CARE HOMES FOR OLDER PEOPLE
Ambassador House 31 Lansdowne Road Luton LU3 1EE Lead Inspector
Leonorah Milton Unannounced Inspection 10th July 2007 09:30 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 Ambassador House DS0000014876.V342250.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. Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Ambassador House Address 31 Lansdowne Road Luton LU3 1EE 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) 01582 486244 F/P 01582 486244 Mr Cornelius Crowley Mr Stephen Giles Ms Patricia Donna Archer Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25), of places Physical disability over 65 years of age (25) Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home can accommodate a maximum of 25 service users of either sex. 16th August 2006 Date of last inspection Brief Description of the Service: Ambassador House is located in a quiet residential suburb of Luton. It is a large extended detached house with an observatory feature within the roof. The home is registered to provide care for 25 older people. The bedrooms are located on all three floors of the building and accessed by stairs and/or a shaft lift. Toilet and bathing facilities are on each floor; eight single bedrooms and the one double room have en-suite toilet facilities. A lounge and a lounge/diner are located on the ground floor with a further lounge/diner on the first floor. Arrangements are in place to ensure that people living in the home are able to receive the services of a visiting hairdresser and a chiropodist; those using these services are responsible for the fees. Satisfactory arrangements are also in place to ensure that referrals to healthcare professionals are carried out. There is adequate parking for staff and visitors with additional road parking available if necessary. Weekly fees are between £420 and £480. Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report sets out the significant evidence that has been collated by the Commission for Social Care Inspection (CSCI) since the last visit to and public report on, the home’s service provision in August 2006. Reports from the home, other statutory agencies, and information gathered at the site visit to the home, which was carried out on 10th July 2007 were taken into account. The visit to the home involved the contribution of a lay assessor who had experience of the care sector. Their views have been incorporated into this report. They met with seventeen people living in the home, were able to hold meaningful conversations with ten of these people and also conversed with three visitors. The visit carried out by the Commission’s representative included a review of the case files for three people using the service, conversations with seven people living in the home, two visitors, two members of staff and the manager. Much of the time was spent with people in the ground floor lounges, where the daily lifestyle and the practice of staff was observed. A partial tour of the building was carried out and other records were reviewed. The proprietor had submitted an annual quality assurance assessment document. Relevant details that were verified at inspection have been referred to in this report. What the service does well:
As had been noted at previous inspections, the skills of the care staff and the layout of the building had enabled the home to develop a service that could provide for people with diverse needs. The premises provided three separate lounges, which had afforded choice to service users and opportunities for those who preferred a quieter space for relaxation. The majority of the staff had worked in the home for a considerable time and were well versed with people’s needs and the home’s daily routines. The example set by the manager had provided the team with a good role model for the care of vulnerable people. The home was well managed. People living in the home had been provided with opportunities to voice their opinions about the service. Personnel had been well supported through individual supervision and group meetings. Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 6 People living in the home and the visitors passed much praise about the service and the conduct of the team. The provision of activities in house for recreation and stimulation was good. Activities had taken account of peoples’ abilities, preferences and needs. The range of activities had catered for those with short- term memory loss, as well as the more able. What has improved since the last inspection?
The home had identified the following improvements to its service, which were validated at the visit to the home: We have ensured that the Statement of Purpose has been updated and reviewed regularly in order to provide service users with relevant and required information. Monitored the recording of all the care plans, supervised staff whilst recording and updating care plans. Involving people and family or representatives where possible, using a person centred approach. Ensuring that staff are aware of people’s right of privacy and record details of specific requests and act upon them. Ensured all designated staff who are trained to administer medication have been supervised and had their Safe Handling of Medication training updated. Kitchen staff have been made aware of the need to clearly display menus for the people and alternatives to meet their choices. Special dietary needs are available in the kitchen. Staff are aware of the difficulties of service users moving into a home and encourage empowerment, their rights, choices and needs and the importance of recording these accurately in their care plan. Ensured the complaints procedure has been updated and reviewed and that a copy is kept with the statement of purpose and the service user guide. Adult Protection has been high on the agenda for staff awareness and training. Improved the lighting in the ground floor front lounge. Otex validated ozone disinfection laundry equipment installed. Introducing the new skills for care common induction standards. Updated and reviewed training according to staff and people’s needs. Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 7 Ensured that people living in the home are aware that their requests are being met. Ensured people have access to their personal money at all times. Ensured risk assessments for all identified hazards are reduced or eliminated and reviewed regularly. What they could do better: 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.
Ambassador House DS0000014876.V342250.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 Ambassador House DS0000014876.V342250.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): Standards 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had obtained information about people’s needs before admission to ensure the home had the capacity to properly care for them. EVIDENCE: A copy of the Statement of Purpose was given to the inspector. It provided an easy read guide to the service. Three cases files were assessed at this inspection. Each showed that detailed pre-assessments of need had been carried out before people had been admitted. These had included information from placing authorities, and health care providers where people had been admitted from hospital. The home had an established admissions procedure that included its own written assessment of need that was also used unless people were admitted under an emergency situation.
Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 10 In most instances, people moving into the home had been reliant on their relatives to visit and assess the home on their behalf. A family member of a person living in the home stated that they had visited several homes before deciding on Ambassador House and had chosen this home because of the friendly staff. They said they were “still glad to have made this choice”. The home did not provide an intermediate care service. Ambassador House DS0000014876.V342250.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 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home were satisfied with the ways in which their care needs had been met. EVIDENCE: Three case files were assessed. The care plans seen were based on detailed assessments of need. Plans covered people’s personal, physical, health, recreational, social and emotional needs. A “pen profile” had been completed which listed people’s preferences for their daily lifestyle. These referred to preferred times for getting up and going to bed, preferred meals, beverages, frequency for bathing, and similar. Observation of the daily lifestyle and conversations with staff showed that personnel were familiar with people’s needs and how these were to be met. Risk assessments had been carried out in relation to the risks for each individual. In most instances this was in relation to moving and handling procedures and the risks of falls. Risks had been assessed in relation to those who had diabetes that was insulin controlled. Whilst these assessments noted, “”staff awareness required at all
Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 12 times”, they did not note what staff must be aware of or detail what immediate action to take in the event of symptoms of uncontrolled diabetes, other than to make contact with the emergency services. It was explained that training had been provided recently about this health condition. People who contributed to the inspection at the visit were positive about the conduct of staff, describing them as “Good”, “Very friendly” and “Kind”. One stated, “ It is fine here. We are looked after OK”. Another said, “I like living here because we have everything done for us”. There was evidence to show that people had been supported to access health care appointments for routine treatments such as chiropody, optical tests and had been referred to their doctors and other specialists as need be. Medicines were stored in a purpose built, lockable trolleys. One was stored in an area of a dining room. It was noted, as the inspection began, that it was not secured to the wall, as it must be when not in use. This was later remedied. The other trolley for use on the upper floor was secured in a locked room when not in use. Controlled drugs were stored appropriately in another office. Medicines were only administered by members of the team who had received training in safe practice. A member of staff who had undertaken such training was observed as they administered medicines. During this they were able to explain their understanding of safe practice and were seen to be diligent in this practice. Records inspected showed that medicines had been administered as prescribed. People living in the home had been treated with kindness and respect. One person stated they found the staff to be, “Very respectful” and another said, “Staff knock before entering my bedroom and treat me well”. Ambassador House DS0000014876.V342250.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): Standards 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had been supported to achieve a lifestyle that within the limitations of their physical and mental health needs met their preferences. EVIDENCE: People living in the home who contributed to the inspection indicated they were satisfied with the arrangements for daily routines. People described their daily routines and evidently were able to choose times for getting up and going to bed and similar routines. People passed positive comments were passed about the provision for stimulating activities. “You can join if you want to”, and described frequent games of dominoes, cards and musical evenings. The lay assessor reported conversations with people living in the home, “They chatted about activities and outings that were arranged for them and were keen to point out photographs on the walls that had their pictures on and supported their stories. I was also told they had visitors on occasions to entertain and linedance. They also said they had a group of people that came in to sing hymns, which they enjoyed. A couple of ladies said that they used to do knitting but
Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 14 hadn’t done any for a long while, maybe they could have a go again as a change from reading.” The assessor reported on the level of support they observed to be given to people with cognitive impairment. “A member of staff was with them all the time and was interacting with all of them in turn by singing to them, talking or just holding their hands. There was music playing in the background and the atmosphere was a very peaceful one”. Visitors had been welcomed into the home. It was explained by a person living in the home that their visitors could come into the home at anytime and could come to their bedroom for more privacy. A visitor who came to the home at least twice each week remarked on the welcome they had received and confirmed that there were no restrictions on visiting. Records indicated that nutritional needs had been assessed. Special diets were catered for as required. A carer cooked often cooked meals of a Caribbean cuisine for people who had previously enjoyed such food. The menus seen showed a nutritious choice throughout the day. The inspector sat with people as they took their mid-day meal. The atmosphere in the dining area was congenial. The meal took place at an unhurried pace and was an enjoyable social experience. A member of staff was observed to provide sensitive assistance to a person who was unable to feed them self. It was noted that plated meals were not covered for hygienic transportation around the home. People described the food served to them as “OK”, “Good”, OK and enough”. The assessor reported, “All that I spoke to said the meals were good and many had their favourites. The main meal was served at lunchtime and, although plated up and brought to the tables uncovered, was warm. Several people told me that at teatime they could have a choice of sandwiches or something on toast, e.g. egg or cheese. At lunch- time the staff were around to help those who needed a hand”. Ambassador House DS0000014876.V342250.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): Standards 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and safeguarding procedures were in place to enable people living in the home to raise concerns and to safe guard them from abuse. EVIDENCE: Previous inspections had established that the home had satisfactory written complaints and safeguarding procedures. The manager reported that there had been no complaints about the service since the last inspection. None had been made to the Commission. People living in the home confirmed that they felt able to raise concerns. “I would speak to the head one if I was worried”. “I am able to speak my mind”. They also described meetings they had attended were they had been invited to comment on aspects of the service. The home also operated a “comment card” system on which people, their visitors or professional visiting the home could pass remarks about the service. Records indicated that personnel had been informed about safeguarding issues. A carer spoken to showed understanding of safeguarding issues. Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 16 Three personnel files were assessed. Each contained records to show that robust recruitment practice had been followed that included the checking of employment history through references and checks via the Criminal Records Bureau and the Protection of Vulnerable Adults Register. Ambassador House DS0000014876.V342250.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 19,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The appearance of the home had deteriorated, so that some areas of the building were shabby and did not meet expected standards of décor and furnishings. EVIDENCE: The AQAA stated , “Service Users live in a safe, clean, comfortable, well maintained, homely, accessible environment, offering facilities that suit service users individual needs as described in our service user guide”. It showed future plans for the environment as, “Replacement of some furnishings, redecorating and recarpeting in identified areas”. This inspection identified this self-assessment to be inaccurate in relation the environment being wellmaintained and the plans for re-decoration to be much needed: Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 18 As described previously the layout of the building was suitable for the care of frail older people. Areas of the building seen at this inspection were clean and orderly. Information given on the AQAA and visual checks indicated that routine maintenance checks and servicing of equipment had taken place. The standard of décor around the home varied considerably. The communal lounges, bedrooms in the relatively new extension and some bedrooms in the original building were well decorated and furnished to a satisfactory standard. Other bedrooms seen were showing signs of wear and tear, as were chairs and suchlike in these rooms. The bathrooms in the original building were in a poor decorative state. The paintwork to the walls looked old and shabby. It explained that the proprietor had applied to the Local Authority for a grant to improve these aspects of the home and also other areas of the environment. Ambassador House DS0000014876.V342250.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 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People in the home had been well cared for by an experienced and committed care team. The numbers of ancillary personnel were low and members of the care team carried some of these duties. This meant that care staff could not concentrate all their efforts on meeting the personal care needs of the people living in the home. EVIDENCE: The home’s staff team was an asset to this home. Members of staff on duty, care and ancillary, were observed to treat people living in the home with kindness and skill. In conversation with the inspector, members of staff showed empathy and commitment to those in their care. People using the service were complimentary about personnel. “ They are good to me”, “Nice”, “Kind and very helpful”. Visitors were also positive about the team. The assessor reported “I spoke to three visitors to the home who were all happy with the care that their relatives were receiving.” Information supplied by the provider showed that the majority of the care team had worked in the home for a significant time and were well versed in the home’s day-to-day routines and the needs of people living in the home.
Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 20 Rotas indicated that the minimum number of care staff required to care for the numbers of people living in the home had been rostered on duty. The manager’s working time was not completely supernumerary as her time was included in the care staffing numbers in the afternoons. Ancillary staff consisted of a cook, a domestic for five days of the week and a maintenance employee who also carried out duties in the proprietors’ other care homes. Lunch was served at an early time at 12 noon. The cook’s working time at 13.30. Two members of the care team were observed to be engaged in the late afternoon preparing the evening meal. A senior team was in place to support the manager and the team. Members of staff remarked that they felt well supported by the senior team, who were always available to provide guidance and reassurance if need be. Records indicated that the home had a satisfactory training programme. It covered topics required to ensure that staff had sufficient knowledge about the needs of older people and health and safety arrangements to enable them to properly care for people using the service. The home had recently signed up to the Skills for Care induction programme. The manager stated that it was planned to introduce this programme in the near future for all new starters. The progress to achieve a high percentage of the team with National Vocational Qualifications in care was good. Fourteen of the twenty-two care staff (64 ) had achieved this award. It was reported that three other staff were working towards this award. Recruitment procedures as outlined in section four were robust. Records indicated that equal opportunities procedures had been followed. Applicants for jobs had completed written application forms, and attended for interviews, the results of which had been recorded. References had been taken up and the required checks on identity and background had been carried out. Ambassador House DS0000014876.V342250.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 31,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager had properly supported the team so that they could in turn work effectively on behalf of the people using the service. EVIDENCE: The AQAA stated, “The manager is registered, responsible, fit, qualified, competent, skilled and accountable. Ensures the service users and staff benefit from the ethos, leadership and management approach of the home. The manager is a good communicator, open and approachable, promoting equal opportunities and complying with the General Social Care Council Code of Practice. The manager assures the safeguard of the accounting and financial
Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 22 procedures of the home and the service users financial interests. Staff are approriately supervised formally 6 times a year. The Manager also promotes and protects the health and safety and welfare of the service users, staff and visitors to the home”. This inspection validated this assessment. The manager had carried out her role to a good standard and ensured that decisions about the operation of the service that were within her remit had been made with the best intersts of the people using the service. It was evident that long term decisions about staffing arrangements and redecoration of the home did not fall within her remit. There was evidence to show that the home consulted with people living in the home. Discussions across the lunch period had included comments from people about regular meetings. They stated that issues discussed had been menus, activities and care plans. Examples of questionnaires from the home’s formal consultation system via an annual quality audit were seen. Few people handled their personal monies, although those who wished to were supported to do so. Records seen showed that monies held on behalf of people were to pay for such services as chiropody, hairdressing and for newspapers and similar. Transactions had been properly recorded and substantiated by receipt. Cash seen balanced with records of the same. Records of supervision showed that staff had met regularly with the manager on a one-to-one basis. Systems to manage health and safety throughout the home were thorough. Information provided pre-inspection showed that equipment had been regularly serviced and maintained. This was confirmed during the inspection by visual checks. Records indicated that staff had received appropriate training in safe working practices. Practice observed showed that members of staff were aware of safe practice in relation to moving and handling, infection control and administration of medicine. Food hygiene practice must be reviewed as indicated previously in relation to the transportation of uncovered food around the home. It was noted that the front door of the home was kept locked. Anyone wishing to leave the building had to find a member of staff to unlock the door with a key or by the door release button that was located in the manager’s office. The home must ensure that whilst maintaining the security of the home, it does not infringe on the rights of people living in the home to leave the building without restriction and to also ensure that exit from the building in the event of an fire is not delayed. Risk assessments about these issues must be carried out. Ambassador House DS0000014876.V342250.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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP8 Regulation 13(4)(c) Requirement Timescale for action 31/08/07 2. OP38 12(2), 23(4)(b) The registered person must ensure that individual risk assessments must be carried out for those who have diabetes. Written guidance must be in place to ensure that personnel are aware of the immediate action that must be taken should people have a sudden health crisis that is related to uncontrolled diabetes. 31/08/07 The home must ensure that whilst maintaining the security of the home, it does not infringe on the rights of people living in the home to leave the building without restriction and to also ensure that exit from the building in the event of an fire is not delayed. Risk assessments about these issues must be carried out. Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP15 OP19 OP27 Good Practice Recommendations Plated meals should be covered when they are transported around the home to ensure that hygienic food handling procedures are maintained. The home should introduce a refurbishment programme to ensure that the standard of décor is maintained throughout to a satisfactory standard. There should be a review of the ancillary staffing arrangements to ensure that the care team are not called upon to carry out kitchen and laundry tasks when people living in the home require their attention. Ambassador House DS0000014876.V342250.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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
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