Care Home: Waterside

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What the care home does well The home provides clear information for potential residents about the services it provides. Introductory visits to the home are encouraged. The care plans allow care staff to have good information about the residents` needs, wishes and how they should be cared for. The plans also provide information on residents` cultural and spiritual needs and their leisure interests, this is taken into account when activities are arranged. There is good attention to residents` health care needs. Residents are given the opportunity to manage their own medication. Arrangements for managing medication on residents` behalf are safe and checked by senior staff. Staff are respectful and warm when dealing with residents. Several residents and relatives spoke highly of the care provided at the home. One person described a member of staff as `very good` and `the light of our lives`. Another resident said that the staff are `nice to talk to`. The residents said that generally they like the meals and that choice is available. One person said `there is always something to choose if you don`t like the main dish`. The home is well designed, taking the needs of people with dementia into account. It is attractive and comfortable with high standards of cleanliness. A resident said that one of the things she likes about the home is that it is `very clean`. A relative said in feedback that `the place is immaculate`. The Manager of the home has made significant improvements to the home and her contribution is recognised by relatives. One said `she puts 150% in every day`. The management style was described as `approachable`. What has improved since the last inspection? The home has made very good progress since the last inspection and significant improvements have been made. All of the previous requirements have been met. Several improvements have result from the introduction of the new format for the residents` care plans. The plans are now comprehensive and clear, allowing better recording of a range of needs. Staff said that they find them more useful than the previously used format. The management of medication has improved since the last inspection. The home now has more than 50% of staff who have either achieved or are working towards the NVQ qualification at level 2 or higher. CARE HOMES FOR OLDER PEOPLE Waterside 40 Sumner Road London SE15 6LA Lead Inspector Alison Pritchard Unannounced Inspection 10:15 7 November 2007 th 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 Waterside DS0000052132.V350084.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. Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waterside Address 40 Sumner Road London SE15 6LA 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) 020 7358 5780 020 7703 5206 Marcia.forsythe@anchor.org.uk www.anchor.org.uk Anchor Trust Marcia Elaine Forsythe Care Home 48 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 48 11th June 2007 Date of last inspection Brief Description of the Service: Waterside is a staffed home that provides residential care for elderly people who may also have dementia. The home was purpose built in 2003 and is divided into three units, each situated on a separate floor of the three-storey building. Each unit accommodates 16 residents and has a communal lounge and dining area. The ground and first floor units are for residents with medium dependency needs and the top floor is for residents with low dependency needs. There is adequate parking on the street and access to bus routes. At the time of the inspection there were two vacancies at the home. The home provides an information pack about the service to any prospective resident and a copy of the most recent CSCI inspection report is available in the reception area on the ground floor of the home. Fees are £536.18 per week for residents with medium dependency needs and £510.10 per week for residents with low dependency needs. Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over one day in early November 2007. The inspection methods included observation of care practice, discussion with residents and staff, inspection of residents’ files and a range of other records. Care plans were checked on each floor of the home, and aspects of these residents’ care were examined by case tracking. The inspector also observed a meeting during which information about residents’ progress and needs was handed between staff on different shifts. Involved professionals and relatives were sent survey forms so that they could contribute to the inspection process. The Inspector is grateful for the contributions of everyone who responded to surveys and all of the people who spoke to her during the inspection. A document called an ‘Annual Quality Assurance Assessment’ was completed by the Registered Manager of the home in advance of the inspection and returned it to the inspector. It provides information about how the home is addressing the National Minimum Standards along with factual information about the operation of the home. The CSCI also has access to information gathered through notifications from the home. All of this information has been taken into account in compiling this report. The Deputy Manager and other staff from the home facilitated the inspection visits; they were helpful and courteous throughout the process. The last key inspection of the home took place in June 2007. What the service does well: The home provides clear information for potential residents about the services it provides. Introductory visits to the home are encouraged. The care plans allow care staff to have good information about the residents’ needs, wishes and how they should be cared for. The plans also provide information on residents’ cultural and spiritual needs and their leisure interests, this is taken into account when activities are arranged. There is good attention to residents’ health care needs. Residents are given the opportunity to manage their own medication. Arrangements for managing medication on residents’ behalf are safe and checked by senior staff. Staff are respectful and warm when dealing with residents. Several residents and relatives spoke highly of the care provided at the home. One person described a member of staff as ‘very good’ and ‘the light of our lives’. Another resident said that the staff are ‘nice to talk to’. Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 6 The residents said that generally they like the meals and that choice is available. One person said ‘there is always something to choose if you don’t like the main dish’. The home is well designed, taking the needs of people with dementia into account. It is attractive and comfortable with high standards of cleanliness. A resident said that one of the things she likes about the home is that it is ‘very clean’. A relative said in feedback that ‘the place is immaculate’. The Manager of the home has made significant improvements to the home and her contribution is recognised by relatives. One said ‘she puts 150 in every day’. The management style was described as ‘approachable’. What has improved since the last inspection? What they could do better: Residents had made choices about how often they wished to be checked at nighttime and these preferences were recorded in their care plans. In several instances it was found that these expressed preferences were not being observed. The home has informed the CSCI appropriately of events in the home which require such notification. Staff completing the forms would benefit from management input to ensure that sufficient detail is provided. Some of the records of staff assisting residents with oral care were completed inconsistently. This prevents effective monitoring so needs improvement. Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 7 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. Waterside DS0000052132.V350084.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 Waterside DS0000052132.V350084.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, 3, 5. (Standard 6 does not apply to this service as it does not provide intermediate care). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents have enough information to make sure that they can decide about whether the placement is suitable. Potential residents and people important to them can visit the home to assess whether it will be a suitable place for them to live. EVIDENCE: There is a service user guide and statement of purpose which describe the services the home provides and gives essential information to the potential resident. The document includes information about the fees payable at the home and the services residents can expect to receive for the payment. The written information provided to referrers and to potential residents is very clear about the range of needs the home can meet. Pre admission assessments, both those carried out by the home, and those completed by social workers were seen on residents’ files. A resident confirmed that members of her family had visited the home prior to her admission and judged that it was appropriate for her needs. Whenever possible the potential resident is encouraged to visit the home so that they can be involved in the Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 10 decision-making. The Registered Manager stated that she hopes to arrange visits which involve participation in activities and joining residents for a meal. This is encouraged as it will give potential residents more opportunities to experience what life in the home might be like. Waterside DS0000052132.V350084.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, 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents will benefit from the improved standards of care planning in the home. Greater care needs to be taken to ensure that residents’ recorded wishes regarding nighttime checks are observed. Residents benefit from careful attention to the health care needs and good management of medication. Residents are treated with respect and their right to privacy is maintained. EVIDENCE: Anchor Care has introduced a new format for care planning in this and other residential homes. The new care-planning format has brought considerable improvements to the standards of care planning at Waterside. Staff gave good feedback about the plans, stating that they are more useful than the formats previously used. Four care plans were examined. It was found that the new care plans allow comprehensive information to be available to staff about the residents’ needs and wishes regarding their care. There is also information about residents’ needs with regard to their cultural, spiritual and social backgrounds. Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 12 The plans include relevant risk assessments relating to risk of developing pressure sores, mobility and risk of falls. The resident or a relative had signed the plans. This indicate their involvement in the planning and review process. Residents said that they are happy with they way they are cared for by staff. In relation to one aspect of care there were signs that residents’ wishes were not being observed. Each of the files included a form which gave the residents’ wishes about how often they should be checked by staff at night time. Two of the forms stated that the resident did not wish to be checked at night, nevertheless there were monitoring forms showing that the waking night staff had been carrying out checks of the resident at nighttime. Monitoring forms were completed for various aspects of residents’ care, one of which was oral care. These forms were completed inconsistently. This was discussed with the Deputy Manager who felt that the matter may have been a failure to record consistently rather than to carry out the care. There were good records of residents’ appointments with a range of health care professionals, including the GP, the optician, podiatrist and dentist. Some residents have needs which require nursing input, these are attended to by District Nurses who visit the home at appropriate intervals. Some residents look after their own medication and are provided with safe storage facilities. Risk assessments are carried out to ensure the resident’s safety if they wish to self-medicate and the GP is informed of the decision and agreement sought. Each of the three units has safe storage facilities for the main stocks of medication. Medication records on one floor were sampled during the inspection. They were in very good order with no unexplained gaps in the records of administration. The administration of medication on an ‘as needed’ basis was recorded appropriately. Careful recording confirmed changes in medication doses. This is an area of improvement since the last inspection in June 2007. Residents confirmed that they are able to maintain their privacy and that staff treat them appropriately, with respect and regard for their dignity. This was also the inspector’s observation of the attitude of staff towards residents. Warm and relaxed interactions were seen between them and residents spoke highly of staff, one person described a member of staff as ‘very good’ and ‘the light of our lives’. Another resident said that the staff are ‘nice to talk to’. Residents were well dressed and groomed. They are able to see a hairdresser at her regular visits the home. arrangements had been made for the home to be visited the following week by a clothing firm so residents can choose clothes to buy. The care plans include a section to record residents’ wishes about the action the home should take in the event of serious illness. Waterside DS0000052132.V350084.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, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the efforts that are made through the new care planning system to gather information about their social needs and leisure interests. This allows residents’ preferences to be taken into account when arranging activities. Visitors to the home are encouraged and welcomed. The residents are encouraged to make choices about their daily activities. Meals are arranged to reflect residents’ wishes and nutritional needs. EVIDENCE: The new care plans include fuller information than previously on residents’ social history, leisure interest and spiritual needs. This allows staff to have a better understanding of residents’ needs and interests. There is an activity co-ordinator employed at the home. she has devised an activity programme which includes activities such as quizzes, bingo and discussions of current affairs. One of the residents said that she particularly likes the quizzes. In addition to these activities staff on each unit are encouraged to engage residents in individual activities and conversation. The Registered Manager has stated that she hopes to develop this area of work through further training for staff. Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 14 There is some involvement with the local community through visits to the home. Representatives of local churches visit and hold services in the communal lounge on the ground floor. The churches currently represented are the Church of England, Roman Catholic and Pentecostal churches. In addition a local school visits occasionally. The Manager has stated that she hopes to develop the opportunities for the community to be involved in the home. Southwark Library Services bring books, films and music to the home for the residents and there were newspapers and magazines available in the home. Relatives are able to visit freely at all reasonable times. There is a visitors’ room and as the home is spacious residents may choose to see their visitors in private in their room, in the visitors’ room or may use the communal rooms. An aim of the manager is to increase relatives’ involvement in the home through establishing a relatives’ forum. An advocacy service has been involved with the home. Residents are encouraged to bring personal items with them to the home and the bedrooms reflected this. The care plans now used give greater opportunities for residents and relatives to have a say in their personal routines. The care planning system includes nutritional screening, which highlights residents’ particular needs with regard to meals and nutrition. There is a system in place to ensure that catering staff are informed of these needs. Each unit has a dining room with small tables where residents may choose to eat in groups or individually. The tables are attractively dressed with table cloths, condiments and flowers. A survey of residents’ preferences with regard to meals has been carried out and this has led to some changes with the arrangements for mealtimes. The residents said that generally they like the meals and that choice is available. One person said ‘there is always something to choose if you don’t like the main dish’. Residents had their lunch during the inspection and said that they enjoyed it, they were offered choices by staff who assisted them in an unhurried manner. A range of drinks are available throughout the day for residents to choose. Waterside DS0000052132.V350084.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, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies for complaints and dealing with adult abuse contribute to the protection of residents. EVIDENCE: The complaints procedure is clear and available in the home’s statement of purpose and service user guide. Copies of the procedure are also displayed in the hallway of the home and on the three units. No complaints have been made since the last inspection in June 2007. Residents and relatives who gave feedback knew how to make a complaint and said they were confident that any concerns would be listened to and addressed. The Registered Manager said that over the next year she plans to provide staff with training in the use of the complaints procedure. All staff have received training in the safeguarding adults issues. Anchor has appropriate procedures for dealing with issues of concern about the safety of residents. Anchor Trust has produced a leaflet called ‘Combating the Abuse of Vulnerable Adults’. It describes the rights of vulnerable people and the action which must be taken in the event of concerns, including how to protect the person and how to report their concerns and to whom. Anchor runs its own ‘Care Alert’ helpline which can be used in such circumstances. The organisation has appointed a care specialist to provide a consistent approach to adult protection issues and to monitor concerns of this nature. A review of Anchor’s adult protection procedure is to take place over the next year. Waterside DS0000052132.V350084.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, 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. All areas of the home are clean, attractive, homely and comfortable for residents. The building has been designed with consideration of residents’ needs. Redecoration underway at the time of the inspection will further improve the conditions in the home. EVIDENCE: The home is attractively decorated and comfortable. The facilities provided for residents are very good. Each bedroom is single with en suite facilities including a shower. Residents had been able to either furnish or decorate their bedrooms to their own taste. The standard furnishings provided are of good quality. At the time of the inspection redecoration of the building was underway. The stairwells had been completed and redecoration of the ground floor had begun. The intention of the redecoration was to ‘brighten up the building for Christmas’. This shows a commitment to providing a homely and attractive environment for the residents. The colour schemes for the building have been chosen with regard for residents with dementia to ensure that they are assisted to find their way around the building. Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 17 There is a garden to the side of the home, it is equipped with garden furniture including sunshades. Residents have the opportunity to look after the garden. The Manager has stated that over the next year she hopes to develop a scented garden for residents to enjoy. There is a roof terrace on the first floor of the home. The terrace is currently unavailable for use as repairs are underway. The Manager has undertaken a risk assessment of the area to ensure that, when the area can be available for use again, any risks to residents are minimised. One of the safety precautions to be taken is to ensure that residents are always accompanied by staff on the terrace. In the meantime the door to the terrace is locked and cannot be accessed by residents. The layout of the home, with three separate units, each for 16 service users, allows a homely feel to develop within each unit. Each unit has a kitchen, lounge and dining area and there is plenty of space for residents. There are also rooms which can be used for activities for all residents to get together. There is a visitors’ room available which can, by prior arrangement, be used for visitors to stay overnight. The Manager hopes to develop a reminiscence area in the home and to provide a cinema room for residents’ use. The building is very clean and there were no unpleasant odours at the time of the inspection. A resident said that one of the things she likes about the home is that it is ‘very clean’. A relative said in feedback that ‘the place is immaculate’. A small laundry is available for any residents who wish to do their own washing. Residents’ laundry is done individually in a larger well-equipped central laundry. Waterside DS0000052132.V350084.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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough well trained staff to provide good care for the residents. EVIDENCE: The staffing levels are as follows: • On each of the two units providing care for sixteen residents with high care needs (Lavender and Bridgewater) there is a senior member of staff on duty throughout the day, accompanied by three care staff in the morning and two care staff in the afternoon and evening. • On Avon unit, which provides care for sixteen residents with a lower level of need, there is a senior member of staff on duty throughout the day, accompanied by two care staff in the morning and one care staff in the afternoon and evening. • At night time there is a senior member of staff on duty, responsible for the whole building, accompanied by four care staff, all of these staff do waking night duty. Staff reported that they find these staffing levels appropriate for the needs of the residents. Observation during the inspection also showed that residents’ needs can be met with this staffing policy. Over the last year three care staff have left their posts at the home. This is a low staff turnover in a large team and contributes towards consistent care. Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 19 Of the permanent care staff team 76 have or are working towards an NVQ qualification and 42 of the bank staff employed at the home hold NVQ or above. In addition several members of the staff team have received specialist training in working with people with dementia. There has been no staff recruitment since the last inspection so no staff records were checked. The Registered Manager stated that Anchor Trust now has a specialist recruitment team in place, and she identified this as an improvement. The Manager and Deputy manager have undertaken training in human resource issues over the last year. New staff are required to go through an appropriate induction and must complete a probationary period successfully prior to their appointment being confirmed. Waterside DS0000052132.V350084.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, 32, 33, 35, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from effective management systems. The quality of the service provided is assessed regularly and action is taken to make sure it reflects residents’ views. Health and safety is well managed in the home. EVIDENCE: The manager was appointed to her post in November 2006 and was registered under the Care Standards Act 2000 in June 2007. She is appropriately qualified and experienced for the role. The manager was praised by a relative for her commitment and hard work, she said that ‘she puts 150 in every day’. The management style was described as ‘approachable’. There are a number of quality assurance systems used to ensure to monitor the quality of the service. Senior managers from Anchor Homes visit the Waterside each month and complete a report of their findings. The visits Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 21 include discussion with residents, visitors and staff as well as an assessment of the premises, a medication check and examination of records. An annual survey of relatives and residents is conducted across all of the Anchor Homes. The results were published in a report made available to the CSCI. In addition a quality assurance system called ‘Hospitality Assured’ is used at the home. It includes a range of quality assessment measures including a monthly survey of residents’ views on the personal care provided; the approach of staff; catering and mealtimes; housekeeping and GP services. Relatives and other visitors are also asked to complete questionnaires. The monthly residents’ meetings are another important aspect of ensuring that the home meets their needs and preferences. The home has made very good progress towards meeting the requirements of the last inspection report of June 2007. This indicates a commitment to improvement of standards in the home. The manager / owner does not act as appointee for handling the financial affairs of any of the residents. Residents may keep a small amount of money at the home and draw on it as they wish. The records of these are subject to regular checks by the manager. The home has made appropriate notifications to the CSCI about events in the home. In one instance the notification was insufficiently detailed. This was discussed with the Deputy Manager. Further information about the incident was made available to the inspector and found to be satisfactory. Those staff who complete notifications to CSCI would benefit from management input about the issue. See requirement below. Health and safety records were well maintained and showed that checks are carried out at appropriate intervals. The fire alarm and emergency lighting system had been checked in October 2007, and the last fire drill had taken place in October. The fire risk assessment was last reviewed on 2nd November 2006 and is due for review. Assessments of the assistance that each resident would need in the event of an emergency have been carried out. This is a useful tool which contributes to the protection of residents. Waterside DS0000052132.V350084.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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 4 3 X X X X X 4 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 3 X 3 X 2 3 Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 23 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 12(1)(3) 15(2)(c) Timescale for action The Registered Person must 17/12/07 ensure that residents’ expressed preferences for night time checks are observed. Any change to the practice, for instance in the event of residents’ illness, must be recorded. The Registered Person must 17/12/07 ensure that the monitoring form used for oral care is completed consistently. The home has informed the CSCI 17/12/07 appropriately of events in the home which require such notification. Staff completing the forms would benefit from management input to ensure that sufficient detail is provided. Requirement 2. OP7 15(1) 3. OP37 37 Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Waterside DS0000052132.V350084.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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