Inspection on 28/06/05 for Aaron House

This inspection was carried out on 28th June 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Aaron House 29/07/08

Aaron House 04/07/07

Aaron House 22/11/06

Aaron House 05/12/05

Aaron House 21/09/04

Aaron House 22/04/04

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

CARE HOMES FOR OLDER PEOPLE Aaron House 255 Preston New Road Blackburn Lanashire BB2 6PL Lead Inspector Jennifer M. Turner Unannounced 28 June 2005 10:00 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 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. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Aaron House Address 255 Preston New Road Blackburn Lancashire BB2 6Pl 01254 56208 01254 681071 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ahmed Ahmadi Mrs Badrolmolouk Abbaszadi Mrs Alison Foster Care Home only Personal Care 23 23 Category(ies) of Dementia - Over 65 years of age (DE)(E) registration, with number of places Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home must, at all times, employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. Date of last inspection 21st and 24th September 2004 Brief Description of the Service: Aaron House is situated on the outskirts of Blackburn on the Blackburn to Preston main road. The main public park, shops and churches are nearby. The town centre is within walking distance. Aaron House is a detached property and the small front garden leads onto the busy main road. At the rear of the house is a small parking area leading to an enclosed grassed area. The interior of the home is on four levels. The dining room is situated at basement level and leads into the conservatory. The office and staff room and three bedrooms are also situated at basement level. The car park and rear garden are accessed via a ramp from the dining room. There are two lounges on the ground floor and residents are able to access the dining room only via a passenger lift. The upper floors are accessed via the staircase or the passenger lift. In total, there are seventeen single bedrooms and three double bedrooms. Toilet and bathing facilities are easily accessible to residents. At the time of the inspection there were 20 residents accommodated in the home. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 28th June 2005 from 10.00am. The CSCI Pharmacy inspector was also in attendance and her comments are included in this report. Information was obtained by talking with the manager, assistant manager, 4 staff members, a visitor and four residents. A variety of records were examined and a tour of the home was made. Views were obtained from residents, staff and a visitor on a variety of topics and information was also obtained by case tracking. One comment card was returned. These views have been recorded collectively where the answers obtained were similar. Any specific or differing comments have been recorded in the main body of the report. The inspector’s notes have been retained as evidence of the inspection. During the inspection an Immediate Requirement Notice was issued. In the absence of a cook, a thorough cleaning of the kitchen area was required. A response has been received from the registered person indicating that the work has been completed. What the service does well: One resident commented that she “liked the activities” that were provided. Residents were encouraged to bring small personal items into the home. This ensured that their new environment was made “as homely as possible”. A balanced diet was offered and choices were available at mealtimes. Residents commented that the “food was good” There was a good rapport between staff and residents. A resident commented that “staff were good and looked after us” A comprehensive induction and training programme was offered to staff. This ensured that staff were competent and felt confident when carrying out their work. Staff commented, “we do a lot of training here”. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The criterion for “emergency admissions” is required to be inserted into the Statement of Purpose. This will ensure that referring agencies are aware that staff at the home are able to deal with such referrals competently. Although residents room numbers appear in the letter of acceptance and the care plan, provision should be made for this information to be inserted into the residents “Terms and Conditions of Residency” - (contract). Policies and procedures for medication should be reviewed to reflect current practice. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 7 Because of the level of residents’ understanding it was suggested that a visual, illustrated menu could be offered to residents. This may make them more aware of what food is being offered at mealtimes. Kitchen records need to be completed daily and filed away in a more organised manner. There should be a written record of all meals served. wholesome and balanced menu is continually provided. This ensures that a In the absence of a cook, routine cleaning in the kitchen needs to be continued. This ensures a clean and safe working environment for the staff. The complaints procedure must include the time that a complaint will be responded to by the registered person. Such information allows complainants to know that their concerns will be dealt with in a timely manner. Instead of referring to the complaints procedure in the Statement of Purpose, a complete copy should be included. This ensures that anyone wishing to make a complaint has all the relevant information to hand. Some repairs were required to the bath fascia in the upstairs bathroom. This would ensure complete safety for the residents when using the bath. Door locks should be fitted onto bedroom doors. A risk assessment would then indicate whether the resident was capable of managing the lock safely. Contact must be made with the Environmental Health Officer in respect of obtaining appropriate advice in respect of the prevention of legionella. This would ensure that residents and staff lived and worked in a safe environment. The registered person must contact a plumber to ensure that the services and facilities within the home comply with the Water Supply (Water Fittings) Regulations 1999. At the time of appointment all staff should be provided with a Contract of employment. Records relating to residents’ savings must show individual transactions and be able to show individual balances. This would ensure that residents and relatives were immediately aware of the level of their finances. A number of policies and procedures require to be reviewed. This ensures that staff at the home are up to date and aware of current working practices. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1;2;3;4; The home does not offer Intermediate Care. All residents received a contract that outlined the terms and conditions of residency. A comprehensive assessment procedure was carried out prior to people moving into the home. This meant that their needs were known and met. EVIDENCE: The Statement of Purpose and Service Users Guide has been updated but still did not contain the criteria to be used for emergency admissions. Although information was sought from residents and relatives in respect of their views of the home, the results of these surveys are required to be documented in the Service Users Guide. (NMS 1.2) Copies of the Statement of Purpose and Service User’s Guide were on display near to the dining room and anyone was welcome to take one of these. Each resident was issued with a Statement of Terms and Conditions at the point of admission. One resident remembered signing a contract. The assistant manager said contracts were discussed with the resident, although due to varied levels of capability, it was often the family or other representative who was most active in discussing this. Although the number of Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 11 the room allocated to the new resident appeared in the letter of acceptance and the Care Plan, it needs to be recorded in the Terms and Conditions of Residency at the time of admission. The assistant manager stated that all prospective residents had a preadmission assessment undertaken by herself or the manager. This was usually undertaken at the prospective residents home, or in hospital, and information would be gathered from as many sources as possible e.g. prospective resident, relative, involved professionals. The care plans of the most recent admissions were examined. All areas of the standard were covered and a variety of risk assessments were seen. The assistant manager said that any emergency admissions had the documentation completed in the required time. A number of staff at the home had undergone brief training courses in aspects of dementia care. The manager was running in-house training and using videos and written material regarding dementia care. Care plans showed that as assessed needs were identified, other professionals were involved in the care of residents. There was documentation to show that a prospective resident, or their representative, received written confirmation that staff at the home could meet their assessed needs. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7;8;9;10 Resident’s healthcare needs were identified and met. Their personal care was delivered in a way that promoted residents’ privacy and dignity. Medication was generally handled according to current Royal Pharmaceutical Society of Great Britain guidelines although procedures required reviewing. The pharmacy inspector highlighted ways practice could be further improved. EVIDENCE: Three care plans were looked at. The information provided referred to residents individual needs. This also included their needs relating to their dementia and risk assessments were being set up in respect of the resident’s mental state. Written evidence showed that the care staff completed a daily report that was summarised every week by the key worker. The Team Leader and the Deputy Manager reviewed the care plan, risk assessment and other relevant documentation monthly. A signature sheet was in evidence for relatives and residents to sign after each review and written comments were welcomed. Due to their cognitive impairment the residents who were ‘case tracked’ were unable to discuss their care plan with the Inspector. The care plans examined showed a comprehensive approach regarding resident’s physical and mental health needs. A range of assessments were Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 13 seen on files examined, and these included tissue viability, nutrition, and weight. Records showed involvement of other professionals as needed. Staff discussed their observations of residents’ health care and appropriate actions that they took. Only trained staff administered medication and whilst documentation was generally good, the home must ensure that all medications received into the home are recorded, and that a full list of current medication is kept for each resident. On occasions Paracetamol tablets had been ‘borrowed’ and administered to another resident. This practice is not acceptable and the tablets should be taken from separate named supplies or from a homely remedy supply purchased by the home. The Service User Guide clearly outlined the homes approach to privacy and dignity. Staff described care practices that respected these areas. Residents had access to a telephone, although few were able to use the facility due to their inability. There was a jack plug in facility in each bedroom and there was also a mobile handset available. One service user spoke of relatives “ringing in”. The Service Users Guide outlined arrangements for personal belongings. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12;13;14;15 Residents’ dietary, social, cultural and religious needs were being met at the home. Relatives were involved in making choices about residents’ lifestyles. Contact with family and friends was maintained. Meals offered ensured that the individual dietary needs of the residents were met. EVIDENCE: The Service User Guide outlined the provision of activities, both individual and group. An activity list was displayed by the dining room. Staff spoke of discussing activities available with individual residents and of encouraging them to participate. This information was recorded in the residents care plan. One resident was of non-British origin. He was able to carry out his own personal needs and his prayer requirements were respected. A member of staff accompanied one resident to the local Church and Spiritual leaders visited the home monthly. Some residents maintained regular contact with relatives. The Service Users Guide provided information regarding visitors and visiting. One visitor spoken with remembered receiving information relating to visiting. A visitor’s room was available for privacy but visiting also took place in the main lounge or in resident’s bedrooms. Staff said that not many “community groups” visited the home, but a Clothes Party and a “Sweetie” Party had been arranged for the benefit of those residents unable to go out. If a resident did Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 15 not wish to see a particular visitor, the deputy manager said that this would be recorded on the file, although no such arrangements were presently in place. A couple of residents were able to administer their own pensions. There was information on the advocacy service on display near to the dining room for residents and visitors to access. From walking around the home it was evident that residents were able to bring items of their own possession into the home. This information was seen recorded on resident’s files. In the absence of a cook, various records could not be found and some that were available had not been completed correctly. There were some records available for lunches and teas served but no indication of what was available for breakfast or supper. The daily menu was displayed on a board in the dining room. The deputy manager said that staff asked residents in a morning what they wanted for lunch. Because of the level of residents’ understanding, the introduction of a visual, illustrated menu was discussed. The inspector had lunch with the residents and noticed that although residents were encouraged to eat their meals independently, staff were available to assist discreetly if required. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16;18 Residents were protected from abuse and had access to the homes complaints procedure. EVIDENCE: The Service User Guide contained a complaints procedure and a copy of the procedure was posted on the notice board. The time taken for the registered person to respond to a complaint needs to be added to the procedure. The complaints procedure was referred to in the Statement of Purpose, but an actual copy of the procedure must be included. The deputy manager said that the procedure was drawn to the attention of the resident’s representative at the time of admission. When asked if they knew who to speak to if they had any concerns, one resident said ‘I would speak to staff.” A comment card received from a resident showed an awareness of the complaints procedure. There were a number of letters and cards of appreciation on display in the hall. The home complied with the Blackburn with Darwen Borough Council protocol for the Protection of Vulnerable Adults. The majority of staff spoken with had attended an adult abuse course and this was being cascaded to other staff. Staff were aware of differing forms of abuse and able to discuss the right approach to be taken. An appropriate policy regarding physical and verbal aggression was also available. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19;24;25;26 The home was warm, clean and comfortable. A good standard of hygiene was achieved. Further attention is required to the water system to ensure a safe storage and output of water. This would ensure that residents lived in a safe environment. EVIDENCE: There was a routine programme of maintenance and records were kept. Staff recorded in the maintenance book any areas that required attention and the handyman signed the book when the work was completed. The inspector noticed that the bath fascia in the top floor bathroom required repair. Compliance was noted regarding the latest environmental health report. Fire safety issues were maintained in house and regular checks and maintenance was noted. Bedrooms were viewed and were clean and comfortable. Two previous requirements of 29.05.04 and 31.12.04 had not been adhered to for the fitting of locks onto residents’ bedroom doors. Residents were assessed upon Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 18 admission and if they were capable of managing a key, a lock would be fitted onto the bedroom door. Door locks should be fitted to each bedroom door and residents should be provided with a key, which he or she can retain (unless their risk assessment suggests otherwise). This decision should appear in the care plan. A lockable storage facility had been provided in each bedroom but again, keys were not available to all residents. Again, these should be offered unless the reason for not doing so appears in a risk assessment and mentioned in the care plan. Where bedrooms do not have the furniture as recommended in NMS 24.2 a bedroom audit should be carried out. All rooms were individually and naturally ventilated. The windows had been fitted with appropriate restrictors. At the time of the inspection the home was at a comfortable temperature. All of the rooms were centrally heated, with individual thermostatic controls on the radiators. All radiators had been fitted with guards. There was adequate lighting of various types in the communal areas and emergency lighting was fitted throughout the home. Hot water outlets to baths and hand-basins had been fitted with pre-set valves. The manager said that Legionella testing had still not been carried out. This remains outstanding from 29.05.04 and 31.10.04. She said that there was no temperature dial on the boiler and therefore the water storage temperature could not be determined. The registered provider must consult with the authority responsible for environmental health for appropriate advice on this issue. During the inspection an Immediate Requirement Notice was issued. In the absence of a cook, a thorough cleaning of the kitchen area was required. A response has been received from the registered provider indicating that the work has been completed. Laundry facilities met requirements. There was no sluice, although a sink was designated for this purpose only. The shelf coverings in the laundry were worn and required to be replaced. The manager could not confirm that services and facilities complied with the Water Supply (Water Fittings) Regulations 1999. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27;28;29;30 The numbers and skill mix of staff met residents’ needs. Staff were recruited using current guidelines and received training suitable to the residents residing at the home. EVIDENCE: The staff rota showed staffing levels complied with those set by the previous regulatory authority. The manager was presently attempting to employ a designated cook. Staff training was ongoing. Of the eleven care staff, three had completed a National Vocational Qualification (NVQ) at level 2 and the remaining eight staff were undertaking the course. The manager anticipated meeting requirements of 50 care staff obtaining a appropriate NVQ by the end of the year. The files of three recently employed members of staff were examined. The recruitment process had improved. All the requirements of Schedule 2 of the Care Homes Regulations 2001 were addressed but some areas required further input. The inspector advised that references should not be obtained from relatives. There was evidence to demonstrate that CRB’s had been applied for. Staff said that they were issued with a copy of the GSCC Code of Conduct and practice. Staff members spoken to said that they had still not received a contract of employment. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 20 There was an Induction training booklet for staff to complete on commencing employment. This covered issues such as health and safety, personal care for service users, and aspects of employment. Induction training was carried out “in house” and staff then completed the TOPSS requirements through “Learn Direct”. The training matrix demonstrated all course undertaken or currently being taken by staff. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31;33;35;36;37;38 The welfare of residents was sufficiently protected. The home was run in an open and transparent way with a good staff and management team. EVIDENCE: The manager was currently undertaking NVQ level 4 and the Registered Managers Award. She was aware of the need to complete the training by the end of the year. She had obtained her D32 and 33 qualifications, and there was evidence that other relevant courses had been undertaken. Aaron House had achieved the ‘Investors in People Award’. Resident questionnaires (in the main completed by their representatives) contributed towards self-monitoring. Consideration was being given to using questionnaires for other professional opinions. Currently this was informal, Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 22 through ongoing discussion. reviewed. The annual development plan still required to be Pensions were generally paid from the Department of Work and Pensions into the Proprietors account. The residents’ spending money was then forwarded to the manager to administer. She administered the finances of five residents and indicated that the monies were kept in a joint residents account at Barclays Bank. There were no clear records for the inspector to check how much money was held for each resident. It was required that where residents monies are held in a joint residents account, the account records separate deposits and withdrawals for each individual. It must be demonstrated how individual interest is calculated to individual residents own savings. The manager ensured the employment policies and procedures of the home were put into practice. Staff files confirmed appropriate documentation. Discussions with staff confirmed issues such as recruitment and appropriate checks, training and supervision were taking place. Records showed that supervision was taking place at least six times per year. The format covered all criteria. The majority of policies and procedures viewed by the inspector required to be reviewed. It was recommended that they were signed and dated when this was carried out. Records were maintained for accidents. The fire records and fire equipment examined were up to date. Health and safety policies, procedures and legislation were available at the home for staff to ensure the health and safety of residents and each other. The manager continued to address the issue of all staff receiving moving and handling training. The manager was to pursue the outstanding work required following the issuing of the Gas Safety Certificate on 15.06.05 Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x x x 2 2 1 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 x 2 x 2 3 2 2 Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 24 YES 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. Standard 1 Regulation 4. Schedule 1 Requirement The registered person must ensure that all areas listed in NMS 1; Regulation 4 and Schedule 1 are included in the Statement of Purpose and Service Users Guide. (Previous revised timescale of 24.10.04 not met The registered person must ensure that medicines are only be administered to the resident for whom they were prescribed. There must be no sharing of tablets, creams or other preparations. The registered person must ensure that there is a full record of all medication currently prescribed for each resident. The registered person must ensure that specific timescales that a complaint will be responded to, is written in the complaints procedure. The complete procedure must appear in the Statement of Purpose. The registered person must ensure that adequate precautions are taken regarding protection against Legionella. (Previous timescales of 29.05.04 Timescale for action 01.09.05 2. 13(2) 9.4 28.06.05 3. 13(2) 17(1)(a) Sch 3 (i) 22(4) 9.3 28.06.05 4. 16 01.09.05 5. 13 (3) 25 30.09.05 Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 25 and 31.10.04 not met) 6. 16 (2)(j) 23(2)(d) 26 The registered person must ensure that the kitchen area is kept clean at all times and that satisfactory levels of hygiene are maintained in the kitchen area. The registered person must ensure that services and facilities comply with the Water Supply (Water Fittings) Regulations 1999.(Previous timescales of 29.05.04 and 31.12.04 not met) The registered person must ensure that an annual development plan for the home, based on a systematic cycle of planning - action - review, reflecting the aims and outcomes for residents, is produced.(Previous timescales of 29.05.04 and 30.11.04 not met) The registered person must ensure that there are clear and accurate records of the amount of personal allowance received by residents and the individual balance held in safe keeping for them. (Previous timescale of 25.10.04 not met) The registered person must ensure that where residents monies are held in a joint residents account, the account records separate deposits and withdrawals for each individual. It must be demonstrated how individual interest is calculated to individual residents own savings. The registered person must ensure that all staff receive moving and handling training. (Previous timescale of 30.11.04 not met) The registered person must ensure that any outstanding requirements made following the F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc 28.06.05 7. 13 (3) 26 30.09.05 8. 24 (1) (a)(b) 33 30.09.05 9. 17 (2) Schedule 4 (9) 35 30.09.05 10. 17 (2) Schedule 4 (9) 35 30.09.05 11. 13 (5) 38 31.12.05 12. 23 (2)(b) 38 28.06.05 Aaron House Version 1.30 Page 26 inspection of appliances are completed. 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. Refer to Standard 2 OP9.1 OP9.3 Good Practice Recommendations The registered person should ensure that the Statement of Terms and Conditions includes reference to the room to be occupied You should review medication policies and procedures in line with Royal Pharmaceutical Society of Great Britain guidelines to cover all aspects of medicines management. Criteria for the administration of when required and variable dose medication should be clearly defined and recorded for all service users prescribed such items. A second member of staff should witness all hand written annotations on Medication Administration Record charts. The opening date should be recorded on eye drops and other items with a short shelf-life Patient Information Leaflets should be available for all medication in the custody of the home, including that supplied in a monitored dosage system. The introduction of a visual, illustrated menu may increase residents awareness of what is being offered at mealtimes. Records should be available for all meals served. The bath fascia in the upstairs bathroom requires attention. Locks should be fitted onto bedroom doors and the risk assessment should show whether the resident wished to use it or not. Each resident should be offered a key for the lockable facility in their bedroom unless the risk assessment states otherwise. A bedroom audit should be carried out in each residents room showing what furniture is available. The formica covering on the shelves in the laundry area require replacing. At least 50 of care staff should have achieved NVQ level 2 (or equivalent) by the end of 2005. Staff members should be supplied with a contract of F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 27 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. OP9.4 OP9.7 15 15 19 24 24 24 26 28 29 Aaron House 15. 16. 31 37 employment. The manager should complete her NVQ level 4 and Registered Managers Award by the end of 2005. Policies and procedures should be reviewed on an annual basis or more frequently if required. They should be signed and dated when completed. Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road Clayton-Le-Moors, Accrington Lancashire. BB5 5JB 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 Aaron House F57 F07 S5802 Aaron House V225526 280605 Stage 4.doc Version 1.30 Page 29 - 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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