Inspection on 11/10/05 for Alpine Villa

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Alpine Villa 13/05/08

Alpine Villa 25/06/07

Alpine Villa 27/06/06

Alpine Villa 18/04/05

Alpine Villa 22/09/04

Alpine Villa 17/07/04

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

CARE HOMES FOR OLDER PEOPLE Alpine Villa 70 Lowbourne Melksham Wiltshire SN12 7ED Lead Inspector Thomas Webber Unannounced Inspection 11th October 2005 09:40 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 Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Alpine Villa Address 70 Lowbourne Melksham Wiltshire SN12 7ED 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) 01225 706073 Mrs Luzuisminda Mercer Mrs Luzuisminda Mercer Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (15) Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users who may be accommodated in the home at any one time is 15 Date of last inspection Brief Description of the Service: The home is a private residential care home offering accommodation and personal care to a maximum of 15 residents who are over the age of 65 with either dementia and/or mental disorder. The home is a large Victorian house, which is located in the market town of Melksham close to all local amenities. Residents’ accommodation consists of three shared and nine single bedrooms, one of which has en-suite facilities. Residents bedrooms are located on the ground and first floor levels and are accessed by use of a staircase. The home provides a lounge/dining room together with a conservatory and additional lounge and separate dining room. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, undertaken during the course of one day from 09:40 to 17:20. The inspection focused primarily on evaluating how much progress the home had made in addressing the numerous requirements and recommendations at previous inspections. Specific attention was given to checking residents’ care plans, medication, staffing and the environment to ensure that the protection of the residents was being maintained. A tour of the premises was undertaken and the views of a few of the residents in situ were sought on an individual and group basis, regarding the care and services provided by the home. What the service does well: What has improved since the last inspection? What they could do better: There continues to be serious deficiencies within the management of the home that could potentially put residents at risk which still require urgent attention. These relate to the need to provide sufficient numbers of staff on duty, to follow appropriate staff recruitment practices, staff training and ensure that all aspects relating to residents’ care plans and associated assessments and medication are suitably addressed. Deficiencies continue to exist within the Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 6 home’s complaints procedure and copies of how to complain have yet to be given to all residents and/or their representatives. The maintenance of the premises is also deficient in a number of areas. There are practices relating to residents’ privacy choice and some routines of the home that could still benefit from being reviewed and amended. Residents’ right to privacy is not always maintained in relation to the inadequate design and layout of some of the toilets. The arrangements for mealtimes are inadequate to provide sufficient support to the residents. In particular, there are insufficient staff to assist residents and assessments need to be undertaken to ascertain whether specific aids would help residents. These deficiencies are identified within the numerous requirements and recommendations, some of which require urgent action. Although, the deputy manager is attempting to address some of the issues, the progress is not sufficient to ensure that there are no risks to the residents and as a result a meeting is being arranged between the management of the home and the Commission to discuss the current category and registration of the home in light of the home’s continued failure to comply with the required regulations. 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. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 7 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 Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 8 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 the following standard(s): EVIDENCE: These Standards were not assessed during this inspection. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7, 9 and 10 Residents’ care plans are insufficient in detail and do not provide a clear reflection of their individual needs. Residents are unable to self medicate as they are deemed not capable. There are serious deficiencies within various aspects relating to medication which do not protect the residents. Residents’ right to privacy is not always maintained. EVIDENCE: At present residents’ care planning information is limited, insufficiently reviewed and does not contain resident or family input. The deputy manager reported that such shortfalls had been identified and a new format has been devised. This new format is an improvement and details objectives and action required. The format gives an organised, structured plan to work from and space is available for any changes and regular review. It was agreed that if sufficient content were applied, the format would give a clear reflection of individual needs. Each resident has a file containing their care plan and other documentation including reviews, risk assessments and correspondence. However, much of the information is not dated and other documentation is out of date and no longer relevant. There are formats of old assessments such as nutritional Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 10 assessments although these are not completed and have no relevance to the resident’s current provision of care. The deputy manager was advised to review all residents’ documentation and safely store irrelevant information accordingly. All residents’ current plans of care detail basic information although dates are not evident. Particular attention is given to daily living routines such as waking and rising times, personal care needs, mobility and meal arrangements. The welfare of the residents is not being appropriately monitored in that many of the tools available such as weight and fluid charts, manual handling and pressure care management assessments and lists of medication are not being properly completed. Within daily records, it was evident that there were shortfalls with some recording. For example, one entry detailed an injury to one resident by another resident. This was not reported upon within both sets of residents’ plans of care and an accident report was not evident. Another entry detailed a seizure although there was no mention of epilepsy within the plan of care. Some written documentation contained subjective language and in certain instances further detail was required to clarify a situation. Such phrases included ‘behaviour is so challenging’ or ‘can get agitated and not want to comply with staff’ are evident although guidelines to reduce and manage such behaviours do not appear to be provided. The deputy manager was informed of the need to detail strategies for managing such behaviours within the care plan. Within documentation it was also evident that staff required greater support with managing certain situations. This was also discussed with the deputy manager with particular attention given to a resident who was distressed during receipt of personal care. It was evident from the daily record that two staff had assisted the resident, which may have been a contributory factor to her behaviour. The home has established a medication policy. However, none of the residents are deemed capable of being responsible for the administration of their own medication. Therefore, the more experienced staff and those who have completed the ‘Safe Handling of Medicines’ course administer medication to residents. However, examination of the system for the receipt, storage and administration of medication showed that there are still a number of areas of deficiency, which are a cause for serious concern, which require immediate attention. These included the need to ensure that the receipt of medication is always initialled and dated, any hand written additions to residents’ MAR sheets must be initialled by two members of staff (one as a counter signature) and there needs to be clear instructions as to the administration of this medication. The returns book for unwanted medicines is an inaccurate record and does not always record all medication refused by residents. However, it was noted that there had been an improvement in the initialling of medication (tablets) administered to residents by staff, although there were still some Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 11 gaps in residents’ drugs sheets where staff had not initialled for liquid medication administered. Although there was evidence that correspondence had been undertaken with one resident’s GP regarding their refusal to take medication, there was no evidence to show that this had been satisfactorily concluded. Privacy is not aided by the design to a number of toilets for residents’ use both on the ground and first floor levels. These are too small and staff would have great difficulty in assisting a resident who needed it. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 13, 14 and 15 Residents maintain contact with their families and friends according to their individual circumstances. There are still areas of practice relating to choice in respect to getting ready for bed early and showering and bathing which need addressing for the benefit of the residents. A flexible and reasonable diet is provided for the residents. The arrangements for mealtimes are inadequate to provide sufficient support to the residents. EVIDENCE: The home has no restrictions with regard to visiting times and residents’ records confirm that residents receive visits from their families with some being taken out. Some of the residents’ relatives phone in advance of visiting. Residents can see their visitors either in the privacy of their bedrooms, the lounge areas or within the conservatory. Standard 14 was not fully assessed on this occasion, however, the previous report had identified areas within the practice of the home relating to the choice of getting ready for bed early and bathing and showering. Although the home has reviewed its routines, it has not fully addressed this issue. Residents are provided with a choice for breakfast and teatime with a set main meal at lunchtime. It was evident during the course of the inspection that alternatives are provided to meet the preferences and dietary needs of Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 13 residents, however, a number of the residents tend to choose the same meal for breakfast each day. Residents’ case notes also confirm that there is some flexibility with regard to mealtimes and providing residents with food and drinks at other times of the day and night. Residents tend to use the dining rooms for their meals although they could choose where to eat their meals and evidence was available to confirm that some residents have some or all of their meals in their bedrooms. Since the last inspection, the home now ensures that any changes to the menu are suitably recorded and the timing of the main meal has been reviewed and is now held slightly later. Observations of the main meal indicated that additional staff need to be deployed at this time due to the complex needs of the residents such as the inability of some to sit for the duration of the mealtime and who keep wandering. Some assistance with feeding is also necessary with a few residents and the use of two separate dining areas being used at the same time, stretches staff resources. This was emphasised when a member of staff who was being supportive and attentive by assisting a resident with feeding had to go and deal with another resident, which ended up with the initial resident spilling food down her clothing. Residents should have their needs regarding managing their food assessed. This may indicate the need for some residents to have their food cut up or the need for further assistance. The assessments may also identify that some residents would benefit from specific eating aids such as rimmed plates or thick handled cutlery. Residents who commented spoke positively about the quality and quantity of food provided. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 16 Deficiencies continue to exist within the home’s complaints procedure and copies of how to complain have yet to be given to all residents and/or their representatives. EVIDENCE: The home has established a complaints procedure and a copy of this is displayed on the notice board in the hallway by the kitchen. Agreement was reached at the last inspection for relatives of residents who have dementia to be provided with a copy of this procedure as well as a copy being made available within the home’s service users’ guide. A copy of the procedure still needs to be given to those residents with mental health problems. Despite being advised to do so at the last inspection the complaints procedure still needs to be updated to include the address for the Commission for Social Care Inspection and to inform complainants that they can contact the Commission at any stage, should they wish to do so. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 19, 20, 21, 23, 24 and 26 The home is maintained to a reasonable standard being clean and tidy, however, there are aspects of the premises which are not maintained to a sufficient level. The home provides sufficient toilets and bathing facilities, although a number of the toilets are not of a suitable design to aid the privacy and dignity of the residents. Residents’ bedrooms meet their needs and are personalised to their individual wishes. The laundry facilities meet the needs of the residents. EVIDENCE: The building complies with the requirements of both the local Fire and Environmental Health Officers’ departments. A tour of the premises identified a number of improvements that are needed to bring the home up to the relevant Standards. These include the fixing of the hinges to a fire extinguisher and a corridor door was noted to be wedged open. However, management within the home needs to make regular checks of the home to ensure that all parts of the residents’ living environment is suitably maintained as identified in the relevant Standards below. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 16 The home provides sufficient communal space that consists of a lounge/dining room together with a conservatory, a separate dining room and an additional lounge to the front of the property. These areas are furnished and decorated to an adequate standard. The home also provides a small, enclosed rear garden which is used by some residents, particularly those who smoke. The home provides a sufficient number of bath, shower and toilet facilities, which are located within close proximity to residents’ bedrooms and the communal rooms. However, a number of the individual toilets situated on both the ground and first floor levels, and particularly those strategically located close to the main lounge/dining room, are very small in size with some residents having been reported leaving the doors open or holding them open with their feet, seeing them as being somewhat claustrophobic. These toilets are also too small for staff to assist residents who require it, therefore not providing residents with privacy and dignity when being used. A tour of the premises revealed that not all toilets are provided with hand drying facilities. There were also a number of deficiencies to the bathroom on the first floor which included: the replacing of the seat and cabinet, the hot water temperature to the bath and sink is too hot, the cord to the call bell is not low enough and various cleaning materials need removing. The deputy manager reported that the residents do not use this bathroom. However, if this is the case, the residents should not be able to access it. The home provides nine single and three shared bedrooms, two of which are provided with en-suite facilities. Residents’ bedrooms are located on the ground and first floor levels which are accessed by use of a staircase. All rooms are fitted with a call bell system which residents can use to summon staff assistance if required. Residents’ bedrooms are adequately furnished and decorated to varying degrees and the proprietor reported that residents’ bedrooms are normally redecorated and re-carpeted when there is a change of occupation. Residents can and have brought items of personal possessions to make them more homely with residents having personalised their bedrooms to their individual wishes. Residents, who commented, spoke favourably about the standard and cleanliness of their accommodation. However, a tour of the premises revealed that a plug was missing to one bedroom sink, the cord to the call bells of various bedrooms were not low enough, a handle to the dressing table of one bedroom was missing and the commode to the same bedroom needs replacing as it is rusty, there was no toilet seat to one of the bedroom’s en-suite facility, the bedroom door to one bedroom needs adjusting to ensure that it shuts fully on it rebates, the radiators to some bedrooms were not providing sufficient heat and the hot water temperatures are too hot to the sinks of residents’ bedrooms. The home continues to be maintained to a reasonable standard, being clean and tidy and, in the main, free from offensive odours. The laundry room is Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 17 located on the ground floor and provides adequate facilities to meet the needs of the home. Residents’ clothing is labelled to ensure that garments are appropriately returned and care staff, with some input from the waking night staff, undertake this task. Residents, who commented, spoke favourably about the laundry arrangements in place. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 The home does not provide sufficient staff on duty to meet the needs of the residents. The home’s recruitment practices continue to be insufficient for the protection of residents and must be far more robust. EVIDENCE: The staffing levels maintained by the home, during the day, are on occasions still insufficient. This is in spite of being advised at the last inspection to ensure that the minimum staffing levels of the previous registration authority are always maintained, even if it means the employment of agency staff. This also includes either employing additional care staff or appropriate numbers of ancillary staff. This is particularly important due to the complex and high dependency needs of residents accommodated and the type of category of registration i.e. mental health and dementia. Within one resident’s most recent review documentation, it was identified that the resident’s needs were higher than initially anticipated. In response to this, it was recorded that an additional member of staff had been deployed. There was no evidence to support this within the staffing rota. Examination of the staff rotas showed that there are still occasions when there are only two members of staff on duty throughout the waking day with the home providing one member of waking night staff on duty and another member of staff sleeping in each night. The previous registration authority required a minimum of two care staff on duty together with additional ancillary staff to be employed for the number of elderly people accommodated. Since the home provides a more specialist environment, there would be an Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 19 expectation for the home to provide a higher level of staffing and not a reduced level. In addition, the written staff rotas must always reflect and be a true account of all staff on duty and demonstrate which member of staff is sleeping in each night. Concern was also expressed about the home not complying with the requirement of forwarding copies weekly of the staff rotas to the Commission, to monitor and ensure compliance regarding the level of staff being deployed at the home. Residents, who commented, spoke warmly of the care provided by the staff. Two of the most recent staff files were checked to ascertain whether the home had made any progress in ensuring that appropriate staff recruitment practices were being followed as part of the protection for the residents. Despite concerns being expressed at previous inspections, no major progress had been achieved in this area. Although a new application form has been introduced as advised at the last inspection, it does not include names and addresses of references to be sent for by the home. In respect to one applicant: no application form had been completed, therefore there was no full employment history and medical declaration. Although two written references were received and addressed to the proprietor, there was no written evidence to confirm that these had been requested by the home and the references did not confirm dates of employment. Although there was evidence that a satisfactory CRB check (dated 1.10.05) had been received, the staff rota showed that the applicant had started work at the home prior to this being received (13.9.05). Deficiencies with regard to the second applicant’s employment included: a lack of full employment history and no evidence to confirm that gaps within this had been explored and recorded, only one reference was obtained, there was no satisfactory POVA first check and no CRB check appeared to have been obtained. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed during the course of this inspection. Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 21 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 3 2 X 3 2 X 3 STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 22 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 OP1 Regulation 4(1)&(2)& Schedule1 Requirement Timescale for action The registered individual must 31/10/05 ensure that the home’s statement of purpose includes all the information detailed in Regulation 4 and Schedule 1 with a copy being provided to the Commission for Social Care Inspection. (Original timescale of 01/02/04 was not met and was extended to 31/10/05) The registered individual must 31/10/05 ensure that the home’s service users’ guide fully complies with Regulation 5 and Standard 1 .2. Copies of this document must be provided to all residents and prospective residents as well as a copy being provided to the Commission for Social Care Inspection. (Original timescale of 01/02/04 was not met and was extended to 31/10/05) The registered individual must 31/10/05 update the home’s contract to ensure that it complies fully with Regulation 5 and Standard 2.2 and provide residents with the DS0000028251.V257736.R01.S.doc Version 5.0 Page 23 2. OP1 5 3. OP2 5(1)© Alpine Villa revised copy, where appropriate. 4. OP3 14 & 15 The registered individual must 31/10/05 ensure that all residents’ needs and any risks identified by preadmission assessment are incorporated into their care plan with details of how those needs are to be met. (Original timescale of 22/09/04 was not met and was extended to 31/10/05) The registered individual must 31/10/05 obtain a copy of all prospective residents’ community care assessments or the equivalent prior to admission for those residents who are funded by social services. (Requirement not checked on this occasion as there had been no new admissions) The registered individual must 31/10/05 ensure that all residents’ care plans fully reflect their individual needs, are kept up to date and are reviewed at least once a month and revised to reflect any changes in care need. It is also essential that all care needs are fully documented with clear guidance to staff on what actions they should take. (Original timescale of 22/09/04 was not met and was extended to 31/10/05) The registered individual must 15/12/05 ensure that in the event of a resident not eating or drinking sufficiently, a record of all food and fluids consumed is maintained and a nutritional assessment is undertaken. In the event of this continuing, advice must be sought from specialist DS0000028251.V257736.R01.S.doc Version 5.0 Page 24 5. OP3 14(1)(b) 6. OP7 15 7. OP7 17(1)(a) Alpine Villa health care personnel. 8. OP7 15 The registered individual must 15/12/05 ensure that guidelines regarding challenging behaviour and agitation when receiving personal care, form part of the care plan. The registered individual must 15/12/05 ensure that manual handling and pressure care management assessments are undertaken with advice received from professional personnel as appropriate. The registered individual must 15/12/05 ensure that sufficient information is documented within daily records in order to demonstrate intervention to meet individual needs and residents’ wellbeing. The registered individual must 15/12/05 ensure that all accidents are fully reflected within residents’ daily records and the accident book. The registered individual must 15/12/05 gain professional advice in the event of a resident being unable to take their medication. Staff must not undertake any practice such as the crushing or disguising of medication without such discussion and the receipt of a written, signed agreement from appropriate professionals. (Original timescale of 01/08/05 was not met) The registered individual must 15/12/05 always ensure that a record demonstrating the receipt of all medication is maintained. The registered individual must 15/12/05 ensure a record is maintained of DS0000028251.V257736.R01.S.doc Version 5.0 Page 25 9. OP7 17(1)(a) 10. OP7 15 11. OP7 17(2) 12. OP9 12(1)(a) 13. OP9 13(2) 14. OP9 13(2) Alpine Villa all unused medication returned to the pharmacy. 15. OP9 13(2) The registered individual must 15/12/05 ensure that the medication administration sheet is an accurate record of all medication administered. (Previous timescale of 01/08/05 was not met and a new timescale has been set to ensure compliance) The registered individual must 15/12/05 ensure that residents’ privacy and dignity are maintained whilst being assisted or independently using the toilet facilities. Current facilities immediately located by the main lounge do not enable this to be achieved. Therefore the Commission for Social Care Inspection requires the registered individual to submit a written proposal of how she intends to address this issue. (Previous timescale of 05/09/05 was not met and a new timescale has been set to ensure compliance) The registered individual must 15/12/05 review the expectation of residents having a bath or shower every day. If this is required, an agreement must be sought in consultation with the resident’s care manager. (Previous timescale of 05/09/05 was not met and a new timescale has been set to ensure compliance) The registered individual must 15/12/05 review why residents who require assistance are helped into their bedclothes after tea. This routine must reflect the preferences of residents and DS0000028251.V257736.R01.S.doc Version 5.0 Page 26 16. OP10 12(4)(a) 17. OP14 12(1)(a) 18. OP14 12(1)(a) Alpine Villa where this is not possible consultation must be sought from the residents’ families/care managers. (Previous timescale of 05/09/05 was not met and a new timescale has been set to ensure compliance) 19. OP16 22 The registered individual must 15/12/05 update the complaints procedure to include the address for the Commission for Social Care Inspection and to inform complainants that they can contact the Commission at any stage, should they wish to do so. (Previous timescale of 31/08/05 not met and a new timescale has been set to ensure compliance) The registered individual must 31/01/06 ensure that the home is maintained in a good state of repair internally. The registered individual must 31/12/05 ensure that the hot water temperature is suitably regulated to the sinks in residents’ bedrooms sinks and bathrooms where they may have unsupervised access. The registered individual must 15/12/05 ensure that the minimum staffing levels of the previous registration authority are maintained at all times which includes appropriate numbers of ancillary staff. (Previous timescale of 26/05/05 was not met and a new timescale has been set to ensure compliance) The registered individual must 15/12/05 ensure that the written staff rotas always reflect and are a true account of all staff on duty and demonstrate the member of DS0000028251.V257736.R01.S.doc Version 5.0 Page 27 20. OP19 23(2)(b) 21. OP21 13(4)© 22. OP27 18(1)(a) 23. OP27 18(1)(a) Alpine Villa staff sleeping in each night. The home must also send copies of the staff rotas on a weekly basis to the Commission who will monitor staffing levels to ensure compliance. (Previous timescale of 26/05/05 was not met and a new timescale has been set to ensure compliance) 24. OP29 19 The registered individual must 15/12/05 ensure that all new employees complete the home’s application form, which is amended to include names and addresses of references to be requested for by the home. The registered individual must 15/12/05 ensure that a medical declaration and full employment history is obtained in respect to all new employees and any gaps are explored and recorded. (Previous timescale of 31/08/05 was not met and a new timescale has been set to ensure compliance) The registered individual must 15/12/05 always obtain two satisfactory references prior to the employment of new employees and show written evidence that these have been requested by the home. (Previous timescale of 31/09/05 was not met and a new timescale has been set to ensure compliance) The registered individual must 15/12/05 ensure that at the very least a satisfactory POVA first check followed by a CRB check is obtained prior to the employment of new employees. The registered individual must 31/03/06 ensure that all staff have received the various mandatory DS0000028251.V257736.R01.S.doc Version 5.0 Page 28 25. OP29 19 26. OP29 19 27. OP29 19 28. OP30 18(1)© Alpine Villa training courses. 29. OP33 24 The registered individual must 31/12/05 develop and implement a quality assurance system. (Previous timescale of 01/02/04 was not met and therefore a new timescale has been set for compliance) The registered individual must 31/12/05 ensure that all staff receive formal and recorded supervision on a consistent basis and at least six times a year. (Previous timescale of 01/02/04 was not met and therefore a new timescale has been set for compliance) 30. OP36 18(2) 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 OP7 Good Practice Recommendations The registered individual should ensure that the practice of residents wishing to leave the toilet door open is recorded within their individual care plans. The registered individual should ensure that all out of date information and incomplete assessment forms are removed from residents’ files. The registered individual should ensure that all residents have a choice of a bath or a shower. If residents are unable to make this decision, advice should be sought DS0000028251.V257736.R01.S.doc Version 5.0 Page 29 2. OP7 3. OP7 Alpine Villa from the residents’ families and recorded within their individual care plan. 4. OP15 The registered individual should strongly consider undertaking an assessment of residents’ requirements with regard to mealtimes and where necessary provide appropriate aids and/or increased staffing. The registered individual should collate and organise the certificates of staff training as evidence. 5. OP30 Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Alpine Villa DS0000028251.V257736.R01.S.doc Version 5.0 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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