Inspection on 24/04/07 for Ashcroft Rest Home

This inspection was carried out on 24th April 2007.

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

Ashcroft Rest Home 29/05/08

Ashcroft Rest Home 01/11/07

Ashcroft Rest Home 24/11/06

Ashcroft Rest Home 28/06/06

Ashcroft Rest Home 23/02/06

Ashcroft Rest Home 12/04/05

Ashcroft Rest Home 07/12/04

Ashcroft Rest Home 02/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ashcroft Rest Home 27-29 Chadwick Road Leytonstone London E11 1NE Lead Inspector Rob Cole Key Unannounced Inspection 24th April 2007 10:00 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 DS0000007230.V337099.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. DS0000007230.V337099.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft Rest Home Address 27-29 Chadwick Road Leytonstone London E11 1NE 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) 020 8530 6072 F/P 020 8530 6072 Ms Hyacinth Valeska Sandilands Mrs Neva Bernice Gilpin Ms Hyacinth Valeska Sandilands Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places DS0000007230.V337099.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2006 Brief Description of the Service: Ashcroft Rest Home is a care home providing personal care, support and accommodation to up to 15 older people. The home, which is privately owned and operated, is located in a residential area of Leytonstone in East London. There is easy access to local shops and other amenities. The property is two storey with bedrooms situated on both the ground and first floor. There are two double rooms with the remainder for single occupancy. Some bedrooms have a small en-suite providing toilet and hand washing facilities. There is a stair lift available on one set of stairs with a separate staircase for those who are more mobile. Because of the configuration of the building the home would not be suitable for wheelchair users. There is a rear garden available and accessible to residents with support of staff. DS0000007230.V337099.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 24/04/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes manager was present for most of the inspection. Overall, the inspector believes that a considerable amount of work needs to be done before the home is fully compliant with National Minimum Standards and the Care Homes Regulations 2001, although service users spoken to generally expressed satisfaction with the level of care and support received. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000007230.V337099.R02.S.doc Version 5.2 Page 6 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 DS0000007230.V337099.R02.S.doc Version 5.2 Page 7 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): 1,2,4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are given the opportunity of visiting the home before making a decision as to move in or not, but the home must ensure that written documentation about the home is accurate and up to date. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are written in plain English. The Statement of Purpose includes details of the aims and objectives and of the services and facilities provided by the home. However, it was not dated, and there was no evidence that it has been subject to regular review, and was found to contain inaccurate information. For example, the organisational structure for the home said that DS0000007230.V337099.R02.S.doc Version 5.2 Page 8 there was a cook, but in fact care staff were responsible for cooking duties, and the Statement said that the home was for people over the age of 75, when it is in fact for people over the age of 65. It is required that the Statement of Purpose is dated, subject to regular review, and that it contains up to date and accurate information. This Service User Guide also needs to be reviewed, as this too contains inaccurate information. For instance, it states that the CSCI is responsible for carrying out investigations into any adult protection issues, but this is not the case. Contracts/statements of terms and conditions were in place for all service users. These contained details of fees payable and the rights and responsibilities of both parties. There have been no new admissions to the home since the last inspection. However, the home does have an admissions procedure in place. This states that service users will be given the opportunity of visiting the home before making a decision as to move in or not, and that they will initially move in on a trial basis. However, the admissions procedure also states that “Ashcroft House aims to help as many people with mental health needs as possible”, yet the home is not registered to provide support to people with mental health needs. The homes admission procedures must accurately reflect the homes categories of registration. DS0000007230.V337099.R02.S.doc Version 5.2 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. 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. It is the inspector’s view that the home must do more to ensure that service users health and personal care needs are met. Risk assessments must be comprehensive, and service users must have access to relevant health care professionals as appropriate. EVIDENCE: At the previous inspection a requirement was made around care plans. As this requirement had not yet reached its compliance date at the time of this inspection, it was not tested on this occasion. The requirement has been restated in this report, and will be tested as part of the next inspection of the home. DS0000007230.V337099.R02.S.doc Version 5.2 Page 10 The inspector was disappointed to note that very little work has been done around risk assessments for service users. Some service users did not have any risk assessments in place at all, and those that did only had assessments around moving and handling. It is required that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others, ands that these assessments are subject to regular review. Assessments must identify any potential risks, and include strategies to manage and reduce these risks. The manager informed the inspector than service users would be able to remain in the home with a terminal illness, as long as the home was able to meet their medical needs. The home has sought and recorded the views of service users on the arrangements to be made in the event of their death. All service users are registered with a GP. However, the home could not evidence that service users have routine access to all relevant health professionals, for example the manager informed the inspector that not all service users have had any access to dental care, and it is required that service users have access to health professionals as appropriate. It was further found that the home does not keep comprehensive records of all medical appointments. These records must be maintained, including details of any follow up action necessary. Used continence products within the home are disposed of appropriately. The home has a medication policy in place, and the homes manager informed the inspector that all staff undertake training before they administer any medications. Medications are stored in a locked cabinet, and in the fridge. However, those stored in the fridge are not in a locked container, and it is required that all medications are stored securely. No service users currently self medicate, or are on any controlled drugs. Records are kept of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Record charts are maintained. Those seen by the inspector were accurate and up to date. Through observation and discussion there was evidence that service users privacy is respected. For instance, staff were seen to knock and wait for an answer before entering bedrooms. Service users are given their own mail to open, and have access to a telephone they can use in private. DS0000007230.V337099.R02.S.doc Version 5.2 Page 11 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to maintain contact with family and friends as appropriate. EVIDENCE: At the previous inspection a requirement was made around service users been able to make decisions over their daily lives, and having access to social and leisure activities. As this requirement had not yet reached its compliance date at the time of this inspection, it was not tested on this occasion. The requirement has been restated in this report, and will be tested as part of the next inspection of the home. The home has a visitors policy in place, and visitors are welcome at any reasonable time. Service users can see visitors in private if they so wish. DS0000007230.V337099.R02.S.doc Version 5.2 Page 12 At the previous inspection a requirement was made around service users been offered a choice of meals, and these choices been recorded. As this requirement had not yet reached its compliance date at the time of this inspection, it was not tested on this occasion. The requirement has been restated in this report, and will be tested as part of the next inspection of the home. The food served on the day appeared to be appetizing and nutritious. The kitchen was clean and tidy, and food was stored appropriately. Fridge and freezer temperatures are checked daily. However, the home does not have a full set of colour coded chopping boards, and must obtain one, along with a key to indicate which colour board should be used with which food group. The staff member who prepared the lunch on the day of inspection has not had any training in food hygiene, and it is required that all staff involved in food preparation undertake appropriate food hygiene training. DS0000007230.V337099.R02.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that service users are been put at potential risk, through lack of staff understanding around adult protection issues, and inadequate policies and procedures around these same issues. EVIDENCE: The home has a complaints procedure. This included timescales for responding to any complaints made, and contact details of the CSCI. However, the procedure was not on display within the home, and it is recommended that it should be. The home did not have a complaints log in place. It is required that the home maintains a complaints log, which details any complaints received, including details of any investigations, outcomes and follow up action taken. The home does not have a copy of the Local Authorities adult protection procedure, and must obtain one. It has its own policy in place on adult protection, but this was not in line with current legislation, for example it states that the CSCI is responsible for carrying out investigations into any allegations of abuse, but this is not the case. Staff spoken to on the day of inspection demonstrated a poor understanding of their roles and responsibilities with regard to adult protection, the inspector was informed that DS0000007230.V337099.R02.S.doc Version 5.2 Page 14 not all staff have undertaken training in adult protection issues. It is required that all staff who work in the home undertake appropriate adult protection training, and that they have a good understanding of the issues involved. DS0000007230.V337099.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, and service users have access to adequate private and communal space. However, greater attention needs to be paid to the maintenance of bedrooms. EVIDENCE: The home is located in a quiet residential area of Leytonstone, in the London Borough of Waltham Forest. The home is close to shops, transport links and other local amenities, and is in keeping with other homes in the area. The DS0000007230.V337099.R02.S.doc Version 5.2 Page 16 home consists of two terraced houses that have been converted in to one, and is built over two floors. The communal areas consist of two lounges, a kitchen, dining area and well maintained garden, with appropriate garden furniture. The homes utility room is located in the cellar, and laundry facilities are appropriate to the size of the home. The home was generally well maintained, both internally and externally. Furniture and fittings in communal areas were generally well maintained, and domestic in character, and the home was reasonably decorated. The home has toilets and bathrooms in sufficient numbers to meet service users needs, and these have been adapted to make them accessible to all service users. Bathrooms were clean and tidy, and free from offensive odours. All bathrooms had locks fitted, including an emergency override device. However, there was no flooring in one of the downstairs toilets. The manager informed the inspector that it was planned that appropriate flooring would be installed soon, and this is required. The home has eleven single bedrooms, and two double bedrooms. Bedrooms have been decorated to service users personal tastes, for example with family photographs, and were homely in appearance. Bedrooms had adequate natural light and ventilation, and all have central heating. Heating appliances are appropriately boxed in. Bedrooms meet NMS on size requirements. No bedrooms are ensuite, but all have hand basins in them. Bedrooms contained adequate furniture, including table and chairs, wardrobes and chest of draws. Thee were found to be some minor maintenance issues with some of the bedrooms, all of which must be addressed: • • • • Screening must be provided in double rooms. There was an offensive odour in two bedrooms, this must be dealt with. The dirty bedroom carpet in room 7 must be cleaned or replaced. The broken cupboard in room 10 must be repaired or replaced. It was further found that not all of the emergency alarm call points were in working order, and this must be addressed as a matter of priority. There was evidence that the home has taken steps to help prevent the spread of infection, for example hand washing facilities are situated around the home, and protective clothing such as gloves and aprons are available to staff. DS0000007230.V337099.R02.S.doc Version 5.2 Page 17 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): 27,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector believes that the home is staffed in sufficient numbers to meet service users needs. However, service users would further benefit from the staff team having access to appropriate training, including in working with older persons, and around health and safety issues. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display, this accurately reflected the staffing situation on the day of inspection. However, the rota did not indicate who was in charge of the home at any given time, and this must be addressed. The inspector was pleased to note that staffing levels have increased since the last inspection, and are now adequate to meet service users needs. Through observation and discussion there was evidence that staff have built up good relationships with individual service users, and were seen to interact with them in a respectful and friendly manner. Staff have been provided with a copy of their job description. DS0000007230.V337099.R02.S.doc Version 5.2 Page 18 The home has a policy in place on recruitment and selection, but did not have any policy around equal opportunities, and this must be addressed. The inspector checked staff employment files, for all but one staff these were found to contain necessary documentation, including proof of ID and CRB checks. However, for one member of the staff team, this documentation was not in place. The manager informed the inspector that this staff member had worked at the home for a number of years, however, it is nevertheless required that the home has all records required by Schedule 2 of the Care Homes Regulations 2001 in place for all staff working at the home. At the previous inspection a requirement was made around staff qualifications. As this requirement had not yet reached its compliance date at the time of this inspection, it was not tested on this occasion. The requirement has been restated in this report, and will be tested as part of the next inspection of the home. The inspector checked staff training records, as stated in this report, staff must have relevant training in adult protection issues and food hygiene. It was further found that not all staff have had health and safety training as appropriate, for instance several staff have not had any training around first aid or fire safety. It is required that staff undertake all necessary statutory health and safety training as appropriate. It was further found that many staff have not had any training in working with older persons, and this is required. Recent staff training includes medication and infection control. DS0000007230.V337099.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the homes manager is suitably experienced and qualified, more attention must be paid to health and safety management within the home. EVIDENCE: The homes manager has many years experience of working in care, and has managed the home for the past eighteen years. They are a registered nurse, and informed the inspector that they are close to completing the Registered Managers Award. Staff and service users informed the inspector that they DS0000007230.V337099.R02.S.doc Version 5.2 Page 20 found the manager to be approachable and accessible, and staff were observed to interact with the manager in a relaxed manner. It was however found that record keeping in the home was not of a satisfactory standard. Some records, for example comprehensive risk assessments were not in place at all, and others, such as care plans, were not subject to regular review. It is required that the home maintains all records required by the National Minimum Standards and the Care Homes Regulations 2001. Confidential records were found to be stored securely, and staff and service users could access their records as appropriate. At the previous inspection a requirement was made around staff supervision. As this requirement had not yet reached its compliance date at the time of this inspection, it was not tested on this occasion. The requirement has been restated in this report, and will be tested as part of the next inspection of the home. Fire extinguishers were situated around the home. These were last serviced in February 2007. Fire alarms are tested weekly, and were last serviced on the 26/2/07. However, the home does not hold regular fire drills, and it is required that these take place at least once every three months. COSHH products were stored securely, and the home tests fridge and freezer temperatures daily. However, the home does not test hot water temperatures, and it is required that all hot water outlets used for personal care are tested at least once a week to ensure that the temperature is 43 degrees centigrade. The home had in date certificates for PAT testing and electrical installation. However, there has not been a gas safety check carried out within the past twelve months, and this must be addressed. The home had in date employer’s liability insurance cover in place. DS0000007230.V337099.R02.S.doc Version 5.2 Page 21 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 2 3 X 3 2 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 3 3 2 3 2 3 3 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 3 2 DS0000007230.V337099.R02.S.doc Version 5.2 Page 22 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 OP14 Regulation 12 Requirement Timescale for action 25/05/07 2. OP15 16 3. OP36 18 The registered person must ensure that service users are given the opportunity to make decisions about their daily lives and to participate in stimulating activities according to their needs and wishes, including the opportunity of visiting the local community. (This requirement is restated from the previous inspection of the home on the 24/11/06, at the time of this inspection it was still within its compliance date of the 25/05/07, and this timescale is repeated in this report.) The registered person must 30/06/07 ensure that service users are offered choice at meal times so that they can actively decide what they wish to eat. Any choice of meal offered must be recorded. (Timescale 30/03/07 not met) The registered person must 25/05/07 ensure that all staff must receive supervision as laid out in National Minimum Standards, at least six times a year. Records of supervision must be kept. (This DS0000007230.V337099.R02.S.doc Version 5.2 Page 23 4. OP7 15 5. 6. OP26 OP28 16 18 7. OP1 4 and 5 8. OP5 14 9. OP7 13 requirement is restated from the previous inspection of the home on the 24/11/06, at the time of this inspection it was still within its compliance date of the 25/05/07, and this timescale is repeated in this report.) The registered person must ensure that all care plans are subject to regular review, at least once a month. (This requirement is restated from the previous inspection of the home on the 24/11/06, at the time of this inspection it was still within its compliance date of the 25/05/07, and this timescale is repeated in this report.) The registered person must ensure that the carpet in room 7 is either cleaned or replaced. The registered person must ensure that at least 50 of care staff employed at the home has an NVQ Level 2 in Care or equivalent qualification. (This requirement is restated from the previous inspection of the home on the 24/11/06, at the time of this inspection it was still within its compliance date of the 25/05/07, and this timescale is repeated in this report.) The registered person must ensure that the homes Statement of Purpose and Service User Guide are both dated, subject to regular review, and that they contain accurate information about the home. The registered person must ensure that the admissions procedure accurately reflects the homes categories of registration. The registered person must ensure that comprehensive risk assessments are in place for all service users, covering all areas DS0000007230.V337099.R02.S.doc 25/05/07 31/08/07 25/05/07 31/08/07 31/08/07 31/08/07 Version 5.2 Page 24 10. OP9 13 11. OP8 13 12. OP8 13 13. OP15 13 14. OP15 13 and 18 15. OP16 22 16. OP18 13 17. OP18 13 18. OP18 13 of potential risk to themselves and others, and that these are subject to regular review. The registered person must ensure that all medications within the home, including those that are stored in fridges, are stored securely. The registered person must ensure that service users have access to all relevant health care professionals, including dental care. The registered person must ensure that clear and comprehensive records are maintained of all medical appointments, including details of any follow up action. The registered person must ensure that the home has a full set of colour coded chopping boards, and a key chart to indicate which board should be used for which particular food group. The registered person must ensure that all staff involved with food preparation within the home undertake training in food hygiene as appropriate. The registered person must ensure that the home maintains a complaints log, which includes details of any complaints received, and of any investigation, outcomes and action take. The registered person must ensure that the home has a copy of the Local Authorities adult protection procedures. The registered person must ensure that it has an adult protection procedure, which is in line with current legislation. The registered person must ensure that all staff undertake DS0000007230.V337099.R02.S.doc 30/06/07 31/08/07 30/06/07 31/08/07 31/08/07 30/06/07 30/06/07 31/08/07 31/08/07 Page 25 Version 5.2 19. OP24 23 appropriate training in adult protection issues, and that they have a good understanding of their roles and responsibilities with regard to adult protection issues. The registered person must ensure that the following maintenance issues are addressed: • Screening must be provided in double rooms. • There was an offensive odour in two bedrooms, this must be dealt with. • The broken cupboard in room 10 must be repaired or replaced. The registered person must ensure that the emergency call point alarms system in full working order throughout the home. The registered person must ensure that the staffing rota clearly indicates who is in charge of the home at any given time. The registered person must ensure that all staff undertake all necessary statutory health and safety training as appropriate. The registered person must ensure that all care staff employed at the home undertake appropriate training in working with older persons. The registered person must ensure that all documentation required by Schedule 2 of the Care Homes Regulations 2001 is in place for all service users. The registered person must ensure that the home has an appropriate equal opportunities policy in place. The registered person must DS0000007230.V337099.R02.S.doc 31/08/07 20. OP22 13 and 23 30/06/07 21. OP27 17 30/06/07 22. OP29 13 and 18 31/08/07 23. OP29 18 31/08/07 24. OP30 19 31/08/07 25. OP30 12 31/08/07 26. OP38 13 and 23 30/06/07 Page 26 Version 5.2 27. OP38 13 and 23 28. OP38 13 and 23 ensure that the home carries out regular fire drills, at least once every three months. The registered person must ensure that all hot water outlets used for personal care are checked at least once a week to ensure their temperature is 43 degrees centigrade. The registered person must ensure that the home has a gas safety check carried out at least once every twelve months. 30/06/07 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations It is recommended that the home has a copy of its complaints procedure prominently on display within the home. DS0000007230.V337099.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. 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