Care Home: Lisnaveane Ltd

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What the care home does well We were able to speak to 9 of the current 10 residents, and those who were able to communicate told us that they were very happy at the home. One resident told us that "everybody is always so nice and nothing ever seems to be too much trouble." A relative told us "I couldn`t be more pleased with mum`s care, it exceeds our expectations." We observed that all of the residents were well cared for and that pride had been taken in their appearance. Staff spoke to residents in a respectful manner, and it was evident that there was a good rapport between residents and the staff on duty. We were talking to one resident who asked for a cup of tea, and this was heard by a care worker who immediately went to make one for her. The resident told us "that is always the case, I only have to ask and the staff make sure that a cup of tea is made for me." The home is clean and there were no offensive odours. Generally the home is well decorated and there is an ongoing programme of refurbishment and redecoration at the home.Medication administration records (MAR) were in good order, and all staff involved in the administration of medication have received appropriate training. Menus offer a choice of dishes, and other alternatives are always available. We were able to observe lunch being served and this was nicely presented and in accordance with the wishes of the individual. Where residents needed some assistance with eating we observed that this was given in a very sensitive and caring manner, and at a pace suitable for the individual resident. What has improved since the last inspection? There is now a manager in post and her application for registration is being progressed by the Commission. The manager has made considerable improvements in the systems operating within the home, and has introduced audits for medication, care plans, handover periods and accidents. Care plans have further improved and are now much more comprehensive and cover both social and health care needs. There is evidence of night care plans and advanced care wishes. Where appropriate risk assessments are in place, and care plans are being reviewed on a monthly basis or more frequently where necessary. Currently the organisation does not hold monies for any of the residents. Where residents do not control their own finances, the organisation will buy items for the individual at their request, and will then invoice the individual or their representative for the monies spent. CARE HOMES FOR OLDER PEOPLE Lisnaveane Ltd 790 Longbridge Road Dagenham Essex RM8 2AA Lead Inspector Mrs Sandra Parnell-Hopkinson Unannounced Inspection 10th June 2008 08:45 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 Lisnaveane Ltd DS0000027906.V365540.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. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lisnaveane Ltd Address 790 Longbridge Road Dagenham Essex RM8 2AA 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) 0208 592 0022 0208 491 8424 Lisnaveane Ltd Vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 19 28th June 2007 Date of last inspection Brief Description of the Service: Lisnaveane is a residential care home situated within the London Borough of Barking & Dagenham. The building has been converted and extended over time to provide a care home for 19 older people. The home is situated on the corner of a busy road with good transport links. There is on street parking to the side of the property, and very limited parking to the side/rear of the home. Bedrooms are single with a few double rooms, and bedrooms do not have an en suite but all do have a washbasin. There is a lift to the upper level. There are two lounges and a dining room, which all over look a well-maintained rear garden, which is accessible to residents. Currently the home is operated as a ‘homely’ environment where residents and staff know each other very well. A copy of the statement of purpose and service user guide was available during the inspection, and a copy of this can be obtained upon request to the home. At the time of this inspection the fees ranged from £431 to £450 per week. Lisnaveane Ltd DS0000027906.V365540.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 that the people who use this service experience good quality outcomes. This was an unannounced key inspection, which took place on the 10th June 2008 by Mrs. Sandra Parnell-Hopkinson. The inspection site visit took place over 5 hours and included discussions with residents, relatives, staff, the manager and the responsible individual. The files of 4 residents and 3 members of staff were inspected, together with maintenance records, complaints log, staff rotas, medication administration records (MAR), menus, accident records. Further evidence was also gathered from the annual quality assurance assessment (AQAA) and returned surveys which had been sent to residents, relatives and staff. An unannounced visit had been undertaken earlier in the year by officers from the London Borough of Barking & Dagenham and an extract from their report was “in general, all the nine residents were reasonably happy. No concerns were raised during our visit. We were very impressed with what we saw.” People using this service were asked how they wished to be referred to, and the majority said they wished to be called residents because they lived at the home. This is how they are referred to in this report. What the service does well: We were able to speak to 9 of the current 10 residents, and those who were able to communicate told us that they were very happy at the home. One resident told us that “everybody is always so nice and nothing ever seems to be too much trouble.” A relative told us “I couldn’t be more pleased with mum’s care, it exceeds our expectations.” We observed that all of the residents were well cared for and that pride had been taken in their appearance. Staff spoke to residents in a respectful manner, and it was evident that there was a good rapport between residents and the staff on duty. We were talking to one resident who asked for a cup of tea, and this was heard by a care worker who immediately went to make one for her. The resident told us “that is always the case, I only have to ask and the staff make sure that a cup of tea is made for me.” The home is clean and there were no offensive odours. Generally the home is well decorated and there is an ongoing programme of refurbishment and redecoration at the home. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 6 Medication administration records (MAR) were in good order, and all staff involved in the administration of medication have received appropriate training. Menus offer a choice of dishes, and other alternatives are always available. We were able to observe lunch being served and this was nicely presented and in accordance with the wishes of the individual. Where residents needed some assistance with eating we observed that this was given in a very sensitive and caring manner, and at a pace suitable for the individual resident. What has improved since the last inspection? What they could do better: In the 2007 amendment to the Misuse of Drugs (Safe Custody) Regulations 1973, the term nursing home has been replaced by care home. The main impact is that every care home must store controlled drugs in a CD (controlled drugs) cupboard. Although the home does have a controlled drugs cupboard this does not comply with the new requirements. This was discussed with the manager and the responsible individual during the inspection and a requirement will be made for the existing cupboard to be replaced by one that complies with the new legislation. A copy of the Commission’s guidance on the safe management of controlled drugs in care homes was left with the manager. Although notifications under regulation 37 of the Care Homes Regulations 2001 are being sent to the Commission where a resident may require hospital treatment, the regulations require notifications to be sent where any incident at the care home impacts on a resident. This will also include such things as falls requiring no hospital treatment, unexplained bruising, boiler breakdown and breakdown of other essential equipment. This was discussed with the manager during the inspection and she has assured us that notifications as required will be sent in the future. This will be a requirement in this report. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 7 Daily recordings are generally comprehensive but need to be more reflective of the desired outcomes identified in the care plans, and also to be more in line with the requirements of the Mental Capacity Act. A copy of the Commissions guidance on the Mental Capacity Act was left with the manager. 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. Lisnaveane Ltd DS0000027906.V365540.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 Lisnaveane Ltd DS0000027906.V365540.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, 5 (standard 6 is not relevant to this service) People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Prospective residents and their families are given information about the service so that they can make an informed decision about where to live. All prospective residents are given a contract where they are privately funding their care, or a statement of terms and conditions if they are being supported by a local authority. A comprehensive assessment of his/her needs is undertaken and prospective residents and/or their families/friends can visit the home prior to making a decision. EVIDENCE: We case tracked 4 residents, and all had evidence of either a contract or a statement of terms and conditions. Many of the existing residents have lived at the home for several years, but the file of a resident admitted in December 2007 was viewed and this contained a comprehensive assessment of the person’s needs. Pre-admission assessments show evidence that information around a person’s ethnicity, culture and religion are ascertained and recorded. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 10 This information is then included in the care plan which is drawn up from the assessment. A visiting relative told us that she visited the home before making a decision for her mother to move in, and that she felt the home would meet her mother’s needs and she has not been disappointed. The statement of purpose and service user guide can be produced in large print format if this is needed by any of the residents. Lisnaveane Ltd DS0000027906.V365540.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, 10 and 11 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Residents are sure that their health and personal care needs are set out in an individual plan of care, and that their health needs are being fully met. They can be sure that they will be protected because staff involved in administering their medication have been trained and medication is administered in accordance with the home’s current policies and procedures. Residents can be sure that they will be treated with respect and that their right to privacy will be upheld, and also that they will be cared for with sensitivity and respect at the time of their death. EVIDENCE: We cased tracked 4 residents and all of the files showed evidence of the involvement of health care professionals such as the GP, District Nurse (where necessary), the chiropodist, dentist and the optician. Currently the district nurse is visiting a resident to administer injections, and this was supported from viewing the medication administration records (MAR). Another resident is having her blood sugars monitored by the staff, and the records show that this Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 12 is being done in accordance with the instructions from the GP, and also that staff undertaking this task have been trained to do so. Currently none of the residents have any pressure sores. There has been an improvement in the care plans, and all of the files looked at had a night care plan and advanced care wishes where the manager had been able to obtain such information. Staff have received palliative care training through St. Francis Hospice, and staff are now more confident in ensuring that residents who wish to remain at the home at the end of their life can do so, and that they will receive good care. We observed staff interacting well with the residents, and all staff spoken to were very knowledgeable about the individual resident. It was evident when speaking to residents that they felt valued by the staff and that staff treated them with respect. One resident told us “all of the staff are lovely, nothing is too much trouble and they really care about us.” A relative told us “all staff genuinely care about the residents they are looking after and do their very best. Myself, my bothers and sister and my mother’s grandchildren are all satisfied with the care my mother gets, and most important of all my mother is happy with the care she receives.” All of the residents are being weighed on a monthly basis, or more frequently if the need is indicated and any increases/decreases in weights are being monitored with the necessary referral being made to the GP. We saw a member of staff cleaning spectacles for one of the residents, and staff made sure that where a hearing aid was being used this was switched on and had a working battery. During the inspection we observed staff being responsive to the varied and individual needs and preferences of the residents. One resident asked for a cup of tea and a member of staff went and made one for her without any fuss. The resident told us that it was always like that, she went on to say “nothing is too much trouble and we never have to wait a long time.” A comment on a returned questionnaire was “had mother not been placed in care of Lisnaveane Home, she could not have survived at home prior to being hospitalised some six years ago and transferred to Lisnaveane.” Another relative told us “mum had to go into hospital and we were worried that she would not be able to come back to Lisnaveane. Fortunately she been able to return and the care exceeds our expectations.” We were told by residents that they can have a bath when they want one, and that they can get up and go to bed when they choose. Medicating administration records were inspected and these were found to be in good order as was the actual medication. Staff undertaking the Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 13 administration of medication have received appropriate training and are operating in accordance with the home’s policy and procedure. At the time of this inspection none of the residents were self-medicating. Although controlled drugs have been in use at the home until recently, the storage of these is not in accordance with the 2007 amendment to the Misuse of Drugs (Safe Custody) Regulations. The main impact is that every care home must store controlled drugs in a CD (controlled drugs) cupboard. A copy of the Commission’s guidance on the safe management of controlled drugs in care homes was left with the manager, and this contains information on the type of cupboard required. The home did have a controlled drugs register and this was being maintained as required. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Residents at the home experience a lifestyle that meets their needs, and is in accordance with their social, cultural and religious preferences. Residents know that their family/friends can visit them and that they will be made welcome, and also that they can enjoy community activities if they choose. Residents are helped to exercise control and choice over their lives, and receive a wholesome appealing balanced diet in pleasant surroundings. EVIDENCE: We were satisfied from talking to residents and viewing records that people at the home are encouraged to take part in daily activities. Staff are encouraged to set aside time during the morning and the afternoon to specifically do activities with residents according to their choice. However, we also saw staff interacting well with residents at all times, and during the morning a member of staff was “having a picnic” with two of the residents because that was what they wanted. Another member of staff was sitting and chatting to several of the residents, while others were either reading or watching television. One resident told us “I like to sit here dear and either read or watch the Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 15 television.” It was reassuring to see that the television is not automatically switched on, and that residents were able to either sit quietly in one of the lounges, or to listen to soft music in the other. One comment made by a relative on a returned questionnaire was “At times when I visit mother on Wednesdays/Sundays I find due care and attention to other peoples needs relevant at all times. Mother does a lot of reading and these services are well attended to by the home. She is always spoilt by the staff.” However, some residents may need more encouragement with regard to daily life activities, and one comment received was “I do feel that more could be done in the way of stimulation for my mother. There is no occupational therapist visiting the home and, unfortunately, most of the time is spent sleeping. I realise that this is not easy with very elderly people.” On the other hand one of the residents does like to help with washing and drying up and she is helped to do this. Residents told us that everyone’s birthday is celebrated and they always have a cake, which is generally made by the cook. They also told us that they often have an entertainer visit the home, and they enjoy this. Residents are enabled to practice religious observances according to their wishes. One resident mostly speaks Turkish, and although the home has tried to recruit staff who speak Turkish they have not been successful. However, some of the staff have made an effort to learn some Turkish words, and this was confirmed when we spoke to relatives who were visiting. They also told us that the cook has been really good at providing appropriate food, and that all of the staff were very good. The cook lets each resident know every morning what is on the menu, and they in turn let him know if they want the menu choice or prefer an alternative. We observed this during the morning, and some of the residents confirmed that this always happens. We were able to observe lunch being served, and it was evident that care workers gave any assistance necessary in a sensitive and discreet manner. One resident told us “the food is lovely and I am well looked after.” Some of the residents also said that there was so much food that they could not eat it all. Where pureed diets were required, these were also nicely presented on the plate. A record of what each resident chooses and eats is maintained within the home. We looked at the menus and these were varied, nutritious and balanced and there was evidence of fresh fruit and vegetables being available for the residents. The cook has many years experience in various settings, and much of the food is ‘home cooked’ on a daily basis. He also was knowledgeable around special dietary needs, likes and dislikes of the residents. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good outcomes in this area. We have made this judgement based on available evidence including a visit to the service. Residents and their relatives/friends can be confident that their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse and can feel safe when being cared for by the staff. EVIDENCE: There are policies and procedures in place for dealing with any complaints, and when we asked staff they were aware of these procedures and knew how to deal with any complaint made to them. We looked at the complaints book and there was evidence of one complaint which had been responded to in accordance with the home’s policy and procedure. We were told by some of the residents that if they are not happy with anything they just tell the staff and it is immediately put right. A relative told us “I have not needed to raise any issues regarding my mother’s care, but I would speak to the manager if I needed to.” Another comment on a questionnaire by a relative was “we discuss any concerns as to the care of mother where applicable. However to date no complaints.” The responsible individual visits/works at the home several days each week and knows the residents well, and deals with any concerns raised by the residents immediately. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 17 Many of the current staff have worked at the home for some time and those we spoke to confirmed that they had received training in safeguarding vulnerable adults and were able to tell us the process they would take if they witnessed any suspected abuse. There was evidence to confirm appropriate training on their files, and the training schedule indicated dates for future training sessions for new staff and updates for existing staff. There are currently no outstanding safeguarding adults referrals. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 18 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, 21, 23 and 26 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Residents are able to live in a safe, well-maintained environment and have their own possessions around them. However, there are no bedrooms with en suite facilities, but all rooms are within easy reach of a toilet. The home is clean, pleasant and hygienic. EVIDENCE: We undertook a tour of the of the home as part of the inspection process and all parts of the home were found to be clean and hygienic with no offensive smells. Some of the bedrooms have been recently redecorated. Although the bedrooms do not have en suite facilities, all are fitted with a hand basin and are within easy reach of a toilet. Bedrooms are also of a good size and furnished with appropriate furniture. A resident told us that she was involved in the choosing of the new colour scheme in her bedroom. Residents are encouraged to personalise their bedrooms, and those viewed appeared very Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 19 individual with small pieces of furniture and lots of other personal possessions. Locks have been fitted to the bedroom doors that are operable in an emergency from the outside. This allows residents to choose whether they want to lock their doors but feel safe in the knowledge that if an emergency arose staff could gain access. Although some of the bedrooms are double rooms, such rooms are only shared in limited situations and then only by agreement with the people concerned. Currently the shared rooms are vacant, and the provider intends to sell these as single rooms unless a specific request is made for a double room, perhaps a couple who would wish to share. There are a sufficient number of communal toilets and bathrooms with necessary equipment where needed. A record is being maintained of the bath water temperatures prior to a resident taking a bath. The kitchen was inspected and this was found to be clean and tidy and there had been an inspection from the local environmental health department. Two requirements had been made, one for the repair of flooring and one for flaking paint. Both requirements had been complied with. However, we did notice a join, between the kitchen and the corridor, which needed attention and a requirement has been made in this report. Food was found to be stored appropriately with dates and labels with fridge temperatures being taken on a daily basis. A record is also kept of the weekly shopping orders purchased by the home. The laundry area is situated in an external building and on the day of the inspection the tumble dryer had broken, but an order had already been made for its repair. The front and rear gardens were maintained to a good standard, and a new pathway had been laid to the front of the building. We discussed future plans for the premises with the manager and the responsible individual, and consideration is still being given to possible extension works which will involve the provision of en suites to some of the existing bedrooms. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 20 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 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Currently residents’ needs are met by the numbers and skill mix of the care workers, and they can feel that they are in safe hands. The home’s recruitment practices make residents feel that they are supported and protected, and staff are trained and competent to do their jobs. EVIDENCE: On the day of the inspection there were two care workers on duty, one of whom was a senior and in discussions with them it was apparent that they were very knowledgeable about the residents and their individual needs. They confirmed that they had undertaken training in manual handling, safeguarding adults, medication administration, food hygiene and NVQ level 2/3, and this was supported in training records. Information contained in the annual quality assurance assessment indicates that 80 of the current staff team hold a qualification at NVQ level 2 or 3, and again this was confirmed in the training records. The manager was knowledgeable around the Mental Capacity Act 2005 and training has been arranged for staff which will take place during June/July this year. We saw staff interacting very well with all of the residents, and there was a very good rapport between them. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 21 We looked at the files of the 3 most recently employed members of staff and all of these contained application forms, the necessary references and a criminal records bureau disclosure. Staff now have a contract of employment and this was evidenced on the files viewed. Staff are given a job description and have clearly defined roles and responsibilities. Feedback from residents and relatives is that the staff working with them are skilled, competent and able to meet their needs. Since the last inspection, the manager has introduced a structured interview questionnaire and copies of this were seen on the files viewed. There is little use of agency or temporary staff, and permanent staff are generally used to cover any shortfalls. Staffing resources are kept under review by the manager, and adjustments made as necessary and according to the needs of the residents as well as numbers of residents. Staff meetings take place as does regular supervision, and evidence of this was seen when viewing the documentation at the home. Often the manager will sleep in at the home to enable her to supervise night staff. Also where necessary the manager will also provide hands on care. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 22 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, 37 and 38 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. Currently residents can feel sure that the home is being operated in their best interests. Staff are being supervised and the financial interests of residents are safeguarded. The health, safety and welfare of residents and staff are being promoted and protected which is in their best interests. EVIDENCE: Since the last inspection there is now a manager in post, and she is currently applying to be registered with the Commission. The manager has also enrolled to gain the Registered Manager’s Award, and has already begun the induction to this course. In discussions with the manager she was very aware of the importance of equality and diversity issues and this was demonstrated in the care of the residents and documentation. The annual quality assurance Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 23 assessment had been completed appropriately and returned within the required time frame. Although the areas of ‘what we do well’ and ‘how we have improved in the last 12 months’ have been completed to a reasonable standard, more thought must be given to the area ‘what we could do better’ so that the service is demonstrating that it is always moving forward for the benefit of the residents who live at Lisnaveane. The new manager has made improvements to the administration of the home, and has improved many of the systems by introducing audits on medication, staff handover information between shifts, care plans and accidents. Policies and procedures are made available to all staff, and they have to sign to confirm that they have read these. The home is currently being operated in an open and transparent way, and the manager is competent in delivering effective financial planning and budgetary control. Staff are being supervised through 1:1 supervisions and staff meetings, and supervision now also includes care practice observations which has proved beneficial to staff, and subsequently to the residents through improved care practices. No personal monies are held for the residents, and any expenditure for hairdressing, chiropody or other items are paid for by the service and then the resident or family/representative is invoiced. Receipts are maintained of any expenditure on behalf of a resident. Maintenance records were viewed and these included electrics, gas, water, insurance, weighing machine and hoist, fire safety and alarm testing, lift maintenance and bath water temperatures and all were found to be in good order. The insurance policy is for employer’s liability of £10million and public liability of £5million. The responsible individual is doing monthly visits to the home and producing a report of these visits, required under regulation 26 of the Care Homes Regulations 2001, which are kept in the home. Notifications under regulation 37 of the Care Home Regulations 2001 are also being sent to the Commission, but not in all cases. This was discussed with the manager and will be a requirement in this report. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 24 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 x 3 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 2 3 Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement The registered person must ensure that the safekeeping of controlled drugs is in accordance with the 2007 amendment to the Misuse of Drugs (Safe Custody) Regulations 1973. This is in the interests of the safety of the residents. The registered person must ensure that the joins in the kitchen flooring are safe and secure at all times. This will ensure a safe and hygienic working environment for the staff. The registered person must ensure that any incident adversely affecting a resident/residents is notified to the Commission. This is to ensure that residents are safeguarded at all times. Timescale for action 15/09/08 2 OP19 23 30/06/08 3 OP37 37 30/06/08 Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations The registered person should ensure that daily recordings are reflective of the requirements of the Mental Capacity Act 2005 and also reflect the desired outcomes identified in the care plans. Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lisnaveane Ltd DS0000027906.V365540.R01.S.doc Version 5.2 Page 28 - 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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