable Adults Policy and Procedure that was last reviewed in March 2007. A copy of the recent Surrey Multi-Agency Safeguarding Procedures is available in the office for staff to read. The training matrix provided to the Inspector evidenced that staff had received training in regard to Safeguarding Adults. The training plan for 2008 lists dates for all staff to attend refresher training that includes both practical and theoretical training. The manager informed the Inspector that he had attended the Surrey Multi – Agency training in regard to Safeguarding Adults. Staff informed the Inspector they had received training in regard to the Protection of Vulnerable Adults and read the Policies and Procedures in regard to this area. Scenarios in respect of abusive situations were discussed with three members of staff and the manager. They were able to demonstrate an understanding of Safeguarding Adults issues and the procedures to be followed. The manager informed the Inspector that Safeguarding is discussed during staff meetings. The Commission For Social Care Inspection was informed of a Safeguarding referral that has been brought to a satisfactory conclusion. Information provided in the AQAA informs that the home had made five safeguarding referrals during the last twelve months, one of which was in regard to a previous care home a resident had lived in. Four of these had been concluded and one is currently ongoing. The manager informed the Inspector that the Commission For Social Care Inspection are kept informed of all Safeguarding concerns. Information provided in the (AQAA) states that the home has a complaints procedure and all complaints are recorded. Residents are protected from abuse through POVA Training for staff, heightening their awareness of different types of abuse, and encouraging staff to have a greater understanding of specialist needs of individuals. Echelforde Resource Centre DS0000013890.V359322.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22 and 26 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible with a pleasant and homely atmosphere; however, identified issues must be addressed to ensure residents continue live in a safe and wellmaintained environment. EVIDENCE: A tour of the premises and the sampling of residents’ bedrooms were undertaken during the site visit. The accommodation is a purpose built single storey home for older people with dementia and is conveniently located for all the local shops and community facilities. The home is organised into five units each with ten bedrooms. All Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 20 accommodation is offered in single rooms. Each unit has its own lounge dining area and small kitchen. The home is situated in good-sized grounds with safe and well-maintained gardens. There is ample car parking facilities to the front and side of the home. There are laundry and hairdressing facilities, a sensory room and a day centre. Communal baths/showers and toilets had liquid soap dispensers and paper towels. Bedrooms sampled during the site visit were appropriately furnished and residents had their own personal belongings around them including family photographs and televisions. The home employs a team of domestic staff and a person working in the laundry. Discussions were took place with the housekeeper who informed the Inspector that all domestic staff had attended training in regard to Infection Control. The home was clean, tidy and free from offensive odours; however, the following issues were identified and discussed with the manager. Identified bedrooms require attention to the chest of drawers and a wardrobe. The thermostat in Windsor requires the cover to be replaced, and the toilet floor in Balmoral requires attention in regard to the hole that has been covered. The identified door into Sandringham has a door handle missing and one identified bedroom has a large hole in the wall behind the door. A requirement has been made that the identified areas around the home environment must be addressed. The manager informed the Inspector that the organisation is devising a fiveyear plan for the redecoration of all the care homes. It was noted that new carpets had been put into the home, and new walk in showers have been provided that are bright and easily accessible for residents. Discussions took place with the manager in regard to past Regulation notifications when some residents had left the grounds of the home. The manager informed the Inspector that risk assessments have been produced for this. It was noted that the garden area had been secured with a new fence and locks on the gates. Information provided in the (AQAA) states that the home’s bedrooms have been personalised as required by the Residents and their families. There are many other seating areas in the home that allow residents and relatives a variety of options from being very sociable to being able to sit and have some peace and quiet on their own. Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 21 Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 22 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): Standards 27, 28, 29 and 30 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory. Staff are provided with training required to ensure the residents’ needs are met. People who use the service are protected by the organisation’s recruitment policy and procedures. EVIDENCE: The home has a multi-cultural staff team that includes male and female staff. The manager informed the Inspector that he had undertaken a review of the staffing levels for the home, which was a requirement made at the previous inspection. A copy of this was forwarded to the Commission For Social Care Inspection local office. The home works an early and late shift duty rota. There are a minimum of two team leaders, seven care staff and one activity co-ordinator on the early shift. On the late shift there is one team leader, seven care staff and one activity cocoordinator. The manager is supernumerary to the duty rota. Each night there is one team leader and four waking night staff. The home employs a team of domestic and catering staff. The manager informed the Inspector that he considers the staffing levels for the home to be sufficient to meet the assessed needs of the current residents living at the home. Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 23 The AQAA informs that ten staff hold the minimum of NVQ level 2, and twelve staff are currently undertaken this training. The manager provided evidence to the Inspector that six of these had now completed their training and were awaiting their certificates from the training company. The home will have achieved 57 of the staff holding the minimum of NVQ level 2 when the other remaining staff complete their training. The home follows the organisation’s Recruitment Policy and Procedure that was last reviewed in March 2007. The recruitment files of three recently recruited members of staff were viewed. These each contained the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001, as amended, including an application form, full employment history, two written references, Criminal Record Bureau clearances, Protection Of Vulnerable Adults first (POVA) checks and proof of identification. Records of gaps in employment were explored with candidates and recorded. It was noted that one application form did not specify the actual dates or the month their employment commenced and ceased. This was discussed with the manager who has since informed the Inspector that this has been followed up, and that all recruitment files are being audited to ensure there are no other issues in regard to staff employment histories. During discussions, residents and one relative informed the Inspector that there was always a member of staff available to help them, feel that there is enough staff on duty and that staff at the home are very nice and helpful. Staff had received induction training and supervision records were evidenced. The organisation has a staff induction book that includes all the Common Induction Standards. Other training provided to staff includes Dementia, death, dying and bereavement, diversity and cultural awareness, nutrition and Activity Based Care. The manager informed the Inspector that the home has commenced using the E Learning programme that will enable staff to continuously update their mandatory training. Information provided in the AQAA informs that the home has a four-week duty rota available for all staff to ensure that sufficient numbers of suitable staff with the appropriate skills/qualifications are on duty at any given time. All staff have a full induction with ongoing training and development. The Home has over 50 of care staff either already trained to NVQ level II and above or working towards this. Echelforde Resource Centre DS0000013890.V359322.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, and their safety is promoted and safeguarded. The manager must attend to the identified issues in regard to the environment and call alarms to ensure people who use the service continue to be safe and protected from harm. EVIDENCE: The manager has worked in Senior Management of Residential Care with the organisation for five years. The manager informed the Inspector that he has been managing the home since 2005, completed the Registered Managers Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 25 Award (RMA) in April 2007, and is currently undertaking the NVQ level 4 which he hopes to complete in April 2008. Other training undertaken during the last twelve months includes Safeguarding Adults and the mandatory training as required. During discussions, staff informed the Inspector that the manager has an open door policy, is approachable and supportive. Staff stated that they receive supervision every two months, which was verified through the records maintained at the home. Quality assurance is undertaken through monthly meetings with residents. The manager informed the Inspector that the Alzheimer’s Society hold three monthly meetings with the residents in which they are able to discuss their views about the home and the care they receive. Four monthly meetings are held for relatives. Minutes of these meetings were evidenced during the site visit. Annual surveys are undertaken to ascertain the views of residents, their relatives and other associated professionals. The last survey was undertaken in October 2007. The manager has produced a summary of the findings that is available to residents, staff and relatives. The organisation conducts monthly Regulation 26 visits, and copies of these reports were available at the home. The manager informed the Inspector that residents and their families are responsible for their finances. The home holds small amounts of money for residents that are kept secure in a safe. Records of monies held were sampled for three residents. The records balanced with the money held in the individual accounts. The training matrix provided to the Inspector evidenced that staff are receiving the mandatory training as required. During discussions staff stated that they receive regular training, and that the training opportunities provided by the organisation are very good. Staff at the home follow the organisation’s Health and Safety Policies and Procedures that were last reviewed in March 2007. Evidence of staff training in this area was included in the training matrix. Information provided in the AQAA returned to the Commission For Social Care Inspection, informed that health and safety records are appropriately maintained and up to date. During this site visit the following records were evidenced. The annual servicing and monthly testing of the fire alarm systems, Portable Appliance Testing (PAT), electrical circuits, fire risk assessments and legionella. Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 26 Each bedroom had an alarm call, however, when tested by the Inspector staff failed to respond. This was due to the volume of alarm bells being very low. An engineer had tested this system in March 2008 and remarked that it is an old system that could do with an upgrade. The manager informed the Inspector that a request for a new system had been submitted to the organisation; however, this had not been attended to. A requirement has been made that the registered provider must replace or repair the alarm call system to ensure the health and safety of residents is maintained at all times. The Surrey Fire and Rescue Service visited the home in December 2007. They made one recommendation that the fire risk assessments should continue to be reviewed on a regular basis. Echelforde Resource Centre DS0000013890.V359322.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 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Echelforde Resource Centre DS0000013890.V359322.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. Standard OP19 Regulation 23 (2) (b) Requirement The registered person must attend to the identified areas in regard to the environment as detailed in the report. This will ensure that residents continue to live in a safe environment. 2. OP38 23 (2) (c) The registered provider must ensure that equipment provided at the care home for use by the residents and staff is maintained in good working order. The alarm call system must be replaced or repaired to ensure the health and safety of residents is maintained at all times. 26/04/08 Timescale for action 26/05/08 Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 29 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. 2. 3. Refer to Standard OP7 OP7 OP14 Good Practice Recommendations Staff should discuss the care plans with residents to ensure consultation has taken place. Risk assessments should include the action to be taken when residents become exposed to the identified risk. The manager should contact and encourage visits from local church leaders to the home to enable residents to practice their religious beliefs should they wish to. The home should display the menu to enable residents to see the meals that are on offer. 4. OP15 Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Echelforde Resource Centre DS0000013890.V359322.R01.S.doc Version 5.2 Page 31 - 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. 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