Inspection on 18/06/08 for Primrose Lodge

This inspection was carried out on 18th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Primrose Lodge 25/09/08

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Albany Residential Home Albany 29-33 Essex Road Watford Herts WD17 4EL Lead Inspector Pat House Unannounced Inspection 18th June 2008 01:00 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 Albany Residential Home DS0000071687.V365429.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. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albany Residential Home Address Albany 29-33 Essex Road Watford Herts WD17 4EL 0208 9313982 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) albany.home33@yahoo.co.uk Mrs Dhanwantee Seegoolam Mr Bedanan Guru Seegoolam, Mrs Sangeeta Rukunny, Mr Bolah Rukunny Mrs Dhanwantee Seegoolam Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category Code OP The maximum number of service users who can be accommodated is: 21 Not applicable 2. Date of last inspection Brief Description of the Service: The Albany is a residential home providing care for up to 21 older people. The building is a detached Victorian house, which has been converted to provide care over two floors and has staircases and a passenger lift. There are two lounges, a conservatory and dining room on the ground floor and a large paved garden at the back of the house. There are 7 single bedrooms on the ground floor and 13 bedrooms on the first floor. One bedroom is a double room, which can be shared by two people through mutual consent, but has single occupancy at present. The Albany is situated in a residential area of Watford and has a narrow drive to the side of the building for some parking. There is restricted parking in the roads nearby. There are good road and transport links nearby and the town of Watford is within walking distance and has extensive shopping and leisure facilities. The home’s Statement of Purpose and Service User’s Guide are available from the office. Current fees for the home range from £420.00 to £450.00. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The information in this report is based on an unannounced visit to the home by two regulation inspectors carrying out the work of the Commission. For the purposes of this report the Commission will be referred to as ‘we’. Since the last inspection visit the home has changed owners and one of these owners is now managing the home. This was therefore the first inspection for this service, although most of the residents have been in the home for a number of years and the staff team has remained the same. The new manager was on duty during the inspection and provided information about the plans for the home. We spoke with staff members and with residents, both in communal areas and individually in their bedrooms. We also spoke with the relatives of two residents who visited the home during the inspection. We inspected all areas of the home briefly and examined a selection of records. Since the last inspection the manager has completed and returned a selfassessment questionnaire, sent out by the Commission. This is the Annual Quality Assurance Assessment document, called the AQAA in this report. We have included information from this document in this report. Quality surveys will also been distributed to some residents and staff at the home, and comments from these forms, when returned, will be included in the next inspection report. What the service does well: The residents and visitors we spoke with praised the care staff and the new manager. We were told that the staff were caring and met the needs of the residents in the way they preferred. We were also told that the manager spoke with all the residents daily and listened to all concerns. The manager demonstrated to us that she is keen to listen to any complaints and will endeavour to act on them to improve the service. The manager and Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 6 other owners are also planning a variety of improvements to the running of the home. The manager has already reviewed and rewritten many of the home’s policies and procedures and is reviewing the training needs of the staff team. The residents and relatives we spoke with said that care staff respected the different beliefs and attitudes of the residents and in the AQAA the manager states that she was checking that all staff had received training in Equality and Diversity and that the home’s policies covering this subject would be reviewed annually. A new medication trolley has bee provided to improve the storage of medication in the home. What has improved since the last inspection? What they could do better: Care plans need to be reviewed to ensure that information about residents is up to date and provides clear directions about the provision of care so that staff can be sure that all care needs are being met appropriately at all times. Records of the actual food eaten by residents must be completed and kept in line with current health regulations. Activity provision in the home should be reassessed in conjunction with the wishes and preferences of residents and with guidance from current professional advice for activity provision. An action plan is required showing how the home will be upgraded internally with regard to redecoration and especially with regard to toilets and bathrooms where facilities are not acceptable and where there is a risk of infection from poor fittings and sanitary ware. In the AQAA the manager has demonstrated that she is aware of the areas of improvement that are needed in the home and has stated that the owners have begun to draw up an Annual Development Plan – but have had to prioritise the order of work to be carried out. Albany Residential Home DS0000071687.V365429.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. Albany Residential Home DS0000071687.V365429.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 Albany Residential Home DS0000071687.V365429.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): Standard 3. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have their needs assessed before moving in so that all parties can be sure that everyone’s individual needs can be met by staff at the home. EVIDENCE: Most residents have lived in the home for some time but we spoke with a resident and her visiting relative who had been admitted fairly recently. We were told that the resident had visited the home and been given the choice of two rooms before deciding to move in. Since then the resident and relative have been very happy with services provided by staff at the home. We tracked the care plan of this resident during the inspection and saw written evidence that a detailed assessment had been completed before the resident was admitted and saw evidence that the care needs listed were being met ensuring that the resident was happy to be living in the home. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 10 In the AQAA the manager states that she is reviewing the pre-admission forms used to ensure they cover all areas relevant to the assessment of new residents, including details of “Life Histories”. Albany Residential Home DS0000071687.V365429.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): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service feel their health care needs are appropriately met by staff in the home but details recorded in their care plans need updating to ensure that all current needs are identified and that evidence can be seen that these needs have been met. Procedures followed for administering medication have been reviewed and improved to ensure they protect the residents in the home. EVIDENCE: We spoke with a visitor who said that their relative was “well looked after” by staff at the home and always had their personal care needs met. They said that the resident had regular visits from the hairdresser and chiropodist and had seen a dentist and optician recently. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 12 Other residents we spoke with also said they felt their care needs were all being met adequately and as they would wish and that staff treated them with dignity at all times. However, a resident we spoke with in their room was sitting in a chair which was finished in a plastic type material, and had their bare flesh against the seat, with their clothing lowered. The resident said they chose to sit in this way so that they could access the nearby commode and urine bottle more easily. We felt that sitting in this way on a daily basis was undignified for the resident and also presented a risk of skin breakdown through sitting on this plastic type surface. At the time of our visit the call alarm in this resident’s room was not working, which might mean that the resident felt they had to be prepared to get to the commode independently, in case they could not summon help. The manager said the call alarm was usually working but would check this matter out and review the arrangements for this resident. We tracked a selection of care plans after speaking with the residents concerned. These records had mostly been signed by the resident or one of their relatives, and all had regular reviews noted. However, some entries on the plans were not sufficiently detailed to clarify what staff needed to do or had done and some risk assessments gave conflicting information about the current situation. For example one resident’s handling assessment contradicted their risk assessment for preventing falls. This difference could result in care staff providing inappropriate care for residents. Written recording about the wound care provided for one resident was also not detailed enough to evidence that appropriate action had been taken. Records we looked at for another resident showed they had experienced a steady weight loss recently but there were no details recorded that this situation was being monitored or showing what actions had been taken, meaning that the resident’s health might be deteriorating unnecessarily. One resident we spoke with told us about a fall they had had recently but we could not find details of this recorded on their care plan or in the accident book. We also saw or talked to two residents who now use wheel chairs for some transfers but could not see details of this use written in their care plans. It was acknowledged that the staff we spoke with were all clear about the individual needs of the residents, but details of these needs must be kept up to date in plans to ensure that no resident is put at risk from staff reading records with conflicting information. It is also acknowledged that some of the records have details, which were completed prior to the current manager and owners being in charge of the home. We spoke with the manager about the care plan records and she is aware that some entries are not adequate. The manager said she is planning to change the format for care planning but will ensure that records are reviewed and updated immediately. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 13 In the returned AQAA the manager also states that she is re-enforcing the key worker system in the home and would like to train all care staff in care planning within the next twelve months. This will clearly be of great benefit to both the staff and residents as those working most closely with individual residents are usually best placed to know what has changed or what is needed by the residents on a daily basis. Since taking up her post the manager has purchased a medication trolley for the home and staff will be using this to administer medication as soon as equipment is in place to secure the trolley to the wall. The home has separate storage for controlled drugs, although none are administered at present. In the AQAA the manager states that the home is transferring to a new pharmacy provider and the new pharmacist will replace the existing drug storage and provide staff training in medication administration twice each year. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to maintain family links and to make choices about their daily lives so that they can remain as independent as possible. Activities are provided by staff in the home but planning and offering a wider range of events would provide more stimulation for the residents. Well balanced meals are enjoyed by residents in the home and this helps maintain their good health and well being. EVIDENCE: We arrived at the home after the mid-day meal had finished but people we spoke with said they had enjoyed the food, which had been sausages that day, and that meals were “always good”. The menus for the week were displayed in the dining room and the planned food content looked well-balanced and appropriate. Although there is only one main choice of meal each day, residents said they could ask for an alternative if they did not want the planned meal. We did note that no alternative meal Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 15 provision had been recorded since May and reminded staff that these records need to be kept to comply with Environmental Health guidelines. We spoke with residents in the lounge who did not think there were any activities going on that day, although some events were listed on the notice board. “Popular type” music was playing in the conservatory where one resident was asleep and one was reading. In the lounge, one resident was working on a jig-saw puzzle and later in the afternoon one resident was using crayons to fill in a colouring book with staff assistance. At the time the television was also showing a children’s programme, although no-one appeared to be watching this. The staff we spoke with said they provided activities, according to the wishes of the residents,” on the day.” One person we spoke with in their room did comment however that they generally stayed in the room because, in the lounge, “no one talks and they are always asleep”. There is no dedicated member of staff at present who is responsible for planning events or activities in the home and we felt that this was needed so that more stimulation could be provided. We also felt that the residents in the home would benefit from someone from the staff team completing one of the current activity courses available for care homes so that a more imaginative programme of events could be provided for the benefit of current and future residents. The manager said she would be reassessing how activities were provided and would take into account the known interests of residents. In the returned AQAA the manager also states that she has plans to improve activity provision in the home. The visitors we spoke with during the inspection said they were always made welcome in the home and could visit at any time. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that any concerns or complaints they might have will be listened to and acted on and that procedures followed in the home will help to protect all residents from abuse. EVIDENCE: The home has written policies covering complaints and safeguarding. We spoke with care staff who said they were aware of these policies and their implications and were aware of the home’s Whistle Blowing policy. Those we spoke with also said they had completed Safeguarding training recently. One complaint had been received by the Commission since the last inspection. We discussed the issues listed in this written complaint with the manager, who said she welcomed the information and would use the concerns raised to improve services in the home. It was also acknowledged that most issues in the complaint reflected procedures, which had been in place before the new management took over the home and that some issues had already been addressed. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some areas of the home are in urgent need of refurbishment so that residents can live in pleasant surroundings. Some of the sanitary ware and equipment also needs replacing urgently so that the residents can live in a home which is hygienic and where the risk of infection is controlled. EVIDENCE: We visited most areas of the home during the inspection and the communal lounges were quite well decorated and were well maintained. The bedrooms we saw were clean but many were in need of redecoration and much of the furniture was old and some will need replacing soon. Bedding also looked clean but well worn. A commode in one ground floor bedroom was rusted and should be replaced to reduce the risk of infection. Corridors had quite a lot of scratched paint evident and there were no light covers on the bulbs on the first floor landing. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 18 Although no unpleasant odours were noted in any areas of the home, some of the bathrooms and toilets we saw were in urgent need of improvement. Several toilet seats and bowls in communal rooms were unacceptably stained and some were dirty and the flooring behind one toilet was torn and stained. The hot water tap in one ground floor bathroom would not turn off, although the water from this was cold, and the soap dispenser was empty and broken. A nearby toilet had an extractor fan, which was extremely dirty and the laundry had a working sink but no towel or soap. Flooring in the kitchen had also come away from the walls and the edges were becoming very dirty in places. The poor condition of these rooms could compromise infection control in the home and using the stained toilet seats must be unpleasant for residents and does not promote their dignity. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are satisfied that their needs can be met by the numbers of competent staff employed at the home. Procedures for recruiting new staff must include checks on ancillary staff and volunteers to ensure that residents are protected from harm at all times. EVIDENCE: We spoke with residents and some visitors and all praised the care staff and felt there were always enough staff on duty. Those we asked said that call alarms were answered quickly, when they were used and one resident said that any embarrassing accidents were dealt with in a discreet and professional way. The manager is currently reassessing the training records of the staff team and is planning to provide a large amount of new, external courses. The manager said she wants to be sure that training is thorough for all staff and will be updating many of the training courses already provided to ensure competency. Records of NVQ training courses are also being re-checked by the manager and in the returned AQAA the manager states that over 50 of the care staff are currently completing NVQ training. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 20 The manager is also starting to recruit new senior and domestic staff and demonstrated an awareness of the checks needed to be evidenced before care workers commence duties. However, one new domestic worker, who was on duty during the visit, did not have clearance from the Criminal Records Bureau. The manager said that this person was self-employed. We reminded the manager that anyone working at the home must have clearance from this agency and have proper recruitment checks carried out before starting work. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that the home is well managed and run in their best interests. Procedures followed by staff in the home safeguard residents’ financial interests and ensure that the health and safety of both residents and staff are promoted. EVIDENCE: Those residents we spoke with praised the new manager and said she visited and spoke with all of them every day and listened to their views. Since being registered with the Commission the manager has begun to rewrite all of the home’s policies and is aware of the other areas in need of review in the home, as already commented on. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 22 No hazardous substances were seen left out in any area of the home and the fire hydrants checked had been recently serviced. We discussed some areas of the home where there are significant slopes in corridors and the manager will ensure risk assessments are completed to ensure these areas do not provide a hazard for any of the residents. In the conservatory we noted there was an unlocked fridge and a very dirty microwave oven. The manager said the microwave was not used and that the fridge contained food belonging to the staff. We recommended that this equipment should be removed to ensure residents did not take the food or use the microwave in case this put them at risk of injury. The manager is currently setting up new procedures for Quality Assurance in the home but states in the AQAA that weekly residents’ meetings are held where individual views can be sought and expressed. The manager also states that Quality Surveys will be sent out every six months and comments will be monitored by the manager. Since taking up her role the manager has already made some changes to the home based on the comments she has received :menus have been changed to include a wider variety of cakes and soup at supper time and fruit is available to all residents on request. Some residents continue to have their personal allowances held in the home as this was agreed by the previous proprietors. The monies and records for these three residents were recently audited by an officer from the Local Authority. Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 1 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Not applicable 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 15(2)(b) & Schedule 3(j)(l)(m) (n)(o) Requirement Timescale for action 01/09/08 2 OP15 3 OP19 4 OP26 Care plans in the home must accurately reflect the current needs of every resident and must give clear and detailed information about how needs are to be met and evidence how these needs are being met. Schedule Accurate records must be kept 4.13 showing in detail the food provided for all residents in line with current guidelines for health protection. 23(2)(b)( An action plan for the d) refurbishment and on-going maintenance of the home must be completed with timescales for action so that residents and their families can be assured that the home will be upgraded to an acceptable standard. In particular all bathrooms and toilets must be repaired or refurbished to an acceptable and hygienic standard and the kitchen floor must be made impermeable to the walls and details must be included in the action plan. 13(3)&16( Standards of cleanliness in DS0000071687.V365429.R01.S.doc 01/08/08 01/08/08 01/08/08 Page 25 Albany Residential Home Version 5.2 2)(j) 5 OP29 19(1)(b)& Schedule 2.7.(a) &(b) bathrooms and toilets must be improved and stained toilet seats and flooring in bathrooms must be replaced to ensure good infection control is maintained in the home. No member of staff or volunteer 01/08/08 must commence duties at the home before the appropriate CRB or POVA check has been received so that residents are protected from abuse. 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 Albany Residential Home DS0000071687.V365429.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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