Inspection on 16/09/05 for 8 Graeme Close

This inspection was carried out on 16th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 Graeme Close 30/07/07

8 Graeme Close 15/08/06

8 Graeme Close 26/02/06

8 Graeme Close 15/02/05

8 Graeme Close 19/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 8 Graeme Close Fishponds Bristol BS16 3SF Lead Inspector Nicola Grayburn Unannounced Inspection 16th September 2005 09:30 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 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 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 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 Adults 18-65. 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. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 8 Graeme Close Address Fishponds Bristol BS16 3SF 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) 0117 9652696 0117 9709301 Aspects and Milestones Trust Mrs Rachel Mary Cornell Care Home 16 Category(ies) of Dementia (16), Mental disorder, excluding registration, with number learning disability or dementia (16) of places 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 16 Adults with Mental Disorder excluding those detained under the Mental Health Act 1983 Staffing Notice dated 02/07/1999 applies Manager must be a RN on parts 3 or 13 of the NMC register Date of last inspection 15th February 2005 Brief Description of the Service: Graeme Close is a registered care home providing 16 nursing care places for people between 18 and 65 years of age who have mental health difficulties. The home cannot accept people detained under the Mental Health Act. The building was purpose built in the late 1990’s and offers care over two floors, there is a lift, which gives wheelchair access to the upper floor. Accommodation is offered in single rooms and there is a variety of communal space and quiet rooms. The house is very near to the Fishponds shops, local social venues and is situated on a main bus route. The home encourages residents to be as independent as possible with support and empowerment from full time care staff lead by a team of Registered Nurses. The home is operated as part of the Aspects and Milestones charitable trust. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted by two inspectors over one day. The main purpose was to check on residents’ welfare, ensure the premises was being well maintained and to examine health and safety procedures. In addition to this other key records were inspected, including two care plans. Evidence was primarily gathered through consultation with five residents and five members of staff and examination of records. What the service does well: What has improved since the last inspection? What they could do better: Seventeen requirements are made as a result of this inspection and urgent action needs to be taken by the manager address a number of these. Improvements need to made for monitoring specific healthcare needs and this should include guidelines for staff and information about prescribed medication. The home will then be more able to demonstrate that they are promoting residents emotional and physical wellbeing and that they are being protected. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 6 Some records provide further development – particularly initial assessment and care plans. At present these do not adequately reflect individual needs and preferences. Staff morale is being affected by high levels of staff sickness and action needs to be taken to ensure there is greater consistency. The premises are in a poor state of repair, primarily because of damage caused by smokers. Action needs to be taken to bring a number of rooms up to standard and to replace some carpets so that it is a better environment for all residents to live in. In addition to this some kitchen areas need to be replaced or fixed. Standards of cleanliness need to be improved. 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. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 New residents can expect to receive up to date information and not to be rushed into making any decisions– this means they can move in with greater confidence. The home needs to obtain fuller assessments prior to admission so they can more easily demonstrate that they will have the resources and skills to meet with assessed needs. EVIDENCE: A previous requirement regarding the availability of the home’s Statement of Purpose had been met. There was a home’s guide available in the hallway, which contains, amongst other information, the most recent inspection report, the statement of purpose, how to make a complaint and the local places of worship. Opportunity was taken to look at the newest residents’ file. He has been living at the home for a number of months. It was apparent that, after some difficulties, he has begun to settle in well to the routines of the home. It was concerning, however, that there was little recorded information, for example, in the form of an initial care plan received about him prior to his moving to Graeme Close. There was an assement carried out by the manager but this did not contain sufficient information about his mental illness, past behaviours or strategies which may have worked whilst he was in hospital to help him manage his illness. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 9 Subsequent discussions with staff indicated that the amount of information received during the admission process varies greatly depending on where the person is moving from. Action needs to be taken by the home to improve this situation, if they do not receive a full initial assessment and care plan then the manager would need to complete one. Residents confirmed that they were able to visit the home on several occasions prior to moving there and the staff team reiterated this. Several examples were seen where the admissions process had been achieved over a considerable time to enable residents to feel more confident about moving there. This is good practice. Aspects and Milestones issue terms and conditions and completed copies of these were seen on files. This meets with requirements of the legislation. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Residents can expect to receive support from key staff who get to know them well. Care plans, however, need to be developed so that the home can evidence that it is providing a consistent personalised service. EVIDENCE: Two files were looked at in detail. These contained personal information, correspondence, various assessments and care plans. One of the residents had only recently moved to the home so there were a series of short-term plans which were going to be further developed as he settled in. The majority of the information seen had recently been reviewed although it was not clear how involved residents had been in this process or whether they received copies of their care plans. The information seen covered several broad issues. It was noted, however, that some care plans contained limited information about the person and their preferences, for example when bathing. This was discussed with senior members of the team. Action needs to be taken to further develop these. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 11 Graeme Close operates a key worker and co-worker system whereby each resident is allocated named members of staff who play more of a central role in coordinating the service they receive. All those staff spoken with displayed a good awareness of their role within this system and were very knowledgeable about individual resident’s needs. This system appears to work well within the home. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,17 Residents can be reassured that staff will support them to take part in activities of their choice and to be part of the local and wider community. Residents are supported to pursue leisure, cultural and religious activities. Residents are provided with a varied, healthy meal choice, and have the opportunity to cook for themselves with support. EVIDENCE: The home employs an activities co-ordinator who was spoken with at length during this visit. She organises a number of activities throughout the week, including discussion groups and numerous trips out. She said that she also endeavours to ensure that each resident has regular one to one sessions although this has been difficult to achieve due to recent staff shortages. Members of staff said that one of the long-term difficulties within the home has been to motivate residents’ and that the development of the co-ordinator role has been a positive one. They were appreciative of her efforts. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 13 Residents also said that they were pleased with the level of activities available. It was apparent that they do not feel that they have to join in unless they want to and many are selective about the sessions that they go to. Residents were observed having unlimited access to all communal areas of the home and some go out independently at different times of the day, which they were observed doing during this visit. There were risk assessments on personal files about road safety although these were not looked at in detail. Members of staff said that they have good relations with their neighbours and an advantage of the home is that it situated in the heart of the Fishponds community and close to many local amenities. Staff also displayed an awareness of the discrimination that residents may face and ways in which they try and help them overcome this. Records and discussion with staff and residents indicated that links with family and friends varies and often relationships are complex. One member of staff gave good examples of how she manages a difficult situation with one family and it was apparent that she was trying to deal with this in a sensitive manner. Such significant issues should be recorded within care plans and this will be a focus of the next visit. Opportunity was taken to join residents with their lunchtime meal. Some commented that they enjoyed it and no concerns were raised about the quality and quantity of food. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 Action needs to be taken to improve support given for identified medical needs. It would then be more evident that the home is appropriately and safely meeting residents physical and emotional needs. EVIDENCE: Staff were observed positively interacting with residents and relationships were respectful and friendly. All residents spoke warmly about the staff team and were pleased with the support they got from them. Records provided evidence that residents are supported to see the relevant health professionals, including specialists. In addition to this they are encouraged to attend regular check ups. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 15 It was of concern that one resident, identified as having diabetes, was not having his bloods checked on a weekly basis (or it was not being recorded), as stated that it should be on his initial assessment. In addition to this the levels were seen to be erratic. Staff said that the GP had been consulted but there was no record of this and it was not clear what they should be doing. Prompt action needs to be taken by the staff team to ensure his medical needs are being met appropriately and consistently. In addition to this there should be guidelines within personal files about the level of risk of a diabetic induced coma or other associated medical difficulties such as circulatory problems. This should include signs, symptoms and actions to be taken to reduce the risk. The medication system was found to be in good order. There were photos of each resident with their names on a pin board for verification of administration. There was one controlled drug in use which was kept in a locked metal cupboard. The staff member commended the pharmacy for their advice and guidance. There are two residents who self medicate. One resident said they had a lockable drawer where the medication is stored but there was no key for the drawer, but does lock the bedroom door. The manager must ensure that residents use lockable units to stores their medication. There were medication profiles – these, however, were inconsistently filled out and not detailed enough. It is important that this information is available as many residents have complex mental health needs for which they are prescribed mood-altering drugs. All staff should be aware of the reasons for their use, potential side effects and actions to be taken if a dose is missed. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Staff create an open and honest atmosphere and residents can be confident that they will be listened to. Residents are protected from abuse. EVIDENCE: There is a complaints procedure in the home’s guide in the hallway. This included relevant contact numbers. Residents spoken with confirmed they would raise any concerns or complaints to their key worker and were confident that it would be acted upon. No complaints have been received by the CSCI since the last inspection. The activities co-coordinator convenes a three monthly residents meeting for which there were detailed minutes. This provides an important, more, formal forum, through which residents can influence the running of the home. Aspects and Milestones have a vulnerable adults policy and all staff spoken with said they had received training about abuse. When questioned, they displayed a clear understanding of the issues involved and stated with confidence that they would report bad practice. Financial arrangements vary according to ability. On one personal file there was clear guildines about how they pay their fees and obtain their personal allowances. Some residents require more assistance with their monies and a few were observed coming to get a daily allowance from the office in the morning. This practice may appear institutional but it was apparent that this suits the needs of some residents who rely on these routines. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Urgent action needs to be taken to improve the environment and levels of cleanliness to provide the residents with a safe, clean and comfortable environment. EVIDENCE: The property is a large purpose built building. There are numerous requirements made from this inspection regarding the general environment. The rear garden is attractive and has recently had a summer house installed for the use of the residents. Residents confirmed that the home has barbeques and garden parties when the weather permits. However, it is recommended that the front garden would benefit from some work done on it. The majority of the bedrooms were entered, however some were locked or residents were still sleeping. The general property was also inspected. The bedrooms were personalised and those residents with limited mobility had bedrooms on the lower floor ensuring that their independence was retained. There is also a lift to gain access to both floors. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 18 Three bedrooms were identified which require carpets being replaced immediately. Residents smoke in their bedrooms and the home does not allow this, there are no ashtrays supplied. Therefore, the residents are using the floor. Members of staff said that this was a source of frustration for them. Further action needs to be taken to instil in residents that they cannot smoke in their bedrooms, as this is both damaging the flooring and presents a signicant health and safety risk. It was evident that smokers are using other rooms. Both ‘Quiet’ rooms are in need of immediate refurbishment and new carpets. The two lounges are also in need of appropriate furnishings for the clients. It is recommended that staff take appropriate action to enforce the home’s smoking policy, possibly by means of reiterating the terms and conditions. In one room the floor was found to be wet. This poses a risk of slipping and falling for the resident and staff. On closer inspection, the protector sheet on the bed was dirty and had a cigarette burn in it. Staff confirmed this would be cleaned up. The previous requirement of replacing the walk in shower has been completed. A low level screen is provided to prevent the water from being dispersed, however, it is unsteady and must not be used as a mobility aid. This must be made more secure. There are many bathrooms and toilets for use of residents. The majority of them were clean and had appropriate grab rails. However, in one toilet there was no bin and a torn plastic bag was tied to a grab rail. Adequate bins are required to be provided in all toilets. Downstairs, there is a Parker bath for the use of one resident with limited mobility, which promotes their independence. There are numerous areas for residents to spend time out of their rooms. The main lounge area is the designated smoking room for residents. There is also a seating area adjoined to the dining room, which overlooks the garden. On the ground floor there is also a communal dining room where residents eat their meals together. The kitchen was also inspected and was found to be needing repair. The cupboards holding crockery, and a drawers unit must be replaced due to safety issues. Staff stated that these are due to be replaced in the very near future. The deep fat fryer was ‘rejected’ from the recent Portable Appliance Testing (electrical). This needs to be removed immediately. The fault is to be fixed or the appliance replaced. There are problems with the gas oven as well. The hobs do not light effectively when one is in use, and the main oven does not work properly. This must be reassessed due to the dangers involved with gas. The fridge, freezer and larder were well stocked with foods, with appropriate labelling. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 19 There is also a ‘training kitchen’ kitchen for residents to cook in with assistance if need be. This was not inspected. The home requires an entire deep clean of all areas. An external cleaning company recommended this in a report. However, it was noted on the report that the Property Manager was not prepared to fund this. There was also an historical report from the Food Hygiene Inspection Department from Bristol City Council stating that the home’s cleaning schedule was in need of review. Staff confirmed that the domestic staff does not work many hours. It is advised that the number of hours worked be reviewed against the need of the large property. This will be the subject of an additional unannounced visit. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35 Staff are clear about their responsibilities and work well as a team. Action needs to be taken to reduce staff sickness so that residents receive a more consistent service. EVIDENCE: Opportunity was taken to consult with five staff members. They all displayed a clear understanding of their roles and responsibilities and all said that they felt they worked well together as a team. It was apparent that they felt there was goodwill amongst them and that they could rely on each others support. One of the main issues of concern that all members of staff spoke about was the high level of long-term sickness. They said that this was having an effect on staff morale, particularly as there was a high use of agency staff which increased their workload and reduced consistency. This was confirmed through inspection of the staff rotas. In addition the residents had a recent meeting where they asked about staff sickness and it was apparent that they have noted the shortfall. They said they preferred to have support from people they knew as opposed to strangers. This situation is having a negative impact on the home and a requirement is made that Aspects and Milestones review this situation with a view to implementing contingency measures to improve consistency. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 21 All staff spoken with confirmed that they receive formal supervision. Staff were also satisfied with the opportunities they were given for training. They said that Aspects and Milestones have an annual training programme from which they could choose courses. In addition to this they confirmed that they received statutory training. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The home is safe. Action must be taken to improve fire safety to ensure the safety and welfare of the residents. EVIDENCE: The policies, procedures and guidelines had been revised and updated on 1/5/5 by Aspects and Milestones. Avon Fire Brigade visited on 4th February 2004 requesting a generic fire risk assessment to be carried out. There was no evidence of this; therefore a requirement has been made regarding this. Risk assessments regarding other areas of health and safety were in place. All other fire checks had been completed within the stated regulated timescales. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 23 The last fire training session for staff had been carried out on 26th November 2004. There is a requirement regarding the consistency of these training sessions, which must be conducted at least every 6 months for day staff and 3 monthly for night staff. Training sessions must be recorded with detail of what was covered and who attended. Residents confirmed, against records, that the home carry out fire drills with the last one being done on 21/06/05. COSHH assessments were reviewed on 30/06/05. Gas safety and boiler annual check had been completed on 15/4/5. Parker bath check is due next month. The lift’s six monthly check had been carried out on 11/07/05 A number of staff spoken with said the home might benefit from developing a deputy role, which would be of more assistance to the manager. It is recommended that this be considered. 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 x 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 1 2 2 2 1 3 1 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 x 2 x 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 8 Graeme Close Score x 1 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x DS0000020242.V249362.R01.S.doc Version 5.0 Page 25 NO Are there any outstanding requirements from the last inspection? 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 2 3 4 Standard YA2 YA6 YA19 YA19 Regulation 14 15 13(b) 12(1)(a) Requirement Ensure a full assessment is obtained prior to admission. Further develop the care plans Ensure the identified medical needs of diabetic residents are met Ensure care plans include risks associated with specific medical conditions. This should include signs, symptoms and actions taken All residents who self medicate to have a lockable storage facility Improve detail on medication profiles Staff to ensure that local smoking policies are adhered to Replace carpets in identified bedrooms Low level screen in shower room to be made secure Ensure all bathrooms have bins Refurbish “Quiet” rooms Fix or replace kitchen cupboards Remove fat fryer Replace\repair oven Improve standards of cleanliness DS0000020242.V249362.R01.S.doc Timescale for action 30/09/05 30/12/05 22/09/05 11/10/05 5 6 7 8 9 10 11 12 13 14 15 YA20 YA20 YA24 YA25 YA27 YA27 YA28 YA28 YA24 YA24 YA30 13(2) 12 (1)(a) 23 (a)(b) 16(2)(c) 13(4)(c) 12(1)(a) 23(2)(d) 23(2)(b) 23(2)(c) 23 (2)(c) 23(2)(d) 13/10/05 30/10/05 30/10/05 20/11/05 12/10/05 17/09/05 25/11/05 30/09/05 30/09/05 30/10/05 16/09/05 Page 26 8 Graeme Close Version 5.0 16 17 18 YA33 YA42 YA42 18(1)(a) 4(a) 4(d) Review levels of staff sickness 15/10/05 and implement contingency measures to improve consistency Develop work place fire risk 30/10/05 assessment Ensure all staff receive re-fresher 30/10/05 fire training at the prescribed intervals 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 YA24 YA24 YA25 YA37 Good Practice Recommendations Cut the grass in the front garden Take the appropriate action to enforce the smoking policy Replace furniture in lounge Create a deputy post 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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 8 Graeme Close DS0000020242.V249362.R01.S.doc Version 5.0 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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