Inspection on 03/07/05 for Annandale

This inspection was carried out on 3rd July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Annandale 13/04/07

Annandale 09/12/05

Annandale 05/07/05

Annandale 16/12/04

Annandale 01/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Annandale 1 Victoria Road West Crosby Liverpool Merseyside L23 8UG Lead Inspector Mrs Trish Thomas Unannounced Inspection 10:00 26 June and 3rd July 2006 th 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 Annandale DS0000005370.V295344.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. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Annandale Address 1 Victoria Road West Crosby Liverpool Merseyside L23 8UG 0151 924 3162 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) Mrs Eila Henny Voce Mrs Pamela Veronica Dunn Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 10 OP. Date of last inspection 9th December 2005. Brief Description of the Service: Annandale is a care home registered to provide support to 10 elderly people. The home is owned by Mrs. E. Voce and the registered manager is Mrs. Pamela Dunne. Annandale is situated in a residential street, close to a bus route and shops. The building is a converted Victorian villa with well-maintained front and rear gardens, having steps to the two entrances. Communal areas include a large lounge and a separate dining room. There is a chair lift to upper floors where most bedrooms are situated. The accommodation consists of eight single and one double bedroom. There is a toilet on the ground and one on the first floor. Additionally the home has an assisted bath, and a shower. Grab rails and call buttons are placed throughout the home for residents convenience. The home is staffed throughout the day and night and the service includes personal care and support, home cooked meals and an in-house laundry service. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The methods used in this inspection were carried out over two visits. The manager, Mrs. Dunn, was on leave at the time of the first inspection on 26th June 06 and a second visit was arranged when she was due to return to her duties on 3rd July 06. Four of the eight residents, who wished to comment, contributed to the inspection process, three care plans were tracked and a six of the eight active case files read. A tour of the premises was carried out and health and safety records and maintenance certificates and risk assessments were seen. The manager and staff on duty made comment and staff files and training records were read. What the service does well: What has improved since the last inspection? A new bath aid has been fitted, bedroom 4 and the dining room have been decorated with new chairs and carpet fitted in the dining room. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 6 What they could do better: Some requirements from the last inspection have not been met and these are repeated in the relevant section of this report. The home was not meeting the needs of some of the residents and there was evidence in one assessment that a resident had been admitted last year, whose recorded needs were not within the category of the home. Other residents’ needs have increased over time and professional assessments have not been arranged to ensure that the home can meet their needs. Residents’ mobility should be monitored in relation to the style and layout of the building to ensure they can easily access and exit the their home. Care plan reviews were up to date, but examples were noted where residents’ presenting behaviour had not been addressed in the care plan. Staff lack knowledge of the definitions of abuse and this judgement has been reached as a result of the following practice in the home. A resident is routinely restrained in the dining room by placing a chair behind her dining chair when she is seated to stop her leaving the room and being at risk of falling. Staff appear to be unaware of the implications of restricting a person’s right to freedom movement, choice and dignity. The resident looks well cared for but lacks appropriate support for her mobility and behavioural needs. The standard of record keeping in the home varies according to the writer and resident. The content of records of a resident’s behaviour pattern shows lack of respect for her diversity and dignity. Attitudes towards residents appear to vary according to their levels of dependency, those who are ambulant and who have capacity say they are treated very well and are satisfied with the service. The home is clean and very well maintained but a shortfall was noted regarding infection control by staff who cook. Fire systems tests are not being carried out weekly and the fire drill was overdue. The home did not have an up to date gas certificate. There are flaws identified in management of residents’ medication. Administration Records are not accurate and there is an absence of auditing of un-used drugs. The staff roster inspected did not represent the true names of staff who worked the shifts. A number of shortfalls in training have been identified with regards to infection control and Food Hygiene . Please contact the provider for advice of actions taken in response to this Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Annandale DS0000005370.V295344.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 Annandale DS0000005370.V295344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 The quality of this outcome is adequate. This judgement has been made using available evidence including two visits to this service. The home could not demonstrate capacity to meet the assessed needs of some residents who are living in the home and the manager’s assessment of one resident on admission was not within the registered category of the home. EVIDENCE: The care files of three residents were inspected. Each resident had received a professional/social work assessment and/or a home’s assessment. All care plans which were read had been regularly reviewed. Arrangements for medical and paramedical services were satisfactory and evident in care plans. For the three residents whose care plans were tracked, their needs had been assessed by home’s staff using a standard format which addresses physical and personal care needs, health, sensory and mobility support needs and social preferences. Their stated assessed needs had been within the category of the home at their times of admission. A number of care files were read in Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 10 addition to case tracking and the manager’s report on the condition of one resident’s mental health at the time of admission would suggest that her needs were not within the registered category of the home and her presenting behaviour at that time, (eg. Wandering) had not been addressed in her care plan. Another resident was observed in the dining room having been escorted by staff to her seat at the dining table. Staff had placed a chair sideways at the back of her dining chair when she was seated. A member of staff said this is done to prevent her from rising from the dining chair and attempting to walk back to the lounge. The manager, Mrs. Dunne said she was aware of this arrangement, which she considered was in the best interests of the resident, due to risk of falls. On the basis of the evidence, the judgement has been made that the home was not meeting Regulation 13 (7,8) by routinely restraining a resident, and Regulation 14 (1) (2) by admitting a resident not within the registered category. Requirements are made under both regulations. A recommendation is made that a review/re-assessment is arranged for a resident who is subject to restraint. Annandale DS0000005370.V295344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality of this outcome is adequate. This judgement has been made using available evidence including two visits to this service. The home has systems for care planning/reviews, health care and management of medication. The care planning systems are not always used to full effect, and residents’ privacy and dignity are not always respected in the content of records compiled in the home. EVIDENCE: The care plans of three residents were tracked. All followed a standard format and had been regularly reviewed, signed by the manager, Mrs. Dunne, and the relevant resident. From speaking with the residents and by direct observation, it was evident that their care plans were relevant to their presenting needs. One resident said that everything was going well and she had no complaints since moving to Annandale. She said she still goes out and receives all the assistance and support from staff that she needs. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 12 Another resident said she has been happy since moving to Annandale, and she goes out regularly, without escort. Best practice was noted in that discussions a resident and the manager as to health care treatment were recorded on the care plan. A number of entries regarding a resident which did not respect her right to dignity and diversity were read in daily record sheets and discussed with the manager. Mrs. Dunne said she would speak with staff during supervision with regards to continuing respect for residents through report writing. A care plan to address the behaviour referred to and referral to G.P. are recommended if this continues. Arrangements for medical and paramedical services are set out in the home’s brochure and the care plan which were sampled, showed examples of medical and paramedical referrals. Residents said they receive chiropody and district nursing services. Residents’ personal and social preferences and religions are recorded and catered for in the home and they have access to postal votes in general and local elections. The home has a procedure for the management of residents’ medication, which is stored in a locked cupboard. The storage and recording systems were inspected. Medication is in blister packs, supplemented by some drugs in pharmacy containers, which are not in blistered. Some of the non-blistered drugs were out of date or inappropriately labelled. The medication administration sheets were read. Recording of prescribed medication was not satisfactory as there were a number of gaps where either a signature or code must be inserted. There was therefore no evidence whether or not a drug had been administered at certain times for some residents. Staff on duty could not locate the pharmacy returns book. A Requirement given under Regulation 13(2) regarding recording of prescribed medication and the auditing and returns of unused medication. From direct observation during the visit and the comments of residents, no concerns were raised with regards to residents’ privacy and dignity. The content of reports (referred to previously) do not respect the residents’ dignity and diversity. A requirement is made under Regulation 12 (4) (a) (b). Annandale DS0000005370.V295344.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality of this outcome is adequate. This judgement has been made using available evidence including two visits to this service. The lifestyle experienced in the home matches residents’ expectations, preferences and satisfies their social, cultural, religious and recreational interests, however there are restrictions on residents’ freedom of movement. EVIDENCE: Reference was made to the home’s activities calendar, which is laminated and provided to residents. Leisure events include Name that tune, quiz, exercise, foot spa, bingo, residents’ meetings, art and film shows. There are also whist and bridge clubs available for residents’ participation. Residents choose whether or not to take part in activities. There were books (some large print) and newspapers in evidence in the home and one lady said she goes out regularly without escort. There were no activities or visitors in the home at the time of both visits. Four residents who commented said that their visitors are made welcome and they entertain them in the dining room or their bedrooms if they want privacy. Residents’ questionnaires were read regarding visitors and those completed gave satisfactory responses to the Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 14 questions regarding visiting. Religious services take place weekly in the home. There continues to be a relaxed and friendly atmosphere in Annandale, which is registered for ten residents, and domestic in style. Residents appeared to be making choices regarding how and where to spend their time, one resident’s freedom of movement was restricted through restraint, when in the dining room, and a requirement has been given under Regulation 13. Residents’ choices could further be restricted by access to the building, as there are steps to front and back entrances. A requirement is made under Regulation 23 (2) that the manager must ensure that safe access and exit is available in accordance with residents’ mobility. Discussion took place with the manager and reference made to the preinspection questionnaire with regards to residents’ personal allowances. The manager confirmed that the home does not become involved in residents’ financial affairs and the personal allowance of a minority is managed. The records of transactions were read and were satisfactorily maintained. Reference was made to the home’s brochure and menus. Four resident commented and were satisfied with their meals saying drinks are served regularly. There is a three weekly rotating menu, the main meal being at 1.30pm with a choice of light meal served at 5.30pm. There are two care staff on duty throughout the day, one being allocated as cook. The home was catering for diabetic diets at the time of inspection. A recommendation is made that diabetic diets are recorded daily and held with the relevant residents’ care plans. The dining room is pleasant and in good order with enough seating for ten residents. Annandale DS0000005370.V295344.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality of this outcome is poor. This judgement has been made using available evidence including two visits to this service. The home has systems in place for dealing with complaints and protecting residents from abuse, but staff do not appear to have an understanding of the definitions of abuse (with regards to restraint) and their effects on residents‘ rights and choices. EVIDENCE: Annandale has a complaints procedure, which is set out in the home’s brochure. The brochure has not been reviewed since 2003 and should be updated with regards to the title of the Commission for Social Care Inspection. Residents’ comments and questionnaires expressed no concerns and there have been no formal complaints against the home since the last inspection. The home has an Adult Protection Procedure and whistle blowing policy. Staff appear to lack understanding of the definitions of abuse and their effects in practice with regards to restraint and report writing in relation to disability and diversity. A Requirement is made under Regulation 13 (6). that all staff receive training in Sefton Council’s Adult Protection Procedures. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 16 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, 26 The quality of this outcome is adequate. This judgement has been made using available evidence including two visits to this service. Residents live in a clean, attractive and comfortable environment but the style of the building and access arrangements could restrict freedom of movement for more dependent residents. Staff on duty lacked understanding of the need to wear protective clothing when cooking. EVIDENCE: From direct observation during two visits to the home it was evident that the environment is homely, comfortable and well maintained. There could be accessibility difficulties for residents of poor mobility as the home has shallow steps at the front and steep steps to the rear garden. The home does not have a passenger lift but there are stair lifts to both upper floors. There are two toilets in the home, one on the ground floor and one on the first floor. A new mechanical bath aid has recently been fitted and there is also a shower Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 17 unit. There are eight single bedrooms and one double bedroom with screening. Four residents commented and said they were pleased with their bedrooms. The manager said bedrooms are decorated and refurbished as they become vacant. Room 4 was visited and has recently been refurbished to a good standard. The dining room has recently been painted with new chairs and carpet provided. All bedrooms are individual in layout and décor and contain residents’ personal possessions. The good levels of hygiene observed are a credit to the care staff who were undertaking domestic and cooking duties in addition to caring for the eight residents. The were good stocks of cleaning materials and the laundry was in good order. A plastic apron, which may be wiped clean, is provided for staff who cook, but this was not being worn at the time of inspection. To prevent the contamination of food and kitchen utensils, a requirement is made under Regulation 13 (3), that the manager ensures that staff who cook wear protective clothing to be worn solely in the kitchen. The manager said that updates in Infection Control Training for staff had been arranged for 06/07/06 and she has a Primary Certificate in Infection Control. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 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, 28, 29, 30 The quality of this outcome is adequate. This judgement has been made using available evidence including two visits to this service. Staff are vetted and receive mandatory training with further training arranged in response to residents’ changing needs, however NVQ targets have not been met. EVIDENCE: Reference was made to staff rosters and the home was maintaining two staff on duty during the day and night for eight residents. The staff roster, which was read, does not give the full names of staff and their designations. The roster for week of the first visit (w.c. 26/7/06), did not give the true names of the staff on duty, as there had been a swap, which had not been altered on the roster. A requirement is made under Regulation 18 Schedule 4 (7) with regards to maintaining a copy of the duty roster of persons working at the care home and a record of whether the roster was actually worked. The manager confirmed that NVQ training has been arranged but staff have not yet achieved the 50 NVQ2 minimum training standard. A recommendation is made that this NVQ training be completed. Further training confirmed by the manager as being arranged or undertaken is as follows :- Infection Control and First Aid 6/7/06, Dementia, Moving and Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 19 Handling, Fire Safety instruction is delivered during staff meetings, A recommendation is made that all staff who cook, receive training in Basic Food Hygiene. The manager provided three staff files, which were satisfactorily maintained as per schedule 2 including Interview Outcomes, 2 References, Criminal Records Clearances, Contracts of Employment. The content of staff files supported the home’s recruitment procedure. Residents who commented said that they considered staff to be of good character and helpful. Staff confirmed that NVQ training has been arranged and mandatory training is ongoing. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 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): 31,33,35,38 The quality of this outcome is adequate. This judgement has been made using available evidence including two visits to this service. There are satisfactory management systems in the home but staff who are designated to carry out health and safety checks are not consistent in the frequency of tests, placing residents, staff and visitors at risk in the event of a fire. EVIDENCE: Mrs. Dunn was on leave during the first inspection and a second visit was arranged for 3rd July 06 when she was due to return to her duties. Mrs. Dunn confirmed that she is now on the care roster and has designated hours for managerial duties. Mrs. Dunn has many years experience in care and management and her qualifications include B.tec, First Diploma in Caring, City and Guilds Trainer and Assessor in the Workplace, NVQ Level 4 Management. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 21 Mrs. Dunn said the home has a quality assurance system and provided a sample of questionnaires completed by residents. She said these are distributed twice yearly and give pictorial prompts to questions and responses. Mrs. Dunn provided the records of personal allowance for personal allowance held in the home and these were satisfactorily maintained. Mrs. Dunn confirmed that this is a long-standing arrangement and the home does not become involved in residents’ savings which are managed by solicitors or family as appropriate. Staff on duty said they receive formal supervision every six weeks and they consider it to be helpful. Mrs. Dunn confirmed that this is the case and produced a book where she keeps records of staff names and the dates of their supervision sessions. Mrs. Dunn said that staff are also supervised by herself on a day to day basis, when carrying out their care, medication, cleaning, and cooking roles. The laundry and food storage areas were visited and were maintained in good order and there are systems for infection control in the laundry. Cooking and fridge temperatures were satisfactory. Submersible water temperatures had been tested weekly but not recorded. A recommendation is made that these temperatures are recorded in future due to risks of scalds to residents. Legionella procedures were in place and satisfactory. The fire book was inspected and where shortfalls were noted, with regards to frequency of fire systems tests and drills, requirements under Regulation 23 (4) (5) are given. Nurse Call and Chair Lift maintenance was in date. The gas certificate was not available and a requirement is made under Regulation 13 (4)(a) that a copy be supplied to CSCI. The five-year electrical certificate was dated 28/07/06. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 22 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 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 2 Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? 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 14.2(b) Requirement Following a review of all care plans the manager must arrange professional assessments for residents who require ongoing mental health support, to ensure that the training, staffing and resources available in the home can fully meet their needs. Requirement outstanding from the last inspection, extended timescale given. Outstanding from last inspect, extended time limit given. The manager must instruct staff that medication must be signed for as it is administered. Requirement outstanding from the two previous inspections, extended timescales given. The manager must not admit a resident whose needs are not within the registered category of the home. The manager must ensure that a review and assessment are arranged for a resident who is subject to restraint by placing a DS0000005370.V295344.R01.S.doc Timescale for action 06/08/06 2. OP9 13 (2) 06/08/06 3. OP4 14 (1) 06/08/06 4. OP4 13 (7) (8) 06/08/06 Annandale Version 5.2 Page 24 5. OP9 13 (2) 6. 7. OP10 OP18 12 (4) (a) (b) 13 (6) 8. 9. OP26 OP27 13 (3) 18 chair behind her when seated in the dining room. The manager must arrange for unused medication to be returned to the pharmacy each month and obtain a receipt. The manager must arrange for respect for residents’ dignity to extend to record keeping. The manager must contact Sefton Council to arrange for training for staff in adult protection procedures. The manager must arrange for staff to wear protective clothing when cooking. The manager must ensure that staff rosters fully reflect the names and hours of staff who have worked the shift. The manager must arrange for fire systems tests to be carried out weekly and fire drills to be carried out six monthly. The manager must ensure that access to the building does not restrict residents’ choice and freedom of movement. The manager must provide CSCI with a copy of the home’s up to date gas certificate. 06/08/06 06/08/06 06/08/06 06/08/06 06/08/06 10. OP38 23 (4) 06/08/06 11. OP14 23 (2) 06/08/06 12. OP38 13 (4) (a) 06/08/06 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 OP33 Good Practice Recommendations The manager should arrange for quality assurance records to be made available to CSCI in her absence. Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 25 2. OP35 The manager should arrange for records of residents’ personal allowances to be available for inspection by CSCI in her absence. The manager should arrange for diabetic diets to be recorded daily and included on the resident’s care plan. The manager should update the home’s brochure to include reference to the Commission for Social Care Inspection in the complaints section. The manager should arrange for staff who cook to undertake Basic Food Hygiene Training. The manager must arrange for submersible water temperatures to be tested and recorded weekly. 3. 4. 5. 6. OP15 OP16 OP27 OP38 Annandale DS0000005370.V295344.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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. 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