CARE HOMES FOR OLDER PEOPLE
Asmall Hall Nursing Home Asmall Hall Asmall Lane Ormskirk Lancashire L40 8JL Lead Inspector
Vivienne Morris Unannounced Inspection 8th 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 Asmall Hall Nursing Home DS0000025551.V279459.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. Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Asmall Hall Nursing Home Address Asmall Hall Asmall Lane Ormskirk Lancashire L40 8JL 01695 579548 01695 579978 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) JenCare Homes Limited Mrs Jennifer Chapman Care Home 57 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (45), Physical disability (3) of places Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Within the overall total of 57 a maximum of 45 service users requiring either nursing or personal care who fall into the category OP - Old age not falling within any other category. Within the overall total of 57 a maximum of 3 service users requiring either nursing or personal care who fall into the category PD - Physical Disability (age 40-65 years). Within the overall total of 57 a maximum of 12 service users requiring nursing or personal care who fall into the category DE - Dementia. The registered person must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 7th September 2005 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Asmall Hall has fifty-seven beds, the majority of which accommodate elderly service users who require personal or nursing care. Included within the total of fifty-seven, twelve beds are available, in a separate unit, for elderly service users with dementia care needs. Included in the registration are three beds that accommodate service users with a physical disability under the age of sixty-five years. A qualified nurse is on duty in the main part of the home and the specialist unit at all times. Mr and Mrs Chapman privately own Asmall Hall and Mrs Chapman is also the registered manager.The home is set in extensive well maintained grounds in a quiet residential area of Ormskirk. The grounds are accessible to wheelchair users and the less mobile and outdoor seating is provided to enable service users to enjoy the gardens. A number of aids are provided to assist service users with their activities of daily living and to promote and maintain their independence. Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day during March 2006. The inspection process focused on the outcomes for people living at the home. During the course of the inspection service users, relatives and staff were spoken to, relevant records and documents were examined and a tour of the premises took place, when a random selection of private accommodation was viewed and all communal areas and service areas were seen. The Commission for Social Care Inspection had received one complaint about this service since the last inspection, which was referred back to the provider to investigate, which was found to be not upheld. What the service does well:
The policies, procedures and practices of the home demonstrated that service users were treated with respect, their privacy and dignity being upheld. The routines of daily living at the home were found to be flexible, allowing service users to make choices and to take some control over their lives. Activities were provided in general in accordance with service users’ preferences. Complaints were appropriately managed and investigations conducted by the home were recorded and responses were provided within acceptable time scales so that complainants were aware of the progress of complaints and the outcome. Adequate infection control measures were in place at the home to ensure that the health and safety of those living there were sufficiently protected. The premises were clean, hygienic and pleasant smelling throughout and systems were in place to control the spread of infection. A staff training and development programme was in place which demonstrated that all members of staff received adequate core training to ensure that they were able to meet the basic needs of those living at their home. Additional Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 6 specific training was provided to ensure that staff were also able to sufficiently care for those with more complex needs. One relative of a service user no longer at the home forwarded some very positive comments to the Commission for Social Care Inspection, which included, “care and compassion was evident”, “at all times we were made to feel welcome by all of the team. Their care for my relative was exemplary” and “their (the staff) support to us was outstanding yet non- intrusive” What has improved since the last inspection? What they could do better:
The plans of care did not cover all the service users’ assessed needs to ensure that clear guidance was provided for staff as to how these needs were to be appropriately met.
Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 7 The management of medication was of a poor standard. Medication Administration Records were regularly altered by hand, providing conflicting information for those administering the medications, which did not adequately protect those using the service. Policies and procedures had not been up dated to reflect changes in legislation and good practice guidelines. The policies and procedures were not robust enough to adequately protect those living at the home from abusive situations. The remaining carpets, which were in poor condition, need to be replaced in order to provide a comfortable, homely environment for all those living at Asmall Hall Care Home. The home should continue to work towards a minimum ratio of 50 of care staff achieveing a National Vocational Award at level two or equivalent to ensure a good percentage of staff are appropriately trained to meet the needs of those living at Asmall Hall. Recruitment practices were found to be unsatisfactory. Appropriate checks had not been obtained for one person prior to employment. Policies and procedures of the home should be periodically reviewed to ensure that up-to-date information was provided for staff. The registered manager should produce an annual development plan to show that of forward planning reflects the aims and outcomes for those living at the home. Service users should be given the opportunity to provide formal feedback about the quality of the service provided so that any positive comments could be noted and any shortfalls could be addressed in order to improve the service for those living at the home. To ensure robust financial procedures, service user’s money should not be ‘pooled’, but individual bank accounts should be available for those wishing to deposit money for safe-keeping. Work must be carried out to ensure adequate fire safety, in accordance with the most recent fire officer’s report and the registered person must be able to demonstrate that adequate controls have been implemented in relation to the risk of Legionella. Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 8 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. Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 9 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 Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 10 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): No standards from this section were fully assessed on this occasion. Staff were not always provided with clear guidance as to how service users’ assessed needs were to be met. EVIDENCE: Although standard 3 was not fully assessed on this occasion, it was evident that the requirement from the previous inspection had been partially addressed. Service users’ had been involved in the care planning process. Although not all assessed needs were consistently recorded within the plans of care their needs in relation to dementia care and social care were well documented, providing staff with clear guidance as to how these specific needs were to be met. Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Assessed needs of service users were not consistently recorded to demonstrate that all needs were being appropriately met. The management of medications was poor which compromised the safety of those living at the home. Service users were treated with respect and their right to privacy was upheld. EVIDENCE: Although standard 7 and standard 8 were not fully assessed on this occasion. The requirement from the previous inspection had been partially addressed. The text in standard 3 of this report highlights areas addressed and areas still outstanding for both these standards. Standard 9 was not fully assessed on this occasion. However, some of the requirements and recommendations from the previous inspection had been addressed, others remained outstanding. The management of medications was in general found to be poor. There were numerous hand written alterations on the Medication Administration Records (MAR), which had not been signed or witnessed. Some of these alterations provided conflicting instructions, as they differed from the previous printed entry, which had not been discontinued. Risk assessments had not been completed or reviewed for those people selfmedicating. Medications were only given to those for whom they were
Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 12 prescribed. There was no documentation or written policies available to clarify the arrangements made with the contractor for the collection and disposal of medications. The deputy manager was advised to forward this information to the Commission for Social Care Inspection once located. The outstanding requirements and recommendations are identified in the relevant section at the end of this report. The plans of care demonstrated that the privacy and dignity of those living at the home was protected at all times and service users confirmed that this was the case. Staff were instructed during induction about how to treat service users with respect and were seen to be knocking on resident’s bedroom doors before entering and were seen to be talking with residents in a respectful manner demonstrating that service users were treated well. The policies and procedures of the home and the service users’ guide demonstrated that the privacy and dignity of service users was respected at all times. Comments received included, “an excellent level of care is provided by caring and friendly staff”, “they (the staff) have exceeded my expectations”, “there isn’t one member of staff that isn’t nice with me” and “The hairdresser is very special – she has an excellent approach”. Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14 The routines of daily living were flexible in accordance with individual preferences and needs. The people residing at the care home were able to exercise choice and take some control over their lives. EVIDENCE: A social care profile had been completed for each service on admission, which provided information about what people enjoyed to do and what their preferences were in relation to activities of daily living. A plan of care had been developed from this information, which provided staff with guidance as to how service users could be supported to maintain their hobbies, leisure interests and daily routines. Freedom of movement was evident at the time of the inspection and service users spoken to confirmed that the daily living routines were flexible and that they were supported in going to bed and rising at times suitable to them, which demonstrated that people were able to make choices about what they wished to do whilst living at the home. Choices of menu were available at each mealtime and the inspector noted that daily menus were available on each dining table so that service users were aware of the choice of meal, which they had selected.
Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 14 The statement of purpose provided detailed information about the daily life within the home and the activities provided. Information about activities was also displayed within the home so that people living there were aware of what activities were planned to enable them to make an informed choice of which they wished to participate in. Service users spoken to indicated that activities were provided, which they enjoyed. However, out of 18 comment cards received from service users, three stated that suitable activities were not provided at the home. At the time of the inspection there was one person using advocacy services to act on their behalf demonstrating that those living at the care home were supported to make decisions and to have some control over their lives. The statement of purpose and the written policies and procedures of the home supported this evidence. It was evident that people were able to take personal possessions into Asmall Hall, which were recorded at the time of admission to ensure the protection of service users’ belongings. Comments received by service users included “It is marvellous here, just like home from home” and “I am happy living at the home, the staff are real treasures”. Asmall Hall Nursing Home DS0000025551.V279459.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): 16 Complaints were well managed, ensuring timely investigations, so that complainants concerns were adequately addressed. The policies and procedures were not robust enough to adequately protect those living at the home from possible abusive situations. EVIDENCE: A complaints procedure was displayed within the home and was included in the service users’ guide. This contained contact details for the Commission for Social Care and Inspection (CSCI) and times scales for action to ensure that people were aware of how to make a complaint should they so wish. The complaints received by the home had been recorded in the complaints book showing that action had been taken within appropriate time scales to ensure that complainants had been kept up to date with the progress and outcome of complaints investigated by the home. Although standard 18 was not fully assessed on this occasion the recommendation from the previous inspection remained outstanding. The policies and procedures in relation to the protection of vulnerable adults had not been revised and therefore contained information, which was not in line with the Department of Health guidance ‘No Secrets’. Policies and procedures had not been implemented in relation to the security and management of service users’ money and valuables. Asmall Hall Nursing Home DS0000025551.V279459.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): 26 The environment was in general of a reasonable standard for people to live in. The home was clean, tidy and pleasant smelling with adequate infection control measures in place. EVIDENCE: Although standard 19 was not fully assessed on this occasion the requirement and recommendation made at the previous inspection were assessed. Some carpets which were identified as being in poor condition had been replaced, others were still in need of replacement in order to provide a homely environment for all service users. The carpet in the lounge on the Mulberry unit was in particular in need of replacement. Some of the requirements and recommendations made by the Environmental Health Officer had not been addressed since the last inspection to demonstrate adequate health and safety procedures were in place. The laundry department was appropriately situated within the home, providing adequate equipment and was well organised demonstrating that service users’ clothing and linen was well laundered and returned to them within an acceptable period of time. One comment received was “the laundry service is very good with clothing returned within 48 hours”.
Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 17 Policies and procedures were in place to ensure that adequate infection control measures were implemented and the correct disposal of clinical waste was in place. The home was found to be clean, tidy and pleasant smelling, providing, in general a pleasant environment for people to live in. Asmall Hall Nursing Home DS0000025551.V279459.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): 27,28,29 and 30. Sufficient numbers of staff were on duty to meets the needs of those living at the home. Not enough staff were appropriately trained to demonstrate that their skills and knowledge were kept up to date in line with changing legislation and good practice guidelines. The recruitment procedures adopted by the home were not totally satisfactory to ensure the continued protection of the vulnerable adults living at the care home. Staff working at the home received a lot of training to enable them to meet the needs of those living at the care home. EVIDENCE: The home was able to demonstrate that the ratios of care staff to service users was determined in accordance with the dependency levels of residents to ensure that assessed needs were being met. The duty rota demonstrated that additional staff were on duty at busier periods of the day and that qualified nurses were on duty at all times to ensure that appropriate care was being provided. The home was of a satisfactory standard of cleanliness and was pleasant smelling, providing a pleasant environment for service users to live in.
Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 19 There were 37 care staff employed at the home, 6 of whom had completed a National Vocational Qualification (NVQ). This percentage was lower than at the previous inspection due to staff leaving. However, other care staff were also in the process of undergoing a National Vocational Qualification demonstrating that the home was working towards a higher percentage of staff being appropriately trained in order to meet the needs of those living at the home. Four staff files were examined at the time of the inspection. It was found that recruitment procedures were not being adequately followed in day-to-day practice. This must be improved as a matter of urgency to ensure adequate protection of those living at the home. Insufficient checks had been undertaken on staff prior to employment to ensure that people living at the home were adequately protected. The inspector noted that references for one member of staff had been obtained following employment. Both a Criminal Record Bureau disclosure had not been obtained and a check of the Protection of Vulnerable Adult register had not been conducted for this employee, therefore a judgement on the suitability of this person to work at the home had not been totally considered. No risk assessments had been conducted for this employee in relation to age or the work being undertaken in order to identify any hazards, which could be eliminated or minimised to ensure the safety of the worker. There were issues around the home not obtaining appropriate consent and not informing relevant authorities about this person being employed at the home. The personal records of three other staff members were satisfactory, appropriate checks having been undertaken. A lot of relevant training was provided for staff and individual training and development programmes were in place so that the manager of the home could determine at what stage staff were at in relation to their training needs and to ensure that those working at the home were competent to do the job expected of them and to ensure that they were able to meet the assessed needs of those living at the home. Asmall Hall Nursing Home DS0000025551.V279459.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. The home was well organised and managed by a person who had relevant experience and training to demonstrate adequate management skills. The system for monitoring the quality of service did not adequately reflect the views of those living at the home. Service users’ financial interests were not sufficiently safeguarded. The health and safety of those living at the home was not adequately protected. EVIDENCE: The environment was relaxed, friendly and organised. Service users were appropriately dressed and well-groomed showing that their personal care needs were being adequately met. Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 21 The registered manager of Asmall Hall is also the owner of the care home; she is a first level registered nurse and has been managing the home for a number of years. Confirmation was seen to show that the registered manager had obtained a National vocational qualification at level 4 to demonstrate some management training had been undertaken. The registered manager has also undertaken periodic training to update her knowledge, skills and competence, was managing the care home. A job description for the registered manager demonstrated her responsibilities in relation to work expected of her. Registered nurses were on duty at all times and a high number of those working on the dementia care unit held qualifications in mental health and therefore had relevant training and experience to meet the specific needs of those living on this specialised unit. One comment received was, “shes (the manager’s) a lovely lady, very caring. She just has one fault, in that she cannot say no to anyone”. An annual development plan could not be located at the time of the inspection to demonstrate that forward planning had been taken into account and which reflected the aims and outcomes for service users. The quality of service provided had been monitored by an external professional and monthly internal audit trails had been conducted so that the home was able to determine any shortfalls or positive outcomes for those living at home. The quality assurance process did not involve formal feedback from service users as to what it was like living at Asmall Hall care home. A variety of meetings were held from time to time, from which recorded minutes were taken and made available to all relevant parties. All staff and stakeholders in the community had the opportunity to be involved in the quality assurance monitoring process, by providing feedback in relation to their views about how the home is achieving goals service users. The registered manager was currently reviewing the policies and procedures of the home. This process should continue to ensure that any changes in legislation and good practice guidelines are available for staff. The records of service users personnel allowance accounts were examined, which were found to be clear and easy to follow. Safe storage facilities were available within the home to ensure the protection of any valuables or money deposited by service users for safekeeping. It was determined that any money accumulated was returned to service users’ families or deposited into a bank account for security purposes. However, any service user’s money, which was transferred into the bank, was deposited into a joint account, which was not totally satisfactory. Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 22 Although standard 38 was not fully assessed on this occasion, it was noted that the recommendation and four of the requirements from the previous inspection had been appropriately addressed. However, work still needed to be completed in relation to the most recent fire officer’s report to ensure adequate fire precautions and the home must ensure that adequate controls have been implemented in relation to the risk of Legionella. Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP3OP7OP 8 Regulation 15(1) Requirement Timescale for action 31/03/06 2. OP9 13(2) 3 OP9 13(2) 17(1)(a) Sch3 4 OP9 13(2) The registered person shall, after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. (Timescale of 15.10.05 not met). The manager must ensure that 31/03/06 self-medication is promoted where appropriate. Risk assessments must be completed (and reviewed) and the resident provided with secure storage facilities within their private room. (Timescale of 31.10.05 not met). Full and accurate records must 31/03/06 be kept of all medicines received, administered and leaving the care of the home. There must be a full record of all medication currently prescribed for each resident. (Timescale of 31.10.05 not met). The disposal of waste 30/04/06 medication must be in line with
DS0000025551.V279459.R01.S.doc Version 5.1 Asmall Hall Nursing Home Page 25 5 OP19 6 OP29 7 OP38 8 OP38 current Waste Regulations The registered person must repair or replace carpets, which are in poor condition. (Timescale of 31st December 2004 and 31st December 2005 not met) 19(1)(b)(i) The registered person must Schedule2 implement robust recruitment procedures by obtaining relevant disclosures from the Criminal Records Bureau and the Protection of Vulnerable Adults register prior to the employment of any new staff members. Two written references in respect of every employee must also be obtained prior to employment. This must be addressed as a matter of urgency. 23(4)(b)(c) All work identified in relation to the fire prevention systems must be carried out and on completion written confirmation sent to the Commission. (Timescale of 31.10.05 not met). 13(4) The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, including solutions to be implemented for the control of Legionella and servicing of the boilers and central heating systems to be conducted. (Time scale of 31.10.05 not met). 16(2)(c) 30/06/06 31/03/06 30/04/06 30/04/06 Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 26 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 OP9 Good Practice Recommendations You should review medication policies and procedures in line with Royal Pharmaceutical Society of Great Britain guidelines to cover all aspects of medicines management. You must develop new procedures for the handling of waste medication in accordance with current Waste Regulations. Criteria for the administration of when required and variable dose medication should be clearly defined and recorded for all service users prescribed such items. A second member of staff should witness all hand written annotations on Medication Administration Record charts. Sticky labels should not be used. There should be a formal system for prompting medication reviews in line with National Service Framework for Older People. Consent to the administration of medication for the younger adult should be recorded in the care plan. The policies in relation to the protection of vulnerable adults should be revised so as not to provide conflicting information and to be in accordance with the Department of Health guidance ‘No Secrets’. Policies should be introduced in relation to the security and management of service users money and valuables retained within the home to ensure adequate protection. It is recommended that the home take action to address the outstanding recommendation made by the environmental health officer. A minimum ratio of 50 of care staff should have achieved a National Vocational Award at level two or equivalent, which should include agency staff working at the home. Consent and agreement from responsible adults and relevant authorities should be obtained prior to the employment of any person below the age of consent. The registered person should develop an annual development plan, which should reflect the aims and outcomes for service users. Service users should be given the opportunity to provide
Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 27 2. 3. 4. 5. 6. OP9 OP9 OP9 YA20 OP18 7. 8. OP19 OP28 9. 10. OP29 OP33 formal feedback about the quality of service provided. The policies and procedures of the home should be periodically reviewed to ensure that any changes in legislation and good practice guidelines are up dated. Service users’ money should not be ‘pooled’, but separate bank accounts should be available for those wishing to deposit any money. 11. OP35 Asmall Hall Nursing Home DS0000025551.V279459.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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