Inspection on 02/03/06 for Archmoor Care Home

This inspection was carried out on 2nd March 2006.

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

Archmoor Care Home 08/07/09

Archmoor Care Home 03/11/08

Archmoor Care Home 13/11/07

Archmoor Care Home 30/08/06

Archmoor Care Home 20/09/05

Archmoor Care Home 01/03/05

Archmoor Care Home 22/06/04

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 Archmoor Care Home Archmoor Care Home 116 Sandy Lane Middleton Manchester Greater Manchester M24 2FU Lead Inspector Diane Gaunt Unannounced Inspection 2nd March 2006 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 Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 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. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Archmoor Care Home Address Archmoor Care Home 116 Sandy Lane Middleton Manchester Greater Manchester M24 2FU 0161 653 2454 0161 653 6698 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) www.archmoorcare.co.uk Mrs Margaret Elizabeth Pilkington Mr Andrew Pilkington Mrs Margaret Elizabeth Pilkington Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number 20, there can be up to : 20 Older People (OP) The service should at all times employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 20th September 2005 Date of last inspection Brief Description of the Service: Archmoor provides personal care and accommodation for up to 20 older persons aged 65 years plus. Staff at the home do not provide nursing care. Archmoor is purpose built and accommodation is provided on two floors in 16 single and 2 double bedrooms. 7 bedrooms have the added provision of an ensuite toilet. A passenger lift services both floors. A lounge, dining area and conservatory are provided on the ground floor. A pleasant and attractive garden/patio area can be easily accessed from the rear of the home. Archmoor is situated approximately 3 miles from Middleton town centre. A regular bus service to the town centre can be accessed within several minutes walking distance of the home. A small car park is available to the front of the home, and on street parking is also available. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A regulatory inspector and a pharmacist inspector visited the home. The home had not been told beforehand that the inspectors would visit. The pharmacy inspector spent 3 hours at the home inspecting arrangements for medication. The regulatory inspector spent 9 hours at the home looking at the building and paperwork about the running of the home and the care given. In order to find out more about the home the inspector spoke with five residents, two senior carers, two care assistants, two relatives, a social worker, a chiropodist, the deputy manager and the owner/manager. Nine requirements listed at the end of the report had not been fully met since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Although residents and relatives said they were happy with the care provided, information about the care needed was not always written, updated and shared with staff. The same applied to assessments of risk for each resident. The last Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 6 inspection required that these assessments and plans were written and updated with every resident and/or their relative. This had not been done. Staff must keep a written record of all medicines, tablets etc delivered to the home and write an assessment for each resident who manages their own inhalers, medicines, tablets and creams etc. They must also write down the assessed and agreed arrangements for residents taking medicines and tablets out of the home. The home had also been required to provide more training for staff but little progress had been made. Of particular importance is health and safety training, but introductory and basic training as well as training in protection of residents must also be provided. The manager or deputy must advise staff about their daily work, and meet with them to discuss their work both on their own and in a group. Activities which residents enjoy must be introduced so they are not bored during the day. The manager or deputy must make sure that the activities happen. Whilst residents said they enjoyed the food served, menus were unplanned and a record was not kept of all food served. Menus must be planned and a record kept to make sure that a variety of healthy food is provided. Staff who cook meals must go on a Food Hygiene course. 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. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Residents’ health and personal care needs were being met in the main, but this was not always reflected in documentation, which could result in staff being inconsistent in their approach. Health care needs were not always appropriately monitored. Systems were in place to facilitate the safe administration of medicines by trained carers but details of how selfadministration should be supported were not recorded. EVIDENCE: Since the last inspection the home had purchased a computerised care planning pack but initial operational problems were being experienced. Inspection of four existing resident files showed that requirements made for improvement of the plans had not made. Of the files inspected, two relating to residents who had lived at the home for approximately 2 and 6 months, did not have care plans in place. This could result in residents not being cared for consistently and in the way the residents wanted. Of the other two files inspected, one care plan had not been reviewed since 27 August 2005 and the other since 16 January 2006. Likewise, risk assessments were not in place or were in need of review. No progress had been made with regard to care plans being written and reviewed in conjunction with residents and relatives. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 10 Residents interviewed said staff responded quickly to call bells and provided the care they needed. One relative interviewed said they were informed of important issues pertaining to residents’ health, another said they had not been contacted on one occasion. Feedback from relative questionnaires circulated by the home indicated their satisfaction with care provided, one person commented they ‘couldn’t ask for better’ and another said they were completely satisfied. Likewise residents interviewed made positive comment about the care which one person said they were ‘very happy’ with. However, one resident said they hadn’t received a weekly bath and this person was observed to be in need of nail care. Records inspected supported the residents statement regarding bathing, although staff said that residents were generally bathed at least once a week. Care plans recorded GP, District Nurse and other professional healthcare involvement. In the main, healthcare professionals were called as and when needed, although one resident had waited a number of weeks before seeing a chiropodist. Pressure relieving equipment was available if necessary, none of the residents had pressure sores at the time of the inspection. Continence needs were appropriately assessed and addressed. Residents said the home called their GP when they needed them and the services of opticians, dentists, chiropodist and audiologist were accessed either at the home or in the community as and when necessary. Policy at the home was to weigh residents when they had their weekly bath. Inspection of records showed that this was not always achieved and in respect of one resident with dietary problems no other monitoring was in place either. Inspection of records showed that food and fluid charts had been introduced in respect of two other residents, resulting in positive outcomes. When completing these charts, staff should be mindful to record amounts of fluid consumed throughout the day. Residents were offered the opportunity for regular exercise in the form of occasional dancing and a monthly visit by a physiotherapist. Staff could develop these sessions further when devising an activities programme. Psychological health was monitored and a care manager commented that the support staff had given the client she visited had been effective. Medication policies and procedures were available within the home but a homely remedies procedure had not been implemented. Two residents were supported to self-administer some medication (inhalers and eye drops) but written assessment had not been completed. Additionally, the supply of leave medication was not recorded. Trained carers administered all other medication. Records of medication administration were generally up-to-date, but when nutritional supplements were given this was not always recorded. The medication audit trail was incomplete because receipt entries were not made for medicines supplied in the monitored dosage system. A signature list was Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 11 not maintained for staff authorised to handle medication. The medication storage was secure and orderly. However, some eye drops were dated on receipt rather than on first opening. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Provision of social activities and integration into community life did not fully satisfy each resident’s social and recreational interests. Visiting arrangements at the home were informal and family and friends were encouraged to maintain contact promoting personal relationships. Menus would benefit from review to increase the number of nutritious, balanced meals and provide residents with more variety. EVIDENCE: Inspection of records, observation and discussion with residents, relative and staff identified the need for an increase in activities at the home. Residents spoke very positively of a monthly musical afternoon provided by outside entertainers. In addition to this, a physiotherapist visited monthly to offer exercise based activities, staff occasionally held reminiscence sessions with small groups of residents, and provided 1 : 1 chats, manicures and nail care. One person said they had enjoyed being taken to the shops in a wheelchair recently, two said they were happy to make their own entertainment. The manager said that when visits to the local garden centre had been arranged, residents changed their minds at the last minute as to whether they wished to go or not. She further said that there was an expectation that staff would undertake some activity with residents each day, whether on a group or 1 : 1 basis. All the feedback indicated this had not occurred. One resident said they were bored during the day, comment was also made that provision of more activities would occupy some residents who wandered around the home during Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 13 the day. Feedback from two relatives questionnaires indicated they were not entirely satisfied with arrangements for activities/stimulation. An activities programme must be provided, along with a record of activities which have taken place and who participated in them. The programme must meet the needs of groups and individuals with a range of interests and abilities. Some but not all care plans inspected recorded some of the residents’ past interests but recorded information had not always been used to introduce appropriate activities. Religious services were not held at the home, although representatives of one Christian faith visited residents regularly to serve communion and offer prayers. A resident who had lived at the home for 2 months had not received this service. The deputy agreed to address the matter when it was raised during the inspection. On the day of the inspection relatives and friends visited freely and were seen to be made welcome. Those spoken with said they were always received well and made to feel at home. One satisfaction questionnaire returned by a relative said that staff were always polite and friendly when they visited and another considered interaction between staff, residents and visitors was excellent. Residents went out with relatives as and when they wished and staff assisted them in preparing for these trips. The choices residents made each day varied, dependent upon their mental frailty but residents who were able generally chose what time to get up, go to bed, what clothes to wear, what to eat, where to spend their day and whether or not to participate in activities. There was evidence of each of these choices being made on the day of inspection. None of the residents managed their own money, having passed the responsibility to relatives. All those spoken with were happy with the arrangements in place. Planned menus were not provided. The cooks ordered food on a weekly basis and decided each evening what they would cook the next day. Records kept of food provided and residents daily choices were not always completed or clearly dated, it was therefore not possible to fully monitor the nutritional balance and variety of meals. However, it was noted that during the month prior to the inspection corned beef hash had been provided three times on one week and twice a week on two other occasions; sausages were regularly served 2 or 3 times a week also. One resident made adverse comment about this provision. Residents were generally offered a choice of hot meals at lunchtime but only one choice was offered at teatime. There was some recorded evidence that sandwiches or another simple alternative would be provided if residents did not want the planned meal. Observation and discussion with one resident provided further evidence of this practice. Discussion with another resident confirmed Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 14 that the cook introduced favourite meals onto the menu if residents requested them. Food served during the inspection was sampled, it looked, smelt and tasted appetising. Suitable provision was made for those needing special diets i.e. diabetic and soft diets. One resident with cultural dietary needs was catered for with the support and advice of her family. Staff gave appropriate assistance to those needing it. Supplementary drinks were provided for those in need of them and their use had proved to be effective. Monitoring of food intake is commented upon in the section on health and personal care above. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 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): None of these standards were assessed on this occasion. EVIDENCE: Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 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 and 26 A safe, clean, pleasant, hygienic and well-maintained building was provided for residents. EVIDENCE: A tour of the building confirmed that the home was safe, well maintained, and clean. Level access was provided along with a passenger lift and handrails in corridors. Everyone spoken with thought the home was a safe place to live and work in. Residents, relatives and the chiropodist spoke positively about the cleanliness, one resident described the home as ‘spotlessly clean’ and a relative returning a satisfaction questionnaire commented that the home was a ‘delight to visit’. Since the present owners purchased the home in 2003 an ongoing, planned maintenance and renewal programme had operated, ensuring the home was kept in good decorative order and furnishings and fittings were renewed as necessary. Since the last inspection new doors had been provided to all bedrooms and plans were in place to replace all doors to communal areas. Lounge chairs and commodes were also to be replaced. Staff and residents Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 17 said that if anything was in need of repair it was addressed quickly as a maintenance worker attended the home on two days each week. Grounds were seen to be safe, tidy and accessible. Residents said they looked forward to sitting outside in the good weather. The Environmental Health Department had undertaken a food inspection in October 2005. Requirements and recommendation had been met. Greater Manchester Fire Officers had not visited since the last inspection as the home is on a 4 yearly inspection programme. Residents spoken with were pleased with their individual rooms and there was evidence they had brought in a number of personal possessions to make them feel more homely. All bedrooms were fitted with door locks and lockable storage space to ensure resident’s valuables were kept safe. Staff have a master key, which could be used to gain access in an emergency. Keys were not given to residents however and four people interviewed expressed a wish to have a key. An infection control policy was in place and staff spoken with described safe infection control practice. Any malodour in the home was confined to two individual bedrooms, the inspector was informed carpets in these rooms were shampooed on a regular basis. Disposable gloves and aprons were provided for staff use when assisting with personal care and cloth tabards were used to cover uniforms when staff were serving food. Liquid soap and paper towels were provided in communal areas. Although this was not available in bedrooms where staff were assisting with personal care, the inspector was informed staff carried an alcohol based cleaning gel in their pockets for use at these times. Satisfactory practice was in place with regard to disposal of clinical waste. The laundry was sited away from the food preparation area and was seen to be clean and orderly. Sufficient and suitable equipment was provided and laundry was attended to efficiently. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 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): 28 and 30 Staff had basic training but needed additional input to ensure their competence. EVIDENCE: Of four senior carers and seven care assistants, two seniors and two carers had an NVQ level 2 and three carers were on the course at the time of the inspection. When these three carers complete their courses the home will have achieved 50 trained care staff. One senior carer also had a certificate in care practices and was planning to begin an NVQ level 3 course. New staff received induction to the NTO specification, either by attendance on a Learn Direct one day course or by use of induction workbooks. This was not always achieved within the first 6 weeks of employment however. New staff also shadowed experienced staff until deemed competent to work alone. For those staff not undertaking NVQ training, NTO specification foundation training was not provided and basic health and safety training not achieved for all staff i.e. health and safety, moving and handling, 1st Aid, infection control, food hygiene and fire safety. Whilst NVQ training addresses each of the required health and safety areas, one staff member had taken the course some years previously and had not attended refresher training. Records showed that five care staff had not attended moving and handling training and four were due for refresher training. One untrained carer was observed using a drag lift during the inspection. The manager is a nurse and she and the deputy had watched a DVD on 1st Aid training. One of the cooks had attended a 1st Aid course, but no other staff held a 1st Aid certificate. At least one staff per shift must have 1st Aid training. Ten care staff and one cook were in need of food hygiene Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 19 training. Likewise, the majority of staff had not undertaken infection control or health and safety training. The home did provide training related to the needs of older people and the majority of staff had attended training in dental and optical care. All those administering medication had attended accredited training. A range of DVD’s and questionnaires evaluated by the manager and deputy were available at the home and since the last inspection staff had begun to use them. They covered a range of areas including dementia care, death and dying, abuse, and risk assessment as well as health and safety issues. Limited progress was seen in relation to training for staff in Protection of Vulnerable Adults, some staff interviewed were not familiar with the term ‘whistleblowing’ although they said they would report concerns if another staff member was abusive to residents. Not all staff had achieved 3 paid days training within the last 12 months. Residents and relatives were complimentary about the staff, describing them as ‘very nice’, ‘marvellous’, ‘very helpful and pleasant’. One resident commented on the fact that they were ‘visible’ and there if they were needed. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 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, and 35. Whilst the home operated adequately, the service would benefit from an increase in management monitoring, review and staff supervision. The home occasionally reviewed aspects of its performance through formal consultation, but the process was not thorough, nor based on seeking residents’ views. Residents’ financial interests were safeguarded. EVIDENCE: The registered manager is also one of the registered provider’s of the home. She holds a nursing qualification and has many years experience working in the NHS and private care homes. The manager attended the Registered Manager’s Award (RMA) course in 2004 but completion of the course was said to be frustrated by poor course coordination. At the time of the inspection the deputy was looking for a suitable NVQ Care level 4 and RMA course on which to enrol. Application would then be made for her to be registered as manager. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 21 Both the manager and deputy undertook care related training which recently had been on an in-house basis. Residents, relatives and staff said the manager was accessible on a daily basis and would listen and address matters raised. The home had the Investors in People Award which had been renewed in November 2004, but an effective quality assurance and monitoring system was not in place. Formal systems with regard to quality assurance were limited to annual circulation of resident and relative questionnaires and occasional staff meetings. Feedback from seven recently returned relative questionnaires was positive with regard to care provided, with only activity provision not being listed as excellent. Resident questionnaires were due to be circulated. Systems such as resident/relative involvement in writing and reviewing care plans; regular staff supervision; and residents’ meetings were not operational at the home however. Action to implement requirements identified in CSCI reports was not taken within agreed timescales. The home did not act as appointee for any residents although they managed personal monies handed to them by relatives for residents’ use. Records in relation to two residents were inspected and were seen to be in order. Incomings, outgoings and running totals were clearly recorded and receipts held. Residents’ monies were held separately and securely. There was evidence that the manager and deputy were taking action to safeguard management of two residents’ monies and had actively sought advocacy on their behalf. Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X X Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 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 OP7 Regulation 15 Requirement Accurate care plans must be written and reviewed with all residents and/or their representatives and include needs, aims and required action. (Previous timescale of 31/10/05 not met) Appropriate risk assessments must be completed in respect of all residents, agreed with residents and/or their representatives and regularly reviewed. (Previous timescale of 30/11/05 not met) Risk assessments, regular weighing and food/fluid intake must be regularly monitored in respect of residents with dietary problems. All medication records including those for: • Receipts • Self-administration and administration • Supply of leave medication must be complete, clear, DS0000042848.V269796.R01.S.doc Timescale for action 30/04/06 2 OP8 12 30/04/06 3 OP8 12 30/04/06 4. OP9 13 10/04/06 Archmoor Care Home Version 5.1 Page 24 accurate and up-to-date. 5 OP12 16 A programme of suitable activities must be agreed with residents to ensure each person’s social, cultural, and rectreational needs are met. Once introduced, the manager must monitor and review to ensure suitable activities are ongoing. A record of all belongings brought into the home by a resident, including furniture must be kept. (Previous timescale of 15/04/05 not met) Menus providing a choice of nutritious, balanced and varied food must be provided and maintained. Staff must receive training in the Protection of Vulnerable Adults (Previous timescale of 31/12/05 not met) and be introduced to the ‘whistleblowing’ policy as part of their induction. A recent photograph of each staff member must be held on file. (Previous timescale of 31/10/05 not met) Care staff must receive NTO specification induction and foundation training within 6 weeks and 6 months of employment respectively. (Previous timescale of 31/12/05 not met) Care staff must be appropriately supervised. (Previous timescale of 30/11/05 not met) 31/05/06 6 OP14 17 30/04/06 7 OP15 17 30/04/06 8 OP18 18 30/06/06 9 OP29 17 30/04/06 10 OP30 18 31/05/06 11 OP36 18 31/05/06 Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 25 12 OP38 18 Staff must receive training in all aspects of health and safety, including moving and handling, food hygiene, infection control, and first aid. (Previous timescale of 30/04/05 not met) Competence, particularly with regard to moving and handling, must be monitored following training. All staff must attend a fire lecture and fire practice every 12 months. (Previous timescale of 31/12/05 not met) All staff who cook at the home must complete recognised food hygiene training. 31/05/06 13 OP38 23 31/05/06 14 OP38 18 30/04/06 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 OP3 Good Practice Recommendations Prospective residents should be assessed by staff prior to admission, and the assessment recorded and agreed by the potential resident and/or their representative. The manager and deputy should work with care staff to complete accurate care plans and reviews, and introduce a monitoring system to ensure they are maintained to a satisfactory standard. Staff should be more pro-active in keeping relatives informed of progress with regard to health issues. The manager or deputy should monitor to ensure residents have at least one bath per week and their nails kept clean. Handwritten MAR entries should be signed and DS0000042848.V269796.R01.S.doc Version 5.1 Page 26 2. OP7 3. 4 5 OP8 OP8 OP9 Archmoor Care Home countersigned. 6 7 8 9 OP9 OP9 OP9 A signature list for staff authorised to handle medication should be maintained. Eye drops should be dated on first opening. Consideration should be given to the implementation of homely remedies policies and procedures. Staff meetings for all staff should be held more regularly. OP36 Archmoor Care Home DS0000042848.V269796.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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