Care Home: Gardenia House

What the care home does well Residents say they are well looked after by staff who are competent, well trained, kind and caring. They know that any requests for care or support will be responded to promptly. Residents physical and mental health needs are well met with access to health professionals. Residents like living in a house that has plenty of communal space, where they have rooms they can personalise and which they know will be kept clean. Residents value the opportunity to be themselves, to be private if they wish or to have activities that they can join in with. There is an open and friendly atmosphere with good interaction between residents, staff and visitors. Residents know there are people who they can talk to about any concerns, who will listen and who will take action to improve the situation. What has improved since the last inspection? Parts of the home have been redecorated. The lounge on the first floor now has a small kitchenette area that residents and their visitors can use. The telephone system for residents has been improved. The range of activities available to residents has been broadened, for example, a visitor comes to the home on alternate Saturdays with their dog Rupert, which they enjoy greatly. When the Activities Co-ordinator is on duty, residents have the opportunity to assist with drinks and biscuits in the lounge. A quote has been obtained for the installation of a loop system to enhance the quality of residents with hearing difficulties. There is a new large screen television in the lounge and new furniture in the dining room. All senior staff are participating in a management development programme operated by Heritage Care. The Manager and a Care Team Leader have been trained to do basic hearingaid maintenance. A wider range of training is available to staff. More records required to be available for inspection are being held at the home rather than at head office. Progress is being made in establishing the home`s perimeters. What the care home could do better: How residents` care needs are to being met would be better evidenced through improved care planning and recording. The home must ensure the Controlled Drugs cupboard complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The number and flexibility of outings, which residents enjoy very much, would be increased if there were more drivers available for the minibus. The quality assurance and monitoring systems should be developed to take account of feedback from relevant health and social care professionals. CARE HOMES FOR OLDER PEOPLE Gardenia House 19 Pilgrims Court Farnol Road Dartford Kent DA1 5LZ Lead Inspector Gary Bartlett Unannounced Inspection 6th May 2008 08:30 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 Gardenia House DS0000023943.V363104.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. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gardenia House Address 19 Pilgrims Court Farnol Road Dartford Kent DA1 5LZ 01322 290837 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) gardeniahouse@heritagecare.co.uk Heritage Care Limited Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (23), Physical disability (1), Physical disability of places over 65 years of age (1) Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Care for people with physical disabilities is restricted to one resident whose date of birth is 11/06/1936. Care for 1 older person with physical disabilities is restricted to a person whose d.o.b. is 21/06/1934. 19th June 2006 Date of last inspection Brief Description of the Service: Gardenia House is owned by English Churches and managed by Heritage Care Limited. It provides residential care for up to 25 people over the age of 65. The Homes staffing team comprises the Manager (acting), senior care staff and care staff who work a roster that gives 24-hour cover. The Home also employs other staff for catering, domestic duties, administration and maintenance tasks. All bedrooms are single and have en-suite facilities some have en-suite showers. Bedrooms are situated over three levels, which are accessed by a shaft lift. The home is situated on the outskirts of Dartford, relatively close to bus and train services and local amenities. There is a small, open, garden area to the rear, an enclosed garden area to the side and limited parking facilities at the front of the home. Fees start at £442.90 per week. Residents pay separately for hairdressing, chiropody, opticians, personal toiletries and newspapers at cost. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Gardenia House from 8:30 a.m. until 2:45 pm. During that time the Inspector spoke with some residents, a visitor, a visiting health care professional and some staff. Parts of the home and some records were inspected and care practices observed. The Manager had completed an Annual Quality Assurance Assessment, from which information was used to inform the inspection process. Residents, their relatives and health care professionals say they like the home and think there are good standards of care. Comments included: • “(The resident) could not receive better care”. • “Staff always give 100 percent”. The home is currently without a Manager and the home’s Senior Care Practitioner has been acting-up in the role since May 2007. For the purpose of the report she will be referred to as the Manager. The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at Gardenia House prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. Although not rostered to be on duty, the Manager kindly came to the home when informed by staff that an inspection was being undertaken. The Inspector would like to thank her and everyone else involved for their contribution to the inspection. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 6 What the service does well: Residents say they are well looked after by staff who are competent, well trained, kind and caring. They know that any requests for care or support will be responded to promptly. Residents physical and mental health needs are well met with access to health professionals. Residents like living in a house that has plenty of communal space, where they have rooms they can personalise and which they know will be kept clean. Residents value the opportunity to be themselves, to be private if they wish or to have activities that they can join in with. There is an open and friendly atmosphere with good interaction between residents, staff and visitors. Residents know there are people who they can talk to about any concerns, who will listen and who will take action to improve the situation. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: How residents’ care needs are to being met would be better evidenced through improved care planning and recording. The home must ensure the Controlled Drugs cupboard complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The number and flexibility of outings, which residents enjoy very much, would be increased if there were more drivers available for the minibus. The quality assurance and monitoring systems should be developed to take account of feedback from relevant health and social care professionals. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gardenia House DS0000023943.V363104.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 Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they are appropriately placed due to good preadmission assessments and benefit from being able to visit the home prior to admission. EVIDENCE: The Manager described how a pre-admission assessment is made of each prospective resident to ensure the home can meet his or her needs. If practical, a member of the management team visits the prospective resident in their home or hospital to ensure the necessary information is current and accurate. Records show that prospective residents, their families, advocates, and relevant health care professionals are involved in the assessment process. Specialist advice is sought from external sources where required. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 11 Residents described how they or their families had been able to visit Gardenia House before moving in. A resident who had been at the home for a short while said staff have been very helpful in assisting them to settle in. Respite care can be provided if a room is available and the service can meet the resident’s needs. There is no specific accommodation for short-term care and the resident is free join in with daily life in the home. Gardenia House does not provide intermediate care. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care and health needs are well met in a dignified and appropriate manner. An improvement to care plan records would better evidence how they are met and the quality of care being given. EVIDENCE: The judgment for this outcome group has taken into account the quality of life for all the residents. The judgement also includes assessment of the level of knowledge and understanding displayed by staff when providing both personal and health care. Comments made by residents, observation during the day of the site visit and as recorded in previous inspection indicates the standard of care provided is very good. Residents say that staff are fully aware of their needs, particularly their key-workers with whom they feel they have a ‘special’ Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 13 relationship. Staff are aware of far more information than is recorded in care plans. A lot of information is shared at handover. Each resident has a care plan, three of which were inspected in detail. Current care plans are adequate. They contain some risk assessments and are accessible to staff. Some detail of individual needs is given including personal preferences and a brief pen picture. Not all parts of the care plans have been completed. The Manager is aware that records of daily care need to be more informative to comprehensively reflect the service given and is addressing this by regularly monitoring them and giving staff guidance as necessary. The Manager described how a computerised care planning system is being piloted elsewhere in the organisation. Risk assessments are not always reviewed or recorded as a result of some incidents or changes in welfare. Some residents are largely self-caring and often go out. Consequently, the scope and content of risk assessments needs to be more comprehensive. Residents consider they have their health needs well met. References were made to visits by the chiropodist, optician and audiologist appointments and of good relationships with local general practitioners. Entitlement to NHS services are upheld and advice given when private funds might be needed. A community nurse who regularly visits the home says staff are good at following advice and guidance given. A relative considers staff to be very good at keeping them informed. The Manager and senior carers are responsible for medication. They have undertaken medication training. The list of authorised staff is being updated. There is a designated medical room and a mobile drug trolley. Standards of storage and cleanliness in the medical room are good. The Manager said she is introducing a system to monitor and record the temperatures of the areas medicines are kept to ensure they are stored as directed. A recent change in the law means that all care homes must now keep all Controlled Drugs, including Temazepam, in a Controlled Drugs cupboard that complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The Manager agreed to ensure arrangements in the home are in line with this. The Medication Record Administration Record (MAR) sheets inspected are completed appropriately. Medicines were seen to be given in accordance with good practice guidelines. Residents feel that staff are kind and gentle, this was confirmed by observation and discussion with visitors. Staff are considerate of the age and dignity of residents and treat them with courtesy. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 14 The home aims to care for people until the last stage of life. Care plans have a facility for last wishes to be identified and recorded and spiritual support can be provided where desired. Relatives and friends can be with the resident if the resident wishes. Gardenia House DS0000023943.V363104.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to this service. Residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: Gardenia House is a place where residents can live a life as much as possible to their own choosing and where they can welcome friends and family. Routines in the home are flexible and residents enjoy the freedom to come and go as they please. Breakfast can be taken at any time between 7.30 and 10.30 a.m. They are able to use all communal areas, some were seen sitting in the lounge and dining room. Residents say they can join in the activities whenever Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 16 they want and enjoy the buffet teas once a fortnight. They also talk of going to shows. The home has a designated Activity Co-ordinator who works commendably hard to try to meet the social and recreational needs of the residents. This person is employed 16 hours per week and does some work in her own time. Her interaction with residents is of very high standard. A range of activities is available for residents to take part in including 40’s and 50’s karaoke, music, books, videos, bingo word games and outings. Details of the activities planned are displayed around the home. The Activities Coordinator is working to develop these even further; consultation takes place with residents to plan activities and outings. When the Activities Co-ordinator is on duty, residents have the opportunity to assist with drinks and biscuits in the lounge. Residents say that a visitor comes to the home on alternate Saturdays with their dog Rupert, which they enjoy greatly. It is not known if the two cats that live at the home, George and Twizzle, share this enjoyment. It is very clear that the residents enjoy having the cats’ company. It is evident from discussion with residents, that outings in the minibus are a highlight for them. A volunteer driver is the only person who drives the minibus currently, so its use is dependant on that person’s availability. There was some discussion about the desirability of increasing the number and flexibility of outings by acquiring more drivers, perhaps by arranging for appropriate staff to be trained to drive the minibus. Residents are encouraged to personalise their rooms with their own possessions if they wish. Most residents have brought items of furniture and plenty of personal effects with them. A newly admitted resident said she liked her room very much. Most bedrooms have televisions, telephones and CD/cassette players. Staff spoken with are aware of the need to get respect residents’ wishes as to how they spend the day whilst safeguarding people from becoming isolated. Family and friends feel welcome and know they can visit at any reasonable time. During the inspection a number of visitors were seen in the home and the visitors book records regular visits by families, friends and others. The design of the Gardenia House provides seating areas within the communal areas where residents can entertain their visitors, in addition to the privacy of their own room. Residents say they like the food and think it is well cooked and presented. They have a choice of meals, menus are regularly updated and advice has been sought from a nutritionist who commended the food and provided Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 17 information for residents and staff about healthy eating. The lunch on the day of the inspection was very good with choice offered of drinks, main course and dessert. Special diets can be catered for. Mealtimes are relaxed; staff are patient and helpful and allow residents the time they need to finish their meal comfortably. Hot and cold drinks and snacks are available through out the day. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 18 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 19 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives know their complaints are listened to and acted on. There are systems to protect residents from abuse. EVIDENCE: Residents are at ease and confident talking with staff who listen to their views and concerns. The complaints procedure is readily available to residents and their relatives. They said they feel confident that they would be listened to and any necessary action would be taken. A visitor said: • “There aren’t usually any problems, but if there are, staff are always quick to sort them out”. Records of complaints and their investigations are kept. The Manager confirmed that people living in the home are protected from abuse and that satisfactory checks had been carried out on all staff via the Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 19 Criminal Records Bureau and POVA. The staff induction and NVQ training have elements of adult protection training and there has been POVA training for staff. Those spoken with have a sound understanding of adult abuse and protection procedures. The Manager stated any allegation of abuse would be referred to the concerned agencies without delay. Since the last inspection there have been two Safeguarding Adults alerts. The home has a system in place, which aims to protect the financial interests of residents and holds small amounts of cash on their behalf. This is kept securely. Transaction records are maintained and receipts are kept for purchases made on residents’ behalf. Cash checked tallied with accounts seen. The Manager said that no one within the organisation is an appointee for any resident. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 20 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, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home is situated within a housing estate on the outskirts of Dartford. It has an entrance lobby leading into the main entrance hall with a lift to bedrooms on the first and second floors. Residents can use grab rails and other aids that have been provided around the home. All bedrooms are single with en suite facilities and some also have a shower. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 21 Residents’ rooms are comfortably furnished and contain the residents’ own furniture and effects and residents said they are comfortable in the home. A staff call system is available with calls being answered promptly at the time of the inspection. There are bathrooms with bath hoists on each floor that are clearly marked so that residents are aware they are bathrooms. Staff say that the bathing facilities are appropriate to the needs of the residents. There is a comfortably furnished lounge on the first floor which also contains a small kitchenette area that residents and their visitors can use. The dining room is on the ground floor with two fire doors leading to gardens to the back and side of the home. There is a designated laundry that is suitably equipped with systems in place to reduce the risks of cross infection. The garden area to the side is surrounded by fencing and clearly belongs to the home. However, at the rear of the property the boundary for the home is not clear. The Manager advised that Heritage Care is currently looking at confirming and identifying the boundaries of the home. The Manager has arranged for the weeds to be removed from the patio areas so residents can use these safely. Gardenia House DS0000023943.V363104.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): 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. Residents are cared for by a well-motivated staff group that they like. EVIDENCE: Residents like the staff and find them approachable, polite and kind. Throughout the site visit there was evidence of good relationships between staff and residents. Staff mentioned how much they liked working with the residents in the home and this was reflected in the way care and support was given. Staff obviously know the residents well and how best to put them at ease. People applying to work at the home have to complete an application form, provide two references and have POVA and Criminal Records Bureau (CRB) checks and attend an interview. The files of the most recently recruited staff show that appropriate checks were made prior to them commencing duties. All staff employed by the home are required to complete the Skills for Care Common Induction Standards. There is also an induction for agency staff to undertake. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 23 Gardenia House is proactive in ensuring staff obtain NVQ qualifications. A number of staff already hold NVQ qualifications with others undertaking NVQs in care. Staff confirm that training is ongoing and relevant. A training matrix is used to give a management overview of staff training needs. All senior staff are participating in a management development programme operated by Heritage Care. The staff rosters seen indicate staffing levels are geared to peak times of activity. It also indicates that the 38 hours of senior staffing allocation have not been filled since the Manager commenced her role in May 2007. Gardenia House DS0000023943.V363104.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): 31, 32, 33, 35, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interim management arrangements leave the home in safe hands and being run in the best interests of the residents. EVIDENCE: The registered Manager left in May 2007. Since that time, the home’s Senior Care Practitioner has been filling the role until a new manager is appointed. To date, efforts to recruit a suitable person have not been successful. The acting Manager is to commended for their efforts, particularly in view of the fact that the 38 hours of their substantive post have not been filled. She has many Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 25 years experience at the home and is studying for the Registered Managers Award. There is a sound system of holding and recording service users’ cash, which is checked by Heritage Care as part of their audit process. There was discussion about the quality assurance system being used. It is not evident that it takes account of feedback from relevant health and social care professionals. This should be done so the service can make a comprehensive assessment of its performance. Records seen are kept in a manner that promotes confidentiality. Current arrangements mean that if the Manager is away, access cannot be gained to staff files, for example during an inspection. The Manager undertook to discuss the possibility of a duplicate key being held at head-office, which is within easy reach of the home. The standard of cleanliness in the kitchen and surrounding area is satisfactory and recommendations made at the Environmental Health Officer’s last inspection have been implemented. There are records of fire systems checks and fire drills/training. Staff spoken with have a god understanding of emergency procedures. The accidents and incidents records seen are completed appropriately. The Manager believes all records of maintenance and safety checks are up to date. These were not inspected on this occasion. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 26 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 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 3 2 X 3 X 3 3 Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 14(2)(b), 15(2), 17 Schedule 3, Schedule 4 Requirement The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service user’s plan under review in that service users’ individual plans and records must be kept and be up to date in that they must be consistent and specific in detail of information required. All service users must have an accurate care plan by the given timescale, if not sooner, which is thereafter maintained 2. OP7 13(4) The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must be consistently recorded/reviewed in response to accidents/incidents and changes in residents welfare. Comprehensive risk assessments must be in place by the given timescale, if not sooner, and Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 28 Timescale for action 30/09/08 30/06/08 3. OP9 13(2) maintained thereafter. “The registered person shall 30/06/08 make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that the home must ensure the Controlled Drugs cupboard complies with the Misuse of Drugs (Safe Custody) Regulations 1973. To be completed by the given timescale. 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. 4. Refer to Standard OP12 OP12 OP31 OP33 Good Practice Recommendations It recommended the home arranges for there to be more people that can drive the minibus to increase the potential for its use. It is recommended specific training in the provision of activities for older persons is made available to pertinent staff. It is recommended a permanent Manager is appointed. It is recommended the quality assurance and monitoring systems is developed to include the views of relevant health and social care professionals. Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 29 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 Gardenia House DS0000023943.V363104.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!