Care Home: Fir Tree House

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What the care home does well The home operates an admission procedure ensuring that all residents have a needs assessment undertaken. This determines if the home can meet prospective resident`s specific need. Contracts of occupancy are also in place. Residents live in a clean and homely environment, which is decorated to a good standard. Communal space is ample and there and there are two lounges providing residents with a choice depending on if they want to sit quietly or be more actively involved. Resident`s bedrooms are personalised to reflect individual personalities. Care plans are well maintained and outline individual care provided and how this care is carried out. Regular reviews of care are undertaken. Appropriate arrangements are in place to meet resident`s health care needs. There is good support from the GP and other health care professionals. The medication administration procedures protect the residents living in the home. Residents are supported to maintain family and friendship links and visitors are welcome in the home at any reasonable time. Several relatives were seen to take an active role during visiting and help with feeding and activities. Staff are employed in sufficient numbers to meet the current needs of the residents. Training and development plans are in place to ensure that the staff team have the skills and qualifications to undertake their specific roles and responsibilities. Staff recruitment protects residents living in the home. The home is managed by an experienced and qualified manager in the best interest of the residents. The health, safety, and welfare of the residents and the staff are observed and promoted. What has improved since the last inspection? The requirements made at the last inspection have been met or currently being addressed. Contracts of occupancy now include an outline of additional charges made which are not included in the fees. Individual risk assessments have been updated to include safe manual handling procedures. Residents are supported to make further choice regarding activities they participate in, and in the care they receive in respect of their continence programmes. A qualified chef has just been employed to manage the catering issues in the home and to improve the quality and standard of the meals provided. The safeguarding procedure in the home has been reviewed in line with local authority procedures. Staff training and development has improved and the staff duty rota outlined that staff are employed in sufficient numbers to meet the assessed needs of current residents. Formal staff supervision is now in place. What the care home could do better: Several relatives were visiting the home and had many concerns about the standard of catering. This was a requirement at the last inspection. The home has now employed a qualified chef who had commenced work the week of the inspection. A lengthy discussion took place between the chef and the inspector and his plan of action to improve the standard of catering was seen. This included a review of the menus, the use of fresh produce and the introduction of a choice of food. It was agreed that the manager and the chef have weekly meetings with residents/relatives to monitor the provision of meals and this to be recorded formally. The provider should ensure that their monthly visits to the home under regulation 26 record all the concerns expressed by a residents, relatives, staff and maintenance issues and the actions taken to address them. Reports to be retained in the service for information. The home has an ongoing problem with the lift breaking down. This was referred to in the previous inspection. On arrival in the home the inspector was informed that the lift was "out of order again and had been for the previous three days". There was an engineer on site repairing this and the lift was in working order when the inspector left the home. Residents and relatives were very annoyed about this as seven residents were isolated in their rooms on the first floor. The manager agreed to notify The CSCI of further breakdowns in order that the welfare of the residents can be monitored. Where furnishings and carpets are soiled or worn they should be adequately cleaned or replaced in order to ensure no loss of dignity to residents living in the home. CARE HOMES FOR OLDER PEOPLE Fir Tree House 2 Fir Tree Road Banstead Surrey SM7 1NG Lead Inspector Mary Williamson Unannounced Inspection 14th January 2009 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 Fir Tree House DS0000013321.V373752.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. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fir Tree House Address 2 Fir Tree Road Banstead Surrey SM7 1NG 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) 01737 350584 Mr Salim Jiwa Maria Varnava Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 2 beds may be used for Respite and Short Term Care Date of last inspection 31st January 2008 Brief Description of the Service: Fir Tree House is a large detached converted domestic property situated on the main A 217. It is close to the community amenities of Banstead Village. The home is registered to provide nursing care for up to thirty-five older people. Accommodation is arranged over two floors with access to the first floor via a passenger lift. Resident’s accommodation consists of twenty-five single and five shared bedrooms. Eight bedrooms have en-suite facilities. Communal space includes two lounges incorporating dining areas in both. There is a conservatory, which can also be used as a visiting area. The garden is mainly a patio. The fees for residential care are currently £600 to £700 per week, depending on the services and facilities provided. Additional charges are made for newspapers, hairdressing, chiropody, transport, and toiletries. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall rating for this service is a TWO star rating. This means that people who use this service experience GOOD quality outcomes. This was the first site visit of a key inspection and was unannounced. The inspection was undertaken by Mary Williamson Regulation Inspector over five hours. The Registered Manager Maria Varnava represented the service for the duration of the inspection. A tour of the premises was undertaken and records relating to the care of the residents and the management of the home were examined. It was possible to meet all the residents in the home and talk with some in detail about their experiences about living in the home. Discussions with staff took place and care practice observed. Several relatives were visiting the home and the inspector had opportunity to introduce herself, explain the inspection process and gain feedback on their views about the home. The manager completed an Annual Quality Assurance Assessment (AQAA), and some of the information provided in this document has been referred to in this inspection report. The Commission for Social Care inspection would like to thank the residents, relatives and staff for their assistance and hospitality during this inspection. What the service does well: The home operates an admission procedure ensuring that all residents have a needs assessment undertaken. This determines if the home can meet prospective resident’s specific need. Contracts of occupancy are also in place. Residents live in a clean and homely environment, which is decorated to a good standard. Communal space is ample and there and there are two lounges providing residents with a choice depending on if they want to sit quietly or be more actively involved. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 6 Resident’s bedrooms are personalised to reflect individual personalities. Care plans are well maintained and outline individual care provided and how this care is carried out. Regular reviews of care are undertaken. Appropriate arrangements are in place to meet resident’s health care needs. There is good support from the GP and other health care professionals. The medication administration procedures protect the residents living in the home. Residents are supported to maintain family and friendship links and visitors are welcome in the home at any reasonable time. Several relatives were seen to take an active role during visiting and help with feeding and activities. Staff are employed in sufficient numbers to meet the current needs of the residents. Training and development plans are in place to ensure that the staff team have the skills and qualifications to undertake their specific roles and responsibilities. Staff recruitment protects residents living in the home. The home is managed by an experienced and qualified manager in the best interest of the residents. The health, safety, and welfare of the residents and the staff are observed and promoted. What has improved since the last inspection? The requirements made at the last inspection have been met or currently being addressed. Contracts of occupancy now include an outline of additional charges made which are not included in the fees. Individual risk assessments have been updated to include safe manual handling procedures. Residents are supported to make further choice regarding activities they participate in, and in the care they receive in respect of their continence programmes. A qualified chef has just been employed to manage the catering issues in the home and to improve the quality and standard of the meals provided. The safeguarding procedure in the home has been reviewed in line with local authority procedures. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 7 Staff training and development has improved and the staff duty rota outlined that staff are employed in sufficient numbers to meet the assessed needs of current residents. Formal staff supervision is now in place. 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. Fir Tree House DS0000013321.V373752.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 Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about living in the home. Contracts of occupancy and pre admission needs assessments are in place. The home does not provide intermediate care. EVIDENCE: The home has a statement of purpose and residents guide in place. This is available to all prospective residents and their relatives prior to admission in order for them to make an informed choice about choosing Firtree House to live in. A copy of this document is also available in individual bedrooms for information. Contracts of occupancy are in place. All residents are issued with a contract on admission to the home. This outlines the accommodation offered, the level of care provided the fees charged, and the method and frequency of payment. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 10 All prospective residents have a needs assessment undertaken prior to admission in order to establish the suitability of the placement. This is undertaken by the manager who will be able to clarify if the home can meet individual specific needs. Three assessments were seen and are detailed and informative. The home does not provide intermediate care. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans outline resident’s health, personal and social care needs. Appropriate arrangements are in place to meet resident’s health care needs. The medication policy protects residents in the home who are also treated with dignity and respect. EVIDENCE: Individual care plans are in place. These are written on information gathered from the pre admission needs assessment, input from the residents whenever possible, information received from relatives and reports from other health care professionals. Other information contained in the care plans included risk assessments, wound management charts, daily records of care provided and visits from health practitioners. The care plans sampled are well maintained and reviewed on a regular basis. Relatives stated that they were consulted about care plans and reviews; one said that “mum would not be able to understand but I am kept informed”. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 12 Residents are registered with a local GP who visits the home every Friday or on request. Chiropody is provided both privately or by NHS. Domiciliary visits take place for dental care and eye tests. Currently there is one resident with a pressure sore and this is being manager by the tissue viability nurse who is a member of staff. There is a wide range of pressure relieving equipment available ripple mattresses, air cushions, and a profile bed. Residents looked well groomed. A relative commented “dad always looks clean shaven and well dressed” another comment, “mum’s hair always looks nice”. Residents being nursed in bed were comfortable and well cared for. The home has a medication policy in place. Staff administer medication in accordance with this policy and The Nursing and Midwifery Council’s (NMC) Code of Professional Conduct. Medication is supplied to the home by Rosehill Pharmacy Carshalton. The proprietor of this pharmacy is also the provider of the home. Medication recording charts (MAR) were seen and are well maintained. The MAR charts also include audit trails of medication entering and leaving the home. The manager stated that she purchases training for the staff from Boots as this is the most appropriate training. Oxygen cylinders are stores correctly and a fridge is available for the safe storage of some medication. Residents are treated with dignity and respect and privacy is observed. Staff were seen to interact with residents in a polite and respectful manner. They were observed to knock on resident’s doors prior to entering. Screens are provided in shared rooms. A conservatory is provided for private visits or for residents wish to have a meal with relatives. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A limited selection of social activities is made available to residents, who are also helped to exercise choice regarding daily living. Family and community links are maintained. Improvements have been made to the poor standard of meals being offered to residents which is currently being formally monitored by the home. EVIDENCE: The home has an activity programme in place which includes bongo, skittles, quiz, board games and floor basket ball. Two staff members have undertaken a study day in activities and coordinate this programme. There is also a music and movement session provided on Tuesdays by an independent therapist. Monthly entertainment is also provided who also provide music for parties and special events. A resident stated that “I do not like to participate in activities and enjoy my own company” one stated “I like a quiz”. Relatives stated that they sometimes organise activities in the lounge. A relative also said that the activities depended on the staff on duty. Family and friendship links are maintained and visitors are welcome in the home at any reasonable time. The relatives spoken to are very active in the Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 14 home, visit regularly take part in care planning and reviews attend relative/residents meetings and take residents out. Spiritual needs are supported and a church service takes place every other Sunday, and Holy Communion provided every Sunday. Visits from all clergy are arranged on request. Residents are supported to make choice regarding aspects of their daily life. A resident stated that she can get up and go to bed when she wants to. A staff member said that residents are given the opportunity to choose what they were, and how they spend their time. However this was restricted on the day of the inspection as the lift was out of order confining seven resident to their rooms. Residents accommodated in rooms above the ground floor who are unable to access communal facilities for activities when the lift is unavailable, should be risk assessed to ensure this does not lead to social exclusion and risk of being isolated. The manager explained that since the last inspection residents are not restricted to a structures continence programme and a more flexible approach is in place. At the last inspection the standard of catering in the home was assesses as poor. Relatives were concerned about the standard of meals being provided, the lack of fresh produce being used, and the choice of food available. The home tried to resolve this issue by providing more training and support for the cook, however relatives stated that the situation did not improve, and the food continued to be unappetising or wholesome. The home has now employed a qualified chef who had commenced employment the week of the inspection. It was possible to have a lengthy discussion with him about his plans to implement and action plan to improve the standard of meals in the home. The chef has several years experience and has a good understanding of the nutritional needs of the elderly. He has started to plan the menus over a four week cycle, and establish an ordering system with the local butcher and greengrocer. Lunch was observed and included pork casserole fresh vegetables and boiled potatoes, followed by milk pudding or fresh fruit salad. All residents and visiting relatives stated that this was a vast improvement to what residents had been used to and were looking forward to more home cooked food. Staff were observed offering support to residents who required help with feeding. Relatives were also observed feeding residents. A heated trolley is provided to keep food hot until staff are available to help with feeding. The inspector recommended that the manager and the chef monitor feedback from residents/relatives and staff regarding the standard of the food provided and to maintain this information in the home for inspection. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure and safeguarding vulnerable adult’s procedure in place protect the residents living in the home. EVIDENCE: The home has a complaints procedure in place which is included in the residents information guide. The manager stated that no formal complaints were received in the home since the last inspection. There was opportunity to talk with several relatives who were visiting the home. Two relatives felt that if they have cause for concern than the manager and deputy manager were prompt in dealing with issues within their control. They also felt more confident that the catering arrangements were now been addressed. The home also maintains a compliments and appreciation folder. The home has a safeguarding procedure in place and all staff undertake training in this procedure. There is a copy of Surrey’s Multi Agencies policies and procedures on Protecting Vulnerable Adults in place and the manager has attended local authority training in these procedures. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 16 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, 20, 22, 24, and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and comfortable environment that is suitable for its stated purpose. The home has been adapted to meet the mobility needs of the residents. However the unreliability of the lift adversely effects the well-being and independence of the residents and must be monitored. EVIDENCE: Residents live in a homely and comfortable environment. There is a programme of routine maintenance and refurbishment in place. Communal space includes two large lounges/ dining areas, a conservatory and secure garden with seating for residents sit and enjoy in the fine weather. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 17 The home has a shaft lift to access the first floor. Visiting relatives spoke of the lift being frequently out of use, and the impact this has on residents living on the first floor. The current episode had left the lift out of order for three days whilst a part was obtained. The manager was observed to address concerns of relatives in a reassuring way. Although the lift was repaired by the conclusion of the inspection the provider must now review the safety and maintenance of the lift and take action to ensure that the lift is in good working order at all times. Bedrooms are comfortably furnished and personalised according to residents needs. Shared rooms have screens to maintain privacy. Mal odour was present in one room which had been identified and being managed by the home. Carpets that are either worn, soiled, or present mal odour must be either deep cleaned or replaced in order for residents to live in a home that promotes their dignity. The residents spoken to said that they liked their rooms. One resident said she “enjoyed the view and the birds”; another said she “liked the company in the lounge but also enjoyed time alone”. There is an infection control policy in place and all staff undertake training in this policy. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the number and skill mix of staff on duty. Training is ongoing and the staff recruitment protects residents living in the home. EVIDENCE: The staff duty rota was seen and allocated staff on duty was sufficient to meet the current residents needs. The manager explained that the number of staff fluctuates according to the number of residents living in the home. It was recommended that the number of staff does not fall below the current number in view of the complex needs of the current residents. Staff training is ongoing, and all staff undertake induction training overseen by the home manager. She is also the manual handling trainer for the home. Some staff have completed an English Language course facilitated by Merton College. NVQ is ongoing at various levels. Staff have achieved NVQ level 2 and others are undertaking this while more have achieved NVQ level 3. Mandatory training is accessed through The Surrey Care Homes Association, or at NESCOT College. Staff recruitment procedures in place protect residents living in the home. Three staff recruitment files were randomly sampled. These are well Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 19 maintained and include all the required employment documentation including two written references, an employment history and a Criminal Records Bureau (CRB) disclosure. No staff work in the home without a POVA first check. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced manager in the best interests of the residents. Resident’s financial interests are safeguarded and the health, safety and welfare of staff residents and staff are protected and promoted. EVIDENCE: The home is managed by an experienced manager who has been in post for nine years. She is a Registered Nurse and has achieved her registered manager’s award and an NVQ level 4. She manages her time effectively between a hands - on manager and allowing herself two days for administration responsibilities. She has the support of a full time deputy manager who is also a registered Nurse. Residents and relatives felt supported Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 21 by the management structure in place and stated that when they have concerns that that the manager will try to resolve issues as quickly as possible if they are within her control. Quality assurance was discussed with the manager and the systems in pace to monitor this. The manager is in daily contact with residents and spends time each morning listen to their views and any concerns they may have. Monthly regulation 26 visits are undertaken. The provider must record and include in this, current monitoring of the service and action taken to address issues brought to his attention by residents, relatives, and staff including the Registered Manager. Although current monitoring under regulation 26 takes place, no action plan or records were seen that related to the actions taken in respect of the problems with the lift, catering, and cleaning carpets. Regular resident/relative meetings take pace and issues noted. The AQAA states that that residents are asked to complete a quality questionnaire with support from families where appropriate. Results of surveys are shared with staff and appropriate action acted upon. There are procedures in place to safeguard resident’s finances. The manager stated that the home does not handle personal finances for any residents and any charges for newspapers, toiletries, chiropody and sundries will be invoiced to the appropriate designated representative. Following the previous inspection a requirements was made that staff must receive formal supervision. This has now been addressed and staff receive formal supervision six ties a year. The manager stated that this is recorded on personal files. There is a wall planner in the office indicating identified dated for individual staff. The manager also works along side the staff daily to monitor and supervise care practice. Health and safety policies and procedures are in place to promote the health, safety, and welfare of residents and staff. All staff undertake training in these policies as part of their induction training. Staff were observed using appropriate manual handling techniques as outlined in individual care plans. This was a requirement as an outcome from the last inspection. Assessments are in place for all identified risks, and safe working practice. The home observes fire safety and all staff undertake annual training in fire safety. Contracts are in place for the maintenance of fire fighting equipment and emergency lighting. Accidents and incidents are recorded in the home. Reporting of all incidents that significantly impact on residents should include reporting under Regulation 37 of the lift being out of order due to breakdown. Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 22 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 3 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 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 2 X 3 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 Are there any outstanding requirements from the last inspection? Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 23 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 OP22 Regulation 23(2)(c) Requirement The registered person must ensure that the equipment provided in the care home is maintained in good working order including the shaft lift, in order to protect the resident’s well-being, dignity, social inclusion and independence. Timescale for action 14/02/09 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 OP15 Good Practice Recommendations Monitoring of the impact the quality of food is having on residents should be included in the report made by the provider following the unannounced visits made to the home monthly under Regulation 26 visits. Should this report indicate significant risk or harm to the health and welfare of the residents than this must be reported to? All matters that have an impact on the health and welfare of the residents must under Regulation 37 have action taken to address them. Records must be kept in the home to evidence that this has been done. When the incident has a significant impact as in the case of the lift breakdown these must be reported to CSCI without delay. 2 OP22 Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 24 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 Fir Tree House DS0000013321.V373752.R01.S.doc Version 5.2 Page 25 - 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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