Inspection on 06/03/07 for Ascot Lodge Nursing Home

This inspection was carried out on 6th March 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

Ascot Lodge Nursing Home 11/03/08

Ascot Lodge Nursing Home 10/04/06

Ascot Lodge Nursing Home 01/11/05

Ascot Lodge Nursing Home 05/07/05

Ascot Lodge Nursing Home 08/09/04

Ascot Lodge Nursing Home 09/06/04

Ascot Lodge Nursing Home 18/02/04

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

CARE HOMES FOR OLDER PEOPLE Ascot Lodge Nursing Home 48a Newlands Road Intake Sheffield South Yorkshire S12 2FZ Lead Inspector Marina Warwicker Key Unannounced Inspection 6th March 2007 7:30 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 DS0000021765.V312438.R02.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. DS0000021765.V312438.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ascot Lodge Nursing Home Address 48a Newlands Road Intake Sheffield South Yorkshire S12 2FZ 0114 264 3887 0114 264 3969 none www.schealthcare.co.uk Southern Cross Healthcare Services Limited 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) ** Post Vacant *** Care Home 50 Category(ies) of Dementia - over 65 years of age (50) registration, with number of places DS0000021765.V312438.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care Home with Nursing Dementia over 60 years. Date of last inspection 24th May 2006 Brief Description of the Service: Ascot Lodge is a purpose built fifty-bedded home providing service for older people with dementia. The home is situated in the Intake area of Sheffield. It has good access to public services and amenities. The accommodation is on two floors and each floor is divided into two units. Most rooms at the home are single rooms with en-suite facilities. There is a car park. The weekly fees for the service users were between £418.00 and £552.00. The administrator explained that the fees were charged according to the dependency levels of the individuals and also according to source of funding. The service users buy their own toiletries and pay for hairdressing and chiropody with their pocket money. DS0000021765.V312438.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection of Ascot Lodge care home was carried out on 6th March 2007 between 7:30 am and 3.00 pm. Time was spent observing the delivery of care and the daily routines of the residents. Five staff were interviewed and further three staff were spoken with. Relatives and visitors were consulted with regards to the home. We (Commission for Social Care Inspection) sent out surveys to 20 relatives, 17 staff and 7 professionals who visit the home. Their comments are included in the report. During the day of the site visit service user plans, medication records, complaint records, staff files and other relevant records were checked and comments from the surveys were shared with the manager. The outcomes from the surveys are included in the body of the report. The inspector wishes to thank the service users, relatives, staff and the management for their co-operation and contribution throughout the inspection process. What the service does well: What has improved since the last inspection? The staff recruitment records have improved. The staff have received mandatory training and the staff commented how they have been helped by the training. The home security system has improved and there is lighting outside the entrance of the home at night. DS0000021765.V312438.R02.S.doc Version 5.2 Page 6 What they could do better: The service user plans must be reviewed and the daily documentation must reflect the actual care given. The manager must check the accuracy of the information. The staff on the units must be aware of those service users who use hearing aids, spectacles and any other aids. They must ensure that the service users are encouraged to use the aids. Records must be maintained to monitor the care plan progress (e.g. food charts, what types of pads to be used) made. The activities must be varied and flexible. They must suit the residents’ expectations, preferences and capabilities. Sufficient staff need to be on duty to allow residents to enjoy leisure activities of their choice The meal times must be unhurried and staff must be available to offer assistance when necessary. The staff must monitor when service users decline to eat or leave meals and take appropriate action to supplement the diet. The service users must have access to drinks and snacks through out the day. The manager must investigate any complaints made under the complaints policy and inform the complainant of the outcome within the stated time. All complaints must be recorded. All parts of the home must be sufficiently heated and the service users must be comfortable. The management of incontinence needs to be reviewed so the home remains free of offensive odour The management approach to Ascot Lodge must help create an open, positive and inclusive atmosphere, so that the relatives, visitors and staff are able to discuss their concerns and share their views of the service. The quality monitoring process must include seeking feedback from staff of the homes’ performance. The staff meetings need to be used as two way discussion rather than yet another form of cascading instructions. The management need to listen to staff, give support, supervision and monitor the quality of the actual care provided to each service user. Regular meetings need to be held to improve communication between the relatives, staff and the management. DS0000021765.V312438.R02.S.doc Version 5.2 Page 7 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. DS0000021765.V312438.R02.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 DS0000021765.V312438.R02.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, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management updates the statement of purpose and the service user guide so that the information with regards to the aims, objectives and the facilities of the service are available for those who are looking for a suitable service. All service users are provided with a statement of terms and conditions explaining the fee, their rights and obligations so that both service users and the provider have clear understanding of the contractual agreement. Most service users have their needs assessed by the placing authority and the management of the home agree to meet those identified needs. This process is to demonstrate that the home is able to meet the specific needs of the individuals. There are opportunities for trial visits for service users so that the service users, their relatives and the staff at the home are able to assess the suitability of the placement. DS0000021765.V312438.R02.S.doc Version 5.2 Page 10 EVIDENCE: Four care plans were checked and five staff were interviewed with regards to this outcome area. The comments from the surveys and interviews from the relatives were also taken into account. The manager said that they had updated the statement of purpose and the service user guide. However, these documents were not readily available for the relatives and the visitors. The surveys revealed that relatives were not aware of the written information, which was available at the home. They commented that when they had visited the home the staff explained to them the running of the home and showed them around the place. Not all service user plans had copies of the needs assessments. The deputy manager said that in some cases this information was filed away. Both relatives and staff said that trial visits were possible. Four service user files were randomly selected to check whether they have been offered a contract. All four had contracts, three were agreed by the social services and one was a self funding service user and there was evidence that the free nursing care contribution had been passed on to the family. The home does not provide Intermediate care. DS0000021765.V312438.R02.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, 10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service user plans are generated from the needs assessment so that the care delivered is appropriate and based on the individual assessments. However not all plans were accurate. The management of the home and the supplying pharmacist ensure that the staff keep records of all medicines and handle medication appropriately in accordance with the legal requirements so that service users are correctly given or helped to take medication. Some organisational practices did not respect the privacy and dignity of the service users. This is explained fully in the section below. The end of life care is given to service users with respect whilst maintaining the persons’ comfort throughout. DS0000021765.V312438.R02.S.doc Version 5.2 Page 12 EVIDENCE: The evidence for this outcome area was collated from direct observation on the day of the site visit, staff interviews, conversations with the relatives and other visitors to the home and also from the feedback from the surveys. It was concluded that although the service user plans were comprehensive; it was too lengthy for relatives to show interest. The care staff said that they needed extra time to absorb the contents of each care file. Discussion took place between the management and the inspector with regards to moving towards user-friendly documentation of care so that the relatives are able to understand without staff having to go through the files. A service user plan indicated that the service user was given a bath when the bath water temperature was 370C. The recommended temperature for the bath water is between (40-43) 0C. According to another care plan a service user has been in the home for two months and has had one bath. These were some of the issues noted during case tracking and the management were made aware of these. It was not customary to encourage the service users’ capacity for self-care. Comments were made that the care staff did not have adequate time to allow service users to help themselves and give ample supervision. The staff and the relatives said that there were enough aids and equipment for the moving and handling of service users. Some service user rooms emitted bad odour due to incontinence. This was accepted by the staff as the consequence of someone being incontinent. Appropriate care and management of the service users who have problems with continence will remove such unpleasant odour. Relatives made comments that the staff did not inform them when hospital appointment had been made and rarely had they been informed of the results of hospital appointment or when the general practitioner had seen them. There is a continuing problem with service users losing their hearing aids, spectacles and dentures. The relatives were disappointed by the lack of progress made in finding these or replacing them. This was passed on to the manager. The nurses administered medications to the service users since the service users were unable to self medicate. The receipt, administration and disposal of medication were checked and it was satisfactory on the day of the site visit. The staff interacted with the service users in a caring and warm manner. DS0000021765.V312438.R02.S.doc Version 5.2 Page 13 There have been problems with service users being dressed in clothing, which did not belong to them. There were clothes found in service users drawers, which did not belong to them, this was witnessed on the site visit. One relative’s comment was “On occasions they seem to have been dressed for some comedy show”. Agency staff were brought in to cover the day shift. They were not given adequate handover; therefore they were working in areas where they were not introduced to the service users and did not know the names of the service users and their likes or dislike. This action did not contribute to or promote the dignity of service users. Staff interviewed said that most of them have had experience with looking after people who were dying. They said, “All care will be given and I will make sure the person is not in pain”, “Stay with them or check on them every half hour if busy. Look after the relatives so that they can stay with the person who is dying”, “I haven’t had any experience but I will look after them as I would like to be cared for”. DS0000021765.V312438.R02.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. The routines of daily living and activities are not flexible and varied therefore they do not suit the expectations, preferences and capacity of the service users. Visitors are able to come into the home at reasonable times so that the service users are able to maintain contacts. The service users are offered three meals a day and snacks in the afternoon. The lack of staff availability during meal times hinders service users getting help and encouragement. EVIDENCE: On the care plans the service users’ interests were recorded but the staff who were looking after the service users did not know this information and therefore the service users were not given opportunities for stimulation through leisure and recreational activities in and outside the home. DS0000021765.V312438.R02.S.doc Version 5.2 Page 15 The staff were not organised to encourage the service users to join in their daily activities of life since this takes time and therefore requires an adequate number of staff on duty. For example: supervise washing and dressing, help to do a simple puzzle, help fold their clothes, pair socks, tidy their room, go for a short walk, go to the shops, go outside the building to have some fresh air, etc. Comments received from the surveys were “The same ones benefited by the organised activities but the others sat doing nothing all day and they looked bored.” “Why can’t staff take the old people for a walk around the neighbourhood?” “Although my mother will not join in activities, she likes people chatting to her and watching others doing activities.” “Staff are too busy to do activities with residents. They need more of them”. The relatives said that staff always made them welcome and offered them a cup of tea. Some rooms had personal possessions of service users. This made the room look homely. It was noted during direct observation that service users in one of the lounges at around 8:30 am were shouting for water. On questioning the staff it was ascertained that when the morning staff came on duty, service users were only given a drink if they asked and the others were given a drink at breakfast which was around 9.00 am. There was no provision for drinks in the lounge. The manager was surprised at this and said that the night staff gave out hot drinks before they went off duty. The service users were given a drink of water immediately by the staff. During breakfast there were staff shortages and this left a unit of 9 residents with one carer and another with one carer and a nurse for 15 residents. The service users during this mealtime did not get sufficient assistance. At mid-morning the service users were offered a hot drink and not any snacks. When questioned the staff said that if they have a snack then they would not have lunch. The staff were informed that this was unacceptable so they offered biscuits. All service users helped themselves to one or more biscuits. The snacks and drinks were not readily available for the residents. At least one staff is expected to be around to supervise the service users in each of the communal areas. Therefore it would be good practice to have snacks and drinks available for service users in these areas under the supervision of staff. DS0000021765.V312438.R02.S.doc Version 5.2 Page 16 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, 17 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents, relatives and visitors have access to a complaints procedure so that they are able to raise their concerns with the manager of the home and if not happy they are aware of the steps to take to resolve their concerns. However further work is required to make sure residents and relatives are satisfied that their complaint has been taken seriously The home has policies and procedures for the staff to follow and ensure that the legal rights of the service users are protected at all times. There are systems in place to safeguard the service users from abuse, neglect, discrimination and inhumane treatment. EVIDENCE: The surveys and interviews confirmed that not all complainants were confident that their concerns were taken seriously and action had been taken. One said, “Have discussed my concerns with the management at the home and as yet to seen little changes”, another said, “I have complained to the management that Personal belongings of my father has gone missing. Such as belt, socks, shirts and slippers. Nothing has been done about it.” DS0000021765.V312438.R02.S.doc Version 5.2 Page 17 Feedback from the surveys highlighted that some of the service users were losing weight and that there wasn’t enough staff to help the residents at meal times. They have mentioned that the manager was made aware of this but no progress has been made. This was noticed on the site visit and both Operations manager and the home manager were made aware of this. Staff knew the procedure to follow when a complaint is made and the need for the home to keep a record. There was a record kept of the complaints received and the action taken by the home. However, not all concerns and complaints raised by the relatives had been recorded in the book. The relatives said if they need to get help from an advocacy service the staff were helpful in facilitating it. Four staff training files were checked and the staff on duty were consulted. The staff had received formal training on protecting vulnerable adults and reporting of incidents. DS0000021765.V312438.R02.S.doc Version 5.2 Page 18 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, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and the layout of the home are suitable for it’s stated purpose. Generally the premises are kept clean and free from offensive odours. There are systems in place to control the spread of infection. EVIDENCE: The grounds were kept tidy. The entrance foyer and some bedrooms emitted unpleasant odour on the day of the site visit. The relatives’ comments too confirmed this. However, the large part of the home was pleasant and tidy. Residents used the communal areas well. DS0000021765.V312438.R02.S.doc Version 5.2 Page 19 Bedrooms were individually and naturally ventilated. Rooms were centrally heated. However parts of the home were cold and some service users commented on this. This was passed on to the staff on the particular unit. Two relatives made comments about parts of the home being too cold during wintertime. Staff said that they had received training on infection control and they were able to comment on the policy on infection control. DS0000021765.V312438.R02.S.doc Version 5.2 Page 20 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 30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staffing numbers are not always sufficient to meet the social needs of the service users. Excessive hours worked by staff may compromise the health and safety of both staff and residents. The care staff are encouraged to complete NVQ level 2 on care so that residents receive a good standard of care. Recruitment procedures are based on equal opportunities, diversity and protection of service users and the others working at the home. Staff receive training and development so that the home is able to fulfil its aims and objectives. EVIDENCE: On the day of the site visit there were two care staff short according to the rota on the morning shift. Out of the two, one staff had not turned up for the shift. However, the management had left the home short of a carer for that morning shift. The staff confirmed that this was a regular occurrence and the DS0000021765.V312438.R02.S.doc Version 5.2 Page 21 surveys too echoed the lack of staff rostered to be on duty. The surveys highlighted that the regular staff were tired of working extra shifts since the management were reluctant to use agency staff. Some staff commented that they appreciate that for the continuity of care it was better for them to fill in the staff gaps. But the staff also remarked since they had not taken their annual leave and the month of March is the year end the staff were either on holiday or off sick with exhaustion. The management were aware of this. Four staff files were checked with regards to recruitment and selection. All four files were up to date and had the necessary information. Staff said that they have received a variety of training and on occasions the trainers had come on to the night shift to give them training. DS0000021765.V312438.R02.S.doc Version 5.2 Page 22 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): 32, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The present manager has been in post since late November 2006. Quality monitoring and quality assurance systems are in place. However improvement is still needed to ensure residents and relatives views are listened to and valued. A responsible individual carries out monthly visits. The information gathered needs to be more comprehensive to aid the measurement of the success of the home in meeting its aims and objectives. Staff receive regular supervisions. There are policies and procedures to ensure that the service users’ and the staffs’ health, safety and welfare are protected. DS0000021765.V312438.R02.S.doc Version 5.2 Page 23 EVIDENCE: The manager is a registered nurse who has worked as a deputy manager in her previous employment. She is to complete the Registered manager’s award this year. The manager is to apply for registration with the Commission for Social Care Inspection. Although there was documentary evidence of quality monitoring at the home, the views of families and friends of service users were as follows. “The same few attend the relatives meetings it is boring.” “What is the point, for the past 15 months the management have not settled. There have been 5 managers and each of them promise to do things and then leave. We are not kept informed by Southern Cross as to why so many changes and what is happening. “We don’t get to know about the relatives meetings in time and I sense that the meetings are not productive.” “When I have asked the manager about poor attendance she tells me that she has one to one” Staff feedback indicated that the staff meetings were used to criticise them and as “Lecturing sessions”. “Often we are told to ‘put up and shut up’ and the answer to our questions is often this is a business.” The monthly provider monitoring records were not informative and discussion took place with the operations manager to improve this. The administrator of the home had written records and receipts of transactions of service users’ money. There was a secure facility for the safe keeping of money. The staff interviewed said that they received regular supervision from their seniors. There were records to demonstrate that staff received regular supervision. The management ensured a safe working environment by training the staff and supervising them. Clarification was offered as to why the Commission for Social Care Inspection needs to be informed of the death of residents in hospital or outside the home i.e. Regulation 37 and Schedule 3. DS0000021765.V312438.R02.S.doc Version 5.2 Page 24 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 X X X X X 2 2 STAFFING Standard No Score 27 1 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 2 X 3 3 X 3 DS0000021765.V312438.R02.S.doc Version 5.2 Page 25 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 OP7 Regulation 14 Requirement Timescale for action 27/04/07 2 OP8 13,12 3 OP8 14,13 The service user plans must be reviewed and the daily documentation must reflect the actual care given. The manager must check the accuracy of the information. The staff on the units must be 27/04/07 aware of those service users who use hearing aids, spectacles and any other aids. They must ensure that the service users are encouraged to use the aids. Previous timescale of 25/07/06 not met. There must be clear instructions 27/04/07 for identified needs. Records must be maintained to monitor the care progress (e.g. food charts, what types of pads to be used) made. The activities must be varied and flexible. They must suit the residents’ expectations, preferences and capabilities. There must be records of activities and the involvement of each resident. Previous timescale of 15/12/05, DS0000021765.V312438.R02.S.doc 4 OP12 14,16 27/04/07 Version 5.2 Page 26 5 OP15 12 6 OP15 16 7 OP16 22, 8 OP25 23 9 OP26 13,16 25/07/06 not met. The meal times must be unhurried and staff must be available to offer assistance when necessary. The staff must monitor when service users decline to eat or leave meals and take appropriate action to supplement the diet. Previous requirement not met 25/07/06, Immediate 06/03/07 and the home must comply from then onwards. The service users must have access to drinks and snacks through out the day. Immediate 06/03/07 and the home must comply from then onwards. The manager must investigate any complaints made under the complaints procedure and inform the complainant of the outcome within the stated time. All complaints must be recorded. All parts of the home must be sufficiently heated and the staff must ensure that the service users are comfortable. Immediate 06/03/07 and the home must comply from then onwards. Management of continence needs to be reviewed to ensure the home remains free of offensive odour. 06/03/07 06/03/07 27/04/07 06/03/07 27/04/07 10 11 12 OP27 OP32 18 10,12 24,26 OP33 Sufficient staff must be on duty 06/03/07 in order to meet the social needs of the residents The management approach must 27/04/07 help create an open, positive and inclusive atmosphere. The quality monitoring must 27/04/07 include feedback from staff of the performance of the home. DS0000021765.V312438.R02.S.doc Version 5.2 Page 27 Previous requirement not met 25/07/06. 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 OP8 Good Practice Recommendations The relatives /representatives of service users should be kept informed of the outcome of general practitioner visits and the hospital appointments. The information shared should comply with the Data Protection act. DS0000021765.V312438.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000021765.V312438.R02.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!