Inspection on 28/06/07 for Albion Park House

This inspection was carried out on 28th June 2007.

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

Albion Park House 21/08/06

Albion Park House 08/11/05

Albion Park House 19/04/05

Albion Park House 03/11/04

Albion Park House 24/09/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Albion Park House 7 Albion Hill Loughton Essex IG10 4RA Lead Inspector A Thompson Unannounced Inspection 28th June 2007 09:15 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 Albion Park House DS0000017746.V344655.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. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albion Park House Address 7 Albion Hill Loughton Essex IG10 4RA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8508 4172 020 8508 4172 Mr Mark Bowman Manager post vacant Care Home 19 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (19) of places Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who require care by reason of old age (not to exceed 19 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 10 persons) The total number of service users accommodated must not exceed 19 persons No more than three persons may attend the home on a daily basis in addition to those 19 accommodated The registered provider must consult with the existing service users and staff every three month on the daily attendance at the home of non-resident persons. The registered provider must respond according to the wishes and feelings of service users in respect of non-resident persons attending the home daily. Copies of the minutes of these meetings must be forwarded to the Commission 21st August 2006 Date of last inspection Brief Description of the Service: Albion Park House is a detached, two story, older style property, situated in a residential area near to Loughton town centre in Essex. The home is registered to provide residential care for 19 Older People (over the age of 65, 10 beds for residents with dementia), the home does not provide nursing care. Service users live in one double and seventeen single bedrooms. The communal rooms include two dining areas, and two lounge areas. The grounds around the property have been developed to provide additional access and facilities for service users, with wheelchair access at the rear via the extension. However due to the location of the house: on a steep hill, only the front garden is accessible for service users to use at present, and only with staff support to negotiate several steps. The home provides 24-hour personal care and support to service users with varying levels of need. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 5 As at 28th June 2007, the acting manager advised that the fees for accommodation ranged from £434.61 . CSCI inspection reports are available from the home and the CSCI internet website Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Thursday 28th June 2007. The content of this report reflects the inspectors’ findings on the day of the inspection along with information provided by the service and feedback by service users, relatives, staff and other parties. Practice and procedures occurring after this inspection will be reported on in future inspection reports. The inspection site visit commenced at 0915 am and lasted until 1700 pm. J Burwood – CSCI Regulation Manager was also present for the morning and assisted with the inspection. The home’s acting manager was present throughout the day. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. Areas for improvement needed on the premises were observed and are detailed in this report. Discussions took place with service users, visitors, the acting manager, and staff. Several service users were unable to express any views on the service owing to their diagnosed dementia. Those spoken to who did have a view confirmed they were generally satisfied with the care they received and with the quality of the food and accommodation offered. CSCI questionnaires were left in the entrance lobby of the home for relatives to complete, to ensure they had the opportunity to make their views on the service known to the Commission. Relatives spoken with on the day said they were generally satisfied with staff attitudes, and with the care and support provided to service users. Overall feedback from service users and relatives was positive about the range of activities offered. There were though some comments suggesting that communication could be better from staff. Staff on the day confirmed they received support from management. They also confirmed that they had been offered training appropriate to their role, although written evidence was not available to fully confirm this. Twenty-six standards were inspected and the outcomes for service users against these standards were varied, with eleven rated as good, thirteen as adequate and two as poor. This report includes nine resulting statutory requirements and seven good practice recommendations relating to the areas rated adequate and poor. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Care plans need to be fully completed, include appropriate risk assessments and medication records must be up to date. Staff must pay regard to protecting the privacy and dignity of service users when supporting them with personal care needs by not leaving bedroom and bathroom doors open. The home must have carried out their own Criminal Records checks on all staff employed. All private and communal areas of the home must be kept clean, odour free and hygienic. External décor and windows must be cleaned periodically. Service users, stakeholders and the Commission must be informed of the results of the home’s quality assurance surveys, and of any actions taken from feedback gathered. Staff must have regular supervision and the management team should be increased to provide a senior/deputy manager presence at all times. The registered provider needs to report in writing each month from visits made to the home. Management should keep relatives aware of all issues relating to the wellbeing of service users, unless otherwise instructed. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. Admission processes ensure that service users can be confident that the home considers they can meet their needs. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Care plans seen evidenced that pre-admission assessments were in place. The acting manager said she completes the home’s own assessment before admission but one file seen only contained a social services assessment. There is a recommendation on this point in this report. Assessment completed included headings of personal details and background information, nok details, GP, social needs, physical health, mental health, personal care, mobility, continence, food and night time needs. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. Care plans were not all fully completed and therefore may not provide up to date information on the health, personal and social care needs of service users. Service users were not always treated with respect. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A random sample of care plans were inspected. Each included background information, personal details, next of kin contacts and a daily health rating assessment. From this there were agreed daily needs and required staff interactions. Also included were daily care notes and risk assessments on pressure care and dependency levels. Unfortunately not all sections of care plans had been completed and risk assessments were not seen for service users who used bed guards. Nutritional assessments were not all complete and daily care notes written by staff were sometimes judgemental and had not been completed on a daily basis for all service users. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 12 Care plan actions for staff did not always include sufficient detail of the level and type of support identified in the plan. Examples seen were: ‘make sure x has support by staff’ and ‘ x to have two staff to help him’. There is a statutory requirement of these shortfalls. The homes medication administration guidance provided basic instructions to staff who handle and administer medication. The manager should develop this to include detailed guidance on ordering, receipt, storage, administration and returns of unused medication. This could be achieved by obtaining a copy of the Royal Pharmaceutical Society’s guidance for care homes. This report includes a recommendation on this point. Supplies of medication are brought to the home on a weekly basis by the pharmacist, who links directly with the GP on the ordering of required stocks. Staff who administer medication had received training which covered safe handling practice, the most recent training had been in June 2007 but no evidence of this was available. There is recommendation on this point in this report. Medication administration records were checked and were not acceptable as not all had been completed. There is a statutory requirement on this shortfall in this report. Discussions with individual service users did not confirm that they all felt they were always treated with respect by staff and the inspectors noted whilst viewing the premises that a bedroom door and a bathroom door had been left open whilst staff were providing personal care assistance to service users. This is regarded as poor practice and there is a statutory requirement on this in this report. Staff were though seen to be caring and friendly in their dealings with service users, and most service users who expressed an opinion said staff were helpful and considerate. Visitors spoken with were also generally satisfied with staff attitudes and the care provided. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. The home provides flexible routines and a lifestyle that enables service users to make choices and to engage in their interests. Service users health and welfare is promoted by the provision of a varied and balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not a designated activities coordinator, instead care staff fill this role. Some activities offered had been recorded, these included chair exercises, reminiscence, entertainers and an outing had been arranged for the afternoon of day of the inspection. However activity records available for inspection did not evidence that service users needs were being met on this subject. There is a recommendation on this point in this report. Service users spoken with did say they were satisfied with range of activities offered. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 14 Service users spoken with about the food provided said it was good. A choice is available and specialist diets are provided, for example for people who are diabetic. Nutrition records evidenced that a good and nutritious range of meals are offered. Food stocks were inspected and were acceptable. Lunch was observed and the meal was well presented and looked appealing. Some service users ate in the small dining room, others in the lounges. Staff were in attendance to support those who needed help with eating. Information from relatives confirmed that they are made welcome by staff when they visit, and could visit at different times of the day. Inspection of private rooms confirmed that service users had been permitted to bring their own personal items with them on admission. There was also confirmation of this direct from service users, who told the inspector of the furniture and personal items they had been permitted to bring in with them. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. Practices in the home did not fully safeguard service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which was seen displayed. Included were timescales for responding to a complainant and a set template for recording the home’s response and outcomes to any investigation. The acting manager said there had not been any complaints since the last inspection. Service users spoken to said they knew who to talk to if they had any concerns or complaints, as did relatives. The home had a policy and procedure on the protection of vulnerable adults from abuse, and guidance documents produced by Essex County Council. The acting manager said that all staff had been issued with a copy of these. There was also clear guidance for staff displayed in the office on what to do and whom to contact if abuse suspected. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 16 Staff had been trained on adult protection issues and POVA but certificates to evidence this for recent training in March 2007 were not available for inspection. This report includes a recommendation on this point. Not all staff had up to date Criminal Records checks, this is a regulatory shortfall resulting in a statutory requirement in this report. Albion Park House DS0000017746.V344655.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): 19,20,21,23,24,26 Quality in this outcome area is poor. Furnishings in the home looked comfortable but work to redecorate and refurbish some areas needs to take place. The premises appeared safe but the grounds were not accessible to service users without staff support. The home was not clean and malodours were prevalent in many areas, including bedrooms, corridors and wcs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the inspectors arrival the home was not clean, and many communal areas and bedrooms had a strong smell of urine. Some bedroom and corridor carpets were dirty and stained, and corridors were cluttered as they were being used as inappropriate storage areas for wheelchairs, coat hangers and other items. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 18 Items were also being stored under the stairs which was unsightly, and may be a fire risk. Some areas of communal corridors and doorways also had damaged/chipped paintwork, and an area of carpet by a rear door had numerous cigarette burn marks. The laundry room was cluttered and the sink was stained. On the outside of the home windows were dirty, and some paintwork was dirty and flaking. The acting manager advised that the home’s cleaner was on holiday and that she had arranged for a member of care staff to do extra duties cleaning later that morning. This did occur and the home was cleaner when the inspector left the home at 5.00 pm, however all of the above issues were still prevalent and require attention by the registered provider. This report includes a statutory requirement that cleaning, improvements, redecoration and renewal of damaged/soiled carpets takes place. Bedrooms seen looked generally comfortable and were acceptably decorated, personal possessions were seen to evidence that rooms may be personalised to individual tastes if wished. Service users spoken with said they were satisfied with their rooms and that they were comfortable, one resident thought her room was a little cold sometimes and the inspector spoke to the acting manager about this who was aware of this issue and an additional heater had been provided in this room, as seen. The laundry did have appropriate washing machines and tumble dryer to cope with the washing needs of residents. Communal space comprised a small dining room with adjoining lounge, with two further adjoining lounges across the corridor. There was also a small private ‘visitors’ room off of one of the lounges. All lounges were at the front of the building. Bathing facilities were not fully inspected but it is understood there have been no changes since the last inspection, when no shortfalls were recorded. However on this visit bathing areas that were seen had limited space for the use of portable hoists. Gardens available to residents were mainly at the front however access to these was via some steps from the front entrance, which meant that service users needed close staff support to actually use the garden. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 19 Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Quality in this outcome area is adequate. Staffing levels met the needs of service users, but recruitment checks on new staff had not always ensured the protection of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Daily staffing levels remain as three carers on mornings and three on afternoons, the manager is supernumary. Rotas were inspected. Night time staffing is two on waking duties. Separate staff are employed to undertake cooking and domestic duties. There is no activities coordinator nor an office administrator. The lack of any administrative support for the acting manager places additional pressures on her time to manage the service. It is understood that maintenance tasks are carried out as when needed by contractors. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 21 Staff records and discussion with staff evidenced that application forms had been completed, interviews held and references obtained. Files checked included a criminal records check undertaken by the home, however one file seen only had a CRB certificate issued by a previous employer. This is not permitted to be used as a check for employment at Albion Park House and represents a shortfall with a resulting statutory requirement. Copies of proof of ID and photographs were on files inspected. New staff should undergo the home’s induction programme which has been changed since the last inspection to meet the Skills for Care Common Induction Standards. This involves a six modular package of training overseen by the manager. Records of this process will be checked at the next inspection. Training records and discussion with staff confirmed that they had been trained in Infection control, bereavement, continence, fire safety, falls, NVQ level 2, BTEC in Care, first aid, POVA and abuse awareness, food hygiene, manual handling, medication, health & safety, risk assessment and dementia. However some of this training had been more than a year ago and certificates were not available to confirm that appropriate update training had occurred in 2007 on the following subjects: POVA, fist aid, food hygiene and health & safety. The manager produced evidence that this training had been booked and said certificates of evidence had not yet been provided. There is a recommendation on this issue. Update infection control training had been booked for August 2007. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 Quality in this outcome area is adequate. The home had been not been run and managed efficiently. Procedures for gaining the views of service users and relatives were in place but had not been fully implemented to ensure the views of service users were listened too. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager had been in post since the previous manager left. She advised the inspector that she had enrolled on a registered managers award course which was due to commence a week after this inspection. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 23 The acting manager had worked at Albion Park House for some time, her hours are supernumery to care staffing hours however she does not have any administrative support to assist with paperwork and record keeping tasks, and there was only one senior carer working days to assist with staff supervision and support. The inspector considers that in order for the manager to have sufficient time to fully fulfil her role there should be an increase in the senior carer team and some designated administrative support hours. There is a recommendation in this report on this point, and a separate recommendation for the registered provider to make application to the Commission for registration of a manager under the Care Standards Act 2000. The home has a Quality Assurance (QA) system in operation. A survey to gauge opinions about the services provided was carried out in 2006, and evidence of responses were seen. However service users had not always been included in the process and no summary of the feedback had not been published. Service users must also be included in the QA process and a copy of the report must be submitted to CSCI, and must also be made known to those who took part in the process. This is shortfall and has resulted in a statutory requirement. The home looks after some service users monies for safe keeping, a random sample of amounts held and associated records were checked and found to be acceptable. The home had a procedure and recording templates for staff supervision meetings. Some staff had received formal recorded supervision since the last inspection but not all had to acceptable timescales, this has resulted in a statutory requirement. Evidence was available for inspection to confirm that the home’s fire equipment & alarms, passenger lift, gas supply, portable electrical appliances and electrical installation supply had all been tested/ serviced within recommended timescales. Staff had been trained in first aid, food hygiene and manual handling, but evidence of some update training was needed. Random samples of records required to be kept were inspected. These included: care plans, assessments, staff rota, staff recruitment, medication, visitors book, fire drills, background information and next of kin details. Regulation 26 reports (person-in-control) had not been completed. This is a requirement shortfall. Evidence was not available to confirm that risk assessments were in place covering safe working practice topics around the home. Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 24 Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 25 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 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 3 3 X 3 3 X 1 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 2 Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 Requirement All sections of care plans must be completed, with detailed needs instructions for staff, so that staff are aware of all service users needs. Care plan risk assessments must also be completed when bed guards are used. Administration of medication must be accurately recorded to ensure the safety of service users. This is a repeat requirement 3 OP10 12 (4) Staff must show regard to the privacy & dignity of service users by keeping doors closed when assisting service users with personal care needs. Criminal Records Bureau checks must be in place on all staff employed so as to protect service users. The home must be kept in a good state of repair both DS0000017746.V344655.R01.S.doc Timescale for action 31/10/07 2 OP9 13 (2) 31/08/07 31/08/07 4 OP18 19 30/09/07 5 OP19 23 (2) 31/10/07 Albion Park House Version 5.2 Page 27 6 OP26 23 (2) 7 OP33 24 internally and externally so that service users live in a safe clean environment. Action must be taken to reduce 30/11/07 malodours prevalent around the home, the laundry room must be kept clean and soiled/stained carpets around the home are cleaned/replaced. The results of the home’s quality 30/11/07 assurance process must be made available to those taking part, and to the Commission. All staff must receive regular recorded 1-1 supervision to ensure they are supported to carry out their duties. 30/11/07 8 OP36 18 (2) 9 OP37 26 The registered provider must 31/08/07 ensure that monthly visits to the home take place and that reports from these are provided to the manager and to the commission, as detailed under regulation 26 of the Care Homes Regulations 2001. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The home should obtain a copy of the Royal Pharmaceutical Society’s medication guidance for care homes to use as a good practice information resource. Staff should ensure that next of kin relatives of service users are consulted with when decisions are made concerning service users healthcare needs. 2 OP10 Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 28 3 OP27 The registered provider should ensure that care staff are appropriately supervised at all times by providing senior/deputy support to the manager. Records of training arranged for staff in 2007 should be available for inspection so as to evidence the actual training undertaken, and by whom. The registered provider should appoint a manager who will apply to the Commission for registration as registered manager. A risk assessment should be available for inspection covering all aspects of safe working practice topics around the home. Records of daily activities and interests offered to service users should be kept available for inspection to evidence that service users social and activity needs are being met. 4 OP30 5 OP31 6 OP38 7 OP12 Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Albion Park House DS0000017746.V344655.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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