Inspection on 12/09/07 for Amber House

This inspection was carried out on 12th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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Heathlands

Aston Court Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Amber House 7/8 Needwood Street Burton On Trent Staffordshire DE14 2EN Lead Inspector Rachel Davis Key Unannounced Inspection 12th September 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 Amber House DS0000068382.V350958.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. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amber House Address 7/8 Needwood Street Burton On Trent Staffordshire DE14 2EN 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) 01283 562674 amberhousecare@aol.com Mrs Karen Marie Shaw Michael Shaw Mrs Karen Marie Shaw Care Home 18 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (13) of places Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 04/07/06 Brief Description of the Service: Amber House is a large Victorian detached house that can provide personal care support to 18 older people. Amber House can accommodate five people who have dementia care needs, it is owned and managed by Mrs Karen Shaw. The home provides accommodation on two floors, there are 2 shared rooms. Communal areas are sited on the ground floor, there are two lounges and a dining room. Suitable facilities are available for people who use the service to sit outside. The home is located in Burton upon Trent and is convenient for shops, amenities and public transport. The registered manager Karen Shaw informed the Commission for Social Care Inspection on 12th September 2007 that the fee level for Amber House is between £357:00 and £397:00 per week. This does not include extra services such as hairdressing, chiropody, toiletries or newspapers. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 8 hours by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. This was a ‘key inspection’ and therefore all the core standards were assessed, it was the first inspection of this service by this inspector. Prior to the inspection the service had completed an Annual Quality Assurance Assessment for the Commission for Social Care Inspection. The Commission for Social Care Inspection analysed the 5 questionnaires returned by the people who use the service and their relatives. A tour of the home was undertaken. On the day of the inspection, the home was accommodating 15 people. A number of people who use the service, some staff and a couple of visitors talked to the Commission for Social Care Inspection on this occasion. The Commission for Social Care Inspection watched staff and resident interaction around non-personal care tasks, lunchtime routines and the medication administration round was also observed. Some care plans were checked and the records of three staff including recruitment documents were seen. There have been no complaints made to the Commission for Social Care Inspection about the service delivered at Amber House since the last inspection and there have not been any vulnerable adult referrals made to Social Services. Ten requirements and thirteen recommendations have been made as a result of this visit. What the service does well: The manager does not admit anyone into the home unless his or her needs have been fully assessed. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 6 A plan of care is developed for all of the people using the service, they are reviewed and amended as changes occur. The people using the service and/or their families can be involved in this process, although not everyone knew this. Comments from the relatives were positive regarding the quality of care provided in the home. Some of these are included in the main body of the report. Health needs are closely monitored and access to other health professionals is arranged as required. Families and visitors are made welcome. The quality of the food is considered to be good, it is home-cooked, there is a plentiful supply of fresh fruit and vegetables and choices are offered at every meal. The home received a 5 star rating following the recent Environmental Health inspection. The home continues to monitor responses to regular residents questionnaires regarding food and the services provided which are then used as an auditing/monitoring tool. What has improved since the last inspection? No requirements were made at the last inspection and this was the first visit for this inspector. Recommendations were made at the last inspection held on 4TH July 2006. These were as follows: • The medicines room on the ground floor should be completed as agreed. This has not yet occurred, it was agreed this would be completed before Christmas 2007. • The shower unit should be reinstated on the first floor of the home, as previously agreed. This was discussed with the Commission for Social Care Inspection during the inspection, the home has a number of environmental improvements that it wishes to make and is considering the best options to meet both the fire officers and the Commissions requirements • The recently purchased sluicing facility should be installed and commissioned as agreed. It was agreed this would be completed before Christmas 2007. Mr and Mrs Shaw have registered with the Commission for Social Care Inspection as the owners of the home, Karen retains the care manager role. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 7 There was evidence to confirm there is a clear vision of what they consider necessary and are in the process of completing a 5 year business plan. 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. Amber House DS0000068382.V350958.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 Amber House DS0000068382.V350958.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): 1, 3 and 4. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information offered ensures that people who use the service and prospective residents can make an informed choice about the home. EVIDENCE: The Statement of Purpose and Service User Guide were not read on this occasion but have previously been inspected and meet with the requirements. Following discussion the home may wish to develop a more ‘user friendly’, ‘easy read’ Statement of Purpose and Service User Guide to assist people with specific and/or complex needs. The care records of a recent admission were checked and contained the needs assessment as required. The manager assessed the needs of the resident prior to admission and a subsequent care plan had been developed, this affords staff the information necessary to provide appropriate care. The home Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 10 should consider further ways to evidence equality and diversity within their service and how they support people with more complex needs. Information received back from questionnaires demonstrated positive comments about the home and their admissions: One person who uses the service had written, with the support of a staff member “ I chose this home as it was more homely.” Questionnaires sent by the Commission for Social Care Inspection askQ1. Have you received a contract? Q2. Did you get enough information regarding the home before moving in? On both counts 100 of returned questionnaires said ‘yes.’ It is strongly recommended that the home should further develop the key worker and/or named worker system to help individuals feel comfortable in their new surroundings, and enable them to ask any questions about life in the home. It will also encourage and help staff to develop a person centred approach to care. The owners recorded on the Annual Quality Assurance Assessment (this is a legal document that must be completed by the home for the Commission for Social Care Inspection) “We have an initial 24 hours assessment form that we fill in, with input from the people who use the service, family, staff or any other relevant person.” The manager was not aware that when the home have agreed they can meet the needs of the people who use the service they must confirm this in writing, a requirement to this effect has been made. Although requiring inspection Standard 6 is not relevant to this home and therefore not assessed. Amber House DS0000068382.V350958.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 and 10. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care needs that people who use the service receive are suitable. Overall the principles of respect, dignity and privacy are practiced. EVIDENCE: The plans of care within the home have been developed to include a variety of information to enable individuals’ needs to be easily identified and the support required by the staff team. It was discussed that these could become more person centred and offer more information where a person who uses the service has complex needs, examples could include life plans, management of dementia related conditions and more evidence of service user and family involvement. The manager needs to ensure that evidence is available to confirm that people who use the service and / or their representatives are offered the opportunity to participate in the care plan and subsequent reviews. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 12 The home is also registered to provide a service for 5 individuals with dementia. There was no evidence to any specific services, facilities or stimulation to meet the needs of this group of residents. This had been recognised by the new providers and a range of therapeutic activities are to be considered. All service users spoken with spoke well of the care provided and people who use the service stated they were treated with dignity and respect, and encouraged to be as independent as possible. The staff observed had a knowledgeable and positive attitude towards people who use the service and feedback from questionnaires was very encouraging about their relationships. “ Since my relative has been at Amber House they have been a lot happier knowing that he has got all his dignity, his care and all his needs are catered for.” Staff were observed knocking on doors, offering people who use the service choice, and allowing them to complete tasks in their own time. Questionnaires returned to the Commission for Social Care Inspection offered satisfactory information regarding health support – Q6 Do you receive the medical support you need? Everyone had recorded ‘always’ One person wrote: “ The medical support is A1.” It was noted by the Commission for Social Care Inspection that bed guards were in use and these had been appropriately assessed. It was also noted that people who use the service who cannot be weighed in the traditional manner should be provided with an alternate, it is not good practice to discontinue weighing identified service users. Medication is stored within a locked cupboard and the NOMAD system is used; a pharmacist reviews the system and offers training on an annual basis. The home appropriately stores and records all controlled drugs within the home. (Although none were in use at the time of inspection) The home does not have a medication fridge and medication was stored in the fridge door in the kitchen, it is required that all medication is stored Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 13 appropriately and securely (this was addressed during the inspection by the use of a plastic petty cash box) preferably a lockable medication fridge should be purchased. A record of the maximum and minimum temperature of medication stored in the fridge must be recorded. All people who use the service and choose to self administer any medication must be assessed as competent to do so, and a subsequent risk assessment needs to be completed, this is a requirement following this inspection. A small stock of homely remedies is maintained, the policy needs to be amended to be in line with the homes practice. The medication administered was observed and of a good standard. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities and stimulation for people who use the service are in place, but could be improved upon to further stimulate the people living at Amber House. The home encourages and welcomes visitors. EVIDENCE: The home does operate a key worker system but it could be expanded upon as only the manager and deputy are presently involved, this would enable closer resident staff relationships where likes, dislikes and needs are shared and should also be recorded. Questionnaires for people who use the service asks: Are there activities arranged that you can take part in? 2 said always 3 said usually 1 said sometimes Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 15 Following discussions and observations there is a requirement to revisit the activities and stimulation provided especially for those with more complex needs, this is to ensure a high quality of life for all the residents. Three out of four people who use the service and who were spoken to by the Commission for Social Care Inspection said they were “bored” “days could be monotonous” “everyday is the same.” The home may wish to consider offering other support such asA means to enable people who use the service with complex needs to identify their own bedrooms. (Individuals names are presently on the bedroom doors.) Pictorial information to help people who use the service make informed choices e.g. for food, where the toilets and bathrooms are etc. More photographs of the people who use the service and the staff group. Developing life books and a family tree. From the records available it was clear there were regular visitors to the home. Questionnaires and discussion confirmed they were made welcome at any time. A number of people who use the service said that they went out of the home with relatives and friends. The home operates an open visiting policy and people were seen coming and going throughout the day. People who use the service and relatives spoken with talked positively about a summer trip to the seaside, visiting the town hall regularly for bingo, going to the chip shop and into town. Staff were seen doing the crossword with some residents but it remained unclear on the structure of the day-to-day activities offered, especially for those with complex needs. The kitchen is well maintained, it was inspected and found to be clean and tidy, crockery and cutlery were of a good standard. All the required records were in place. Food supplies were plentiful and fresh fruit and vegetables were available. Records of fridge and freezer temperatures were kept. The home has recently received a 5 star rating from the Environmental Health. The home has one dining area off the lounge, lunch was relaxed and informal. Food was considered by the residents to be ‘very good’, the Commission observed lunch being served. People who required support with their meal were given sensitive assistance. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 16 Liquidized meals were evident, these were poorly presented in a bowl with all parts of the meal blended together, this does not offer people any variety of taste, texture, colour or visual stimulation. Once discussed this was immediately rectified. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 17 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 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure and ensures the people who use the service are protected from abuse in accordance with written policies. EVIDENCE: The Commission for Social Care Inspection has not received and formal complaints about the home since the last inspection held in July 2006. The manager is happy to promote the recording of complaints in a transparent manner. The complaints procedure is available in the service user guide (all people who use the service have a copy of this in their bedroom) and by the homes’ notice board in the hall. The home should consider making the complaints procedure available in other formats and consider how people with dementia related conditions are able to voice any of their concerns. Relative’s questionnaires and feedback from relatives spoken to evidenced knowledge of the complaints procedure. Q10 asks do you know how to complain? Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 18 All 6 questionnaires returned said yes. Comments, compliments, grumbles or concerns should also be recorded, it is recommended the home should also site a suggestions box in the hall. From the records available on the day of inspection it was clear that the staff are trained to recognise the signs and symptoms of adult abuse, this training is mandatory. No vulnerable adult referral has been made since the last inspection. It is recommended that the home is in receipt a copy of the Safeguarding of Adults policy and protocol to ensure they are up to date with new procedures. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 19 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 and 26. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is clean and hygienic but requires some consideration to utilise space and make it more suitable for the people using the service. EVIDENCE: Amber House is a clean and comfortable and has a homely feel. All questionnaires returned confirmed that this is so. When asked: Is the home fresh and clean? All 6 people who use the service responded always. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 20 Infection control measures are in place, examples of this include: paper towels, liquid soap, laundry management and personal protective clothing. The home is presently considering a sluicing facility and this should be on place by Christmas, presently the home purchases alginate bags to assist with soiled laundry. Presently there are two assisted bathrooms, the one downstairs requires a lock, and the safety of the unguarded radiator needs to be assessed. With 15 residents, the home meets the bathing ratios which is 1 in 8, if the home were to have more than 16 people using the service another bathroom or shower room is required, this is being addressed. The owners of the home need to look at appropriate storage areas for the wheelchairs and the hoist. The lounge area is ‘cramped’, people who use the service have very little ‘person space’, with armchairs being extremely close to one another. One person who uses the service said, “It is overcrowded.” This was discussed with the owners and should be incorporated within their business plan. There is a large garden to the property, which is well maintained, some people who use the service stated they enjoyed sitting outside, a smoking area for residents and seating were available. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 21 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, 28, 29 and 30Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff at the home are suitably trained and sufficient in numbers to meet the needs of the people who use the service. Recruitment procedures are not as robust as required and do not fully protect vulnerable people. EVIDENCE: The number of staff on duty during the inspection was suitable to meet the needs of the people who use the service. It was evident that staffing levels weren’t compromised. The Annual Quality Assurance Assessment says: “We do not use agency or bank staff, we have very low staff turnover.” Two staff files were examined and both demonstrated that recruitment practices were not as thorough as required. The home must ensure• Protection of Vulnerable Adults First checks are not destroyed • Application forms cover any gaps in employment history Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 22 • • • A photograph is on file The Criminal Record Bureau disclosure is specific to Amber House. There is clear evidence of supervision between a Protection of Vulnerable Adults First check, and the receipt of a Criminal Record Bureau disclosure. All staff within the home have received positive and meaningful training, the registered manager prioritises this and enables staff members to undertake training beyond the basic requirements. This ensures a consistent and needs led service is offered to the people who use the service. The manager completed the Registered Managers Award in November 2005, this is a legal requirement for managers of a care service. The manager should consider offering training to the staff on equality and diversity and use a matrix to enable her to easy identify the skill mix of the homes staff group. . Staff also receive an induction that meets with the standards. National Vocational Qualification training is offered to the staff working at Amber House, out of 18 staff 6 have National Vocational Qualification 2 in care and 6 are presently doing their National Vocational Qualification level 2. Regulation states that 50 of the workforce must be trained, this target will be exceeded when the staff have completed their award. The people who use the service were happy with the staff they used words like “kind” “helpful” “friendly.” One questionnaire returned read, “ Got good staff here,” another said, “they look after my relative really well.” Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 23 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, 25 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. An experienced manager manages the home, the management monitor the quality of the service and make changes and improvements where identified and required. EVIDENCE: There is a feeling of warmth and openness in the home and overall staff deliver good care. The registered manager Karen Shaw has been in post for a number of years, since the last inspection Karen and Michael Shaw have become the owners of Amber House and are registered with the Commission for Social Care Inspection Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 24 People who were spoken to were happy with the manager and staff team and felt they were approachable. There is continuous self-monitoring within the home and a quality assurance system is in place within the home, action plans are developed and reviewed as required. Records were seen to confirm staff receive formal supervision and appraisals. The home maintains robust records of all residents’ property, the home are not presently responsible for any residents money. Staff have received fire training including regular fire drills. The manager is aware of the changes to fire safety legislation and the need to undertake individual fire evacuation procedures for each person who uses the service. The home must develop a contingency plan in the event of a fire or major incident and this must include a named place of safety. The Annual Quality Assurance Assessment document completed by the home states the Health and Safety of the environment is regularly checked and action taken to keep the people using the service safe. Amber House DS0000068382.V350958.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 3 X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 26 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 OP4 Regulation 14(1)(d) Requirement The manager must write to confirm to the people who use the service that the home is able to meet their needs once they become a permanent resident. People who use the service and administer their own medication must complete an assessment and consent form. This is to ensure everyone’s safety and understanding. A record of the maximum and minimum temperature of medication stored in the fridge must be recorded. Activities and stimulation must be provided for all of the people using the service who wish to participate, including those with more complex needs to ensure a high quality of life for all the residents. Radiators within the home must be assessed for the risk they present to the people who use the service and action taken to minimise ant identified risk. In this instance the downstairs bathroom. DS0000068382.V350958.R01.S.doc Timescale for action 12/10/07 2 OP9 13(2) 01/10/07 3 OP9 13(2) 01/10/07 4 OP12 16 (2m, n) 12 (4b) 12/10/07 5 OP19 13(4)(a) 01/10/07 Amber House Version 5.2 Page 27 6 OP21 12(4)(a) 7 OP29 19 (1)(b) (i) 8 OP29 19(1)(b) (i) 9 OP29 19(4)(b) 10 OP38 23(4)(c) (iii) A lock is required on the bathroom door to enable the people who use the service to maintain their privacy. The home must ensure that the recruitment procedures are properly followed, this ensures all staff are suitably vetted to protect the people who use the service. An up to date Criminal Record Bureau enhanced disclosure is required for a staff member and must be requested by the timescale date The home must evidence that staff are appropriately supervised between the receipt of a Protection of Vulnerable Adults First record, and the subsequent Criminal Record Bureau disclosure The home must develop a contingency plan in the event of a fire or major incident, this must include a named place of safety. 01/10/07 12/10/07 19/09/07 12/10/07 19/10/07 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 OP1 OP4 OP4 Good Practice Recommendations The home may wish to develop a more ‘user friendly’, ‘easy read’ Statement of Purpose and Service User Guide to assist people with specific and/or complex needs. The home should consider further ways to evidence equality and diversity within their service and how they support people with more complex needs. It is strongly recommended that the key worker system is further developed to encourage a more person centred approach to care. DS0000068382.V350958.R01.S.doc Version 5.2 Page 28 Amber House 4 5 6 7 8 9 OP7 OP8 OP14 OP15 OP16 OP16 10 11 OP18 OP19 12 13 OP30 OP30 Plans of care should be developed to evidence a person centred approach. The home should, where necessary, find alternative methods to ensure all people who use the service have their weight monitored. The manager and staff should explore further how they can enable the people using the service to make choices within their daily lives. The cook should liquidise all parts of a meal individually. The home should offer a suggestions box and/or comments book. In future the manager could improve upon the recording of complaints, however minor they may appear, including the outcome, this will further evidence the homes openness and transparency. The home should ensure they have a copy of the Safeguarding of Adults policy. The manager should seriously consider how best to utilise the space available within the home to enable the people who use the service more choice. This refers specifically to seating arrangements, storage and bathing facilities. The manager should consider using a training matrix. The manager should consider offering training to the staff on equality and diversity. Amber House DS0000068382.V350958.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor, Ladywood House, 45-56 Stephenson Street, Birmingham, B2 4UZ 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 Amber House DS0000068382.V350958.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. Re-publishing this information is in breach of the terms of use of that website. 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