Inspection on 30/09/08 for Astune Rise

This inspection was carried out on 30th September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Astune Rise 114 High Street Eston Middlesbrough TS6 9EJ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Katherine Acheson     Date: 3 0 0 9 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Astune Rise 114 High Street Eston Middlesbrough TS6 9EJ 01912428600 01912428602 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Geraldine Huitson Type of registration: Number of places registered: Popular Care Ltd care home 38 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 38 The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Old Age, not falling within any other category, Code OP - maximum number of places 38 Date of last inspection Brief description of the care home Astune Rise is registered to provide personal and nursing care to thirty eight older people. The home is situated on Eston High Street and as such is close to shops, pubs and churches. The home is a two storey building. A passenger lift gives access to the first floor. There are thirty two single rooms and three double rooms. Not all bedrooms meet space requirements of National Minimum Standards. Eighteen bedrooms have ensuite facilities which comprises of a toilet and sink. There are three communal 0 Over 65 38 Care Homes for Older People Page 4 of 31 Brief description of the care home lounge areas and a separate dining room. There is an enclosed garden and patio area for people who use the service and car parking facilities for visitors. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The Quality Rating for this service is one star. This means that people that use the service experience adequate quality outcomes. The key inspection of this service was carried out on 30th September 2008 and lasted for just over seven hours. The manager completed and returned an Annual Quality Assurance assessment, (AQAA). The AQAA is the services self assessment on how they think they are meeting National Minimum Standards. This information was received before the inspection and was used as part of the inspection process. Care Homes for Older People Page 6 of 31 The reason for the inspection was to see how good a job the home does at meeting National Minimum Standards set by the government for care homes. Numerous records including care plans, complaints, staff recruitment and training records were examined. The Inspector spoke to four people that use the service, two relatives, the office administrator, one care assistant, the domestic supervisor, two laundry assistants and the manager. The Inspector walked around the home with the manager. Before the inspection surveys for people that use the service, relatives and staff were sent to the home for the manager to distribute accordingly. Surveys requested feedback on the service, care given, staff and the way the home is run. We received eight surveys from people that use the service and five surveys from relatives. Comments received can be read within the report. On the date of this inspection the cost of care at Astune rise ranged from four hundred and sixteen pounds and fourteen pence a week to five hundred and twenty four pounds and ninety five pence. What the care home does well: What has improved since the last inspection? What they could do better: Care plans for people that use the service need to be developed to include more detail. Care plans should clearly identify the problem or need and detail care, assistance and treatment required. Care plans should state what the person can do for themselves and the help that they need. Risk assessments for those people who have bedrails need to be developed. The homes complaint procedure needs to be updated to include detail of who to contact and timescales for action. The homes adult protection procedure needs to be updated to include action that staff should take if abuse is suspected. The main lounge area on the ground floor of the home would benefit from redecoration. All new staff who are not qualified to NVQ level 2 in Care must complete an induction that meets with the required standard. Staff are not trained in first aid and although fire training has been provided to staff working at the home this is not as aften as it should be. The home do not have a formal quality assurance and quality monitoring system based Care Homes for Older People Page 8 of 31 on seeking the views of people that use the service and their representatives. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate pre admission assessments of needs are carried out to ensure that people who use the service are offered the right type of care. Evidence: The manager said that before coming into the home people who are to use the service are assessed by a social worker or another health care professional. This assessment determines if the person requires personal or nursing care and also looks at the emotional, psychological and social needs of the person. The manager said that she then carries out a further assessment by visiting the person at home or in hospital to determine if needs can be met at Astune Rise. Records were available to confirm that this was the case. People who are thinking of coming into the home and their relatives are welcome to Care Homes for Older People Page 11 of 31 Evidence: visit to look around and spend some time before deciding if Astune rise is the right place. Once admitted a review is carried out to ensure that care needs are being met and to check that the person receiving care is happy. One person that uses the service that was spoken to during the visit said, I visited three homes before coming here. The reason why we chose this one was because of the nice welcome and forthcoming information. The home does not provide intermediate care so standard six was not assessed. Care Homes for Older People Page 12 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are happy with the care that they receive. Improvement is needed in respect of care planning and risk assessment. Insufficiently detailed plans of care could impact on care given. Evidence: Three plans of care of people using the service were looked at during the visit. The content of care plans examined was inconsistent, some were better than others. One plan of care described in detail how a person liked their tea hot in a cup and not in a beaker, whilst another detailed how to ensure that a person maintained safety due to a poor sitting balance. One plan of care stated that the person had pain, however this plan of care did not identify where the pain was and how the pain is managed. Another plan of care identified that a person needed help with their mobility, however this did not say what the person could do for themselves or what they needed help with. Care plans were evaluated on a monthly basis, however did not include any information in respect of deteriorations or improvements made. Care Homes for Older People Page 13 of 31 Evidence: It was observed that one of the care plans looked at during the visit was that of a person that needed bed rails to ensure their safety. This person did not have a risk assessment within their plan of care to confirm that a multidisciplinary team had been involved in deciding that bed rails should be fitted to ensure safety. This risk assessment needs to include details of safety checks that need to be carried out to continue to maintain safety whilst the bed rails continue to be in use. A long discussion took place with the manager in respect of care planning and risk assessment. The manager said that the home pays for a private physiotherapist to come into the home on Wednesday morning each week. The physiotherapist sees and assesses the mobility all new people who come into the home and also provides treatment to others. The physiotherapist also provides treatment to those people that use the service that have chest infections. Records examined during the inspection confirmed that people that use the service have access to external health care services. Records were available to confirm that GPs and community nurses visited and were consulted for advice and treatment. People that use the service confirmed that their dignity and privacy was respected. People who use the service, relatives spoken to and surveys received stated Staff are very good, respectful and caring We are all like a family.I have made friends and the staff are very good. Whatever I want to do I do You cant say it is home from home but it is the nearest you will get They all look after me well The care of my mother is second to none During the inspection arrangements for receiving, storing, administering, recording and disposing of medication were observed and examined. The home has a medication policy, this was not looked at during the visit. The manager said that the medication policy and procedure is currently under review. Nurses working at the home are responsible for administering medication. Medication systems were looked at during the visit. The ordering and returning of unused Care Homes for Older People Page 14 of 31 Evidence: medication was good and in general records were well written. Controlled drugs are stored securely and appropriate records are kept. It was noted that there were not any photographs of each person using the service on Medication Administrtaion Charts to assist with identification. On a monthly basis staff keep a record of medicines coming into the home and the amount received. The amount of medication received is recorded on the Medicine Administration Chart of the person using the service. Sometimes a new supply of medication may not need to be ordered as there is sufficient left over from the previous month. When this is the case staff should record the amount of medication carried over to the next month the ensure accurate recording and to enable auditing. Care Homes for Older People Page 15 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service lead fulfilling lifestyles through exercising choice and control over how they spend their day. Food provided is enjoyed by people that use the service. Evidence: The manager said that the home employed an activity co-ordinator in June of this year. The activity co-ordinator works ten to sixteen hours per week usually over three days. Activities taking place on a regular basis include, bingo, music, general knowledge quizzes and movie afternoons. The manager advised that the home regularly have guest entertainers. People that use the service celebrated VJ day by decorating the home with flags and listening to an entertainer. A solo guitarist entertained everyone on 16th September 2008 and people that use the service have recently taken part in a memory walk. The memory walk involved people that use the service and staff walking around the grounds of the home. For those people who use the service and are unable to walk being pushed by Care Homes for Older People Page 16 of 31 Evidence: staff in their wheelchairs. The memory walk was organized by the Alzheimers Society in order to raise funds. The manager and staff advised that the event was a great success with the community as a whole taking part. A company called Motivation an Co visit the home on a monthly basis. They organize games and encourage reminiscence among people that use the service. Motivation and Co charge for this monthly visit, the cost of which is shared between those people who want to take part. Comments made by people that use the service and relatives in respect of activities and outings included, We had a sing song yesterday and I enjoyed that, but mostly I prefer my own company I join in most things. I like a glass of sherry every day The home could do with arranging and providing a few more activities The manager said that people that use the service are supported and encouraged to go out independently. One person goes out independently to the local pub whilst another regularly goes to Eston and Normanby shopping. The manager said that although people that use the service go out with their family they have not been on any trips out with the home. The manager advised that she is looking to organize some bus trips out. Visitors are welcome at any time. One relative spoken to during the inspection said, I am made to feel extremely welcome, communication is excellent another said, They welcome with open arms. The manager said that the home support people that use the service to practice their religion. Representatives from the local Roman Catholic and Church of England churches visit on a regular basis. The home is also visited by the ladies choir from the local church, they come in at different times of the year to sing for people that use the service. The next visit is arranged for 8th October 2008. The lunchtime of people that use the service was observed. The lunch time menu of the day was quiche, chips and salad and for dessert there was jam sponge and custard. The manager said that alternatives to the menu are offered at each meal time. Alternatives include, jacket potato, beans on toast, eggs or sandwiches. Some Care Homes for Older People Page 17 of 31 Evidence: people using the service were eating sandwiches at lunch time. Lunchtime was relaxed with appropriate background music being played. Tables were nicely set with vinegar, salt and pepper on tables. A cold drink of water or juice was given to each person. Staff were observed to be sitting with those people who needed help with feeding. People who use the service and surveys received spoke positively about the food provided. Comments made included, The food is fine, I asked for chicken soup yesterday and they brought me some The food is lovely you couldnt wish for anything nicer. There is lots of variety and it is always served with a happy face. Care Homes for Older People Page 18 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are confident that their complaints would be listened to, taken seriously and acted upon, however the complaints procedure needs to be updated to include all of the required information. This will help to ensure that complaints are dealt with promptly and appropriately. The adult protection procedure does not include action for staff to follow if abuse is suspected and as such could impact on safeguarding. Evidence: The home has a complaints procedure, however this is insufficiently detailed. The complaints procedure needs to be updated to include names and contact details of who to complain to and timescales for action. The manager said that there have not been any formal complaints made in the last twelve months. People spoken to during the inspection and surveys received said that they felt that they could approach the staff or manager to raise any concern or complaint that they may have and that they would be listened to. The agency has a procedure in respect of adult protection, this needs to be updated to include action to take if abuse is suspected. Staff spoken to during the visit were aware of what to do and who to contact if abuse was suspected. Care Homes for Older People Page 19 of 31 Evidence: The manager advised that most staff working at the home have completed a Tees wide inter agency adult protection workbook. Some completed work books were available for inspection. The manager said that she has attended adult protection training which she is to cascade to staff working at the home. There have been three referrals to adult protection in the last twelve months all of which have been managed appropriately by the home. Evidence was available in the home to confirm that policies and procedures are being reviewed and updated since the change in ownership. Care Homes for Older People Page 20 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Astune Rise provides people with a comfortable and homely place to live, redecoration of the main lounge area will further enhance this. Evidence: Astune Rise is a care home that is registered to provide both personal an nursing care. The home is situated on Eston High street and as such is close to shops, churches and pubs. The home is a two storey building. There are thirty two single bedrooms and three double bedrooms, however all bedrooms are currently being used for single occupancy. Eighteen of the bedrooms have ensuite facilities which comprises of a hand wash basin and toilet. There is a passenger lift to the first floor. There is a pleasant garden/patio area for people to use, this is well established with trees, plants and shrubs. During the inspection the Inspector walked around the home with the manager. There are two large lounge areas on the ground floor of the home, both are homely, however the main lounge area would benefit from redecoration. Paint was chipped on Care Homes for Older People Page 21 of 31 Evidence: windowsills and skirting boards. The wallpaper border in the second lounge was coming away from the wall and needed repair or replacement. There is a third lounge on the first floor of the home. The manager described this as the activity lounge. There is also a small hairdressing room. Bedrooms visited on the day of the inspection were personalized with many people bringing item of furniture and belongings from home. New carpets had been fitted to some ground floor corridor areas where carpet had been identified as worn and frayed. The manager said that the home has had a problem with damp, however this has been treated and rectified. Appropriate laundry facilities are in place. On the day of the visit it was noted that there was a build up of washing that required to be sluiced. The manager advised that she would address this problem. General discussion took place with the two laundry assistants that were on duty that day both of who were able to inform of infection control procedures in respect of laundry. On the day of the visit the home was generally clean and odour free. Care Homes for Older People Page 22 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes recruitment procedure is good, which helps to ensure that people are protected. Although mandatory training is provided to staff, induction training does not meet the required standard and as such could impact on care given. Evidence: At the time of the visit there were twenty one people using the service. Duty rotas looked at during the visit showed that there were three care staff on duty on a morning, four on an afternoon and either two or three care staff on an evening. On night duty there are two care staff on duty. There is a nurse on duty during the day and night. The manager of the home works three supernumerary days a week and two as the nurse providing direct care to people that use the service. People spoken to during the inspection and all but one of the surveys received felt that there were sufficient staff on duty to meet the needs of people living at the home. The AQAA detailed that twenty one out of thirty nine staff working at the home had achieved a minimum qualification of NVQ level 2 in Care. Records were available to confirm that the manager in general follows good recruitment procedures. Two files of staff working at the home were examined. Care Homes for Older People Page 23 of 31 Evidence: Appropriate references were on file as was proof of identity and evidence of Criminal Record Bureau checks. It was noted that some staff start working at the home on receipt of a satisfactory POVA FIRST check and work supervised until a satisfactory Criminal Record Bureau Check is received, this should be the exception rather than the rule. The homes reference request would benefit from being updated to ask the referee to confirm dates that they were employed to enable the home to explore any gaps in employment. Records were available to confirm that staff working at the home receive induction, however this did not meet with the required standard. The manager said that she was aware that the homes induction was not sufficiently detailed and had already taken steps to address the situation. Records were available to confirm that appropriate checks with the Nursing Midwifery Council are carried out to check that the nurse is eligible to practice before they start work and then checked on a yearly basis thereafter. Staff files examined during the visit contained certificates to confirm that staff had recently attended training in Moving and handling, food hygiene, health and safety, fire and adult protection. Care Homes for Older People Page 24 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. At present there are no formal quality assurance monitoring systems to help to ensure that the home is run in the best interests of people using the service. Lack of first aid training and insufficient fire training could compromise safety of all. The home has a regular programme of routine maintenance and servicing this helps to ensure safety. Evidence: The manager is a Registered General Nurse who has many years of experience working in the nursing home environment. The manager is currently working towards achieving a NVQ Level 4 in Management. The manager said that she has an open door policy which means that people that use the service and their relatives can speak to her at any time. The provider of the home Carrys out monthly audits/visits to monitor standards. At present the home does not have a quality assurance and quality monitoring system Care Homes for Older People Page 25 of 31 Evidence: based on seeking the view of people that use the service. The home looks after small amounts of money belonging to some people that use the service. Appropriate records of transactions are kept. A sample of health and safety records were examined and found to be in order. Records were available to confirm that the homes gas boiler, fire alarm and fire extinguishers had been serviced in the last twelve months. Water temperatures are taken and recorded on a weekly basis to ensure that they are within safe limits. The manager said that weekly tests of the fire alarm system are carried out and seventeen staff attended fire training on 15th July 2008. The manager advised that she is aware of the need to provide fire training twice yearly to day staff and four times yearly to night staff, however is not doing so at the minute. Although the home employs Registered Nurses there are not any staff trained in first aid. The manager of the home is aware of the need to arrange such training. Appropriate records are kept of accidents/fall for people using the service. The manager of the service regularly audits the accident records to try an identify any common factors so that measures can be put in place to reduce/prevent accidents from occurring again. Care Homes for Older People Page 26 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 13 The Registered Person must ensure that a risk assessment is developed and regularly reviewed for those people who require bed rails To help to ensure safety of people using the service 30/10/2008 2 30 18 The Registered Person must 30/12/2008 ensure that all new staff who are not qualified to NVQ level 2 in Care complete the Skills for Care Induction programme To help to ensure that staff are appropriately trained to meet the needs of people using the service 3 38 13 The Registered Person must 30/11/2008 ensure that staff receive first aid training This will give knowledge of how to deal with accidents and health emergencies Care Homes for Older People Page 28 of 31 4 38 13 The Registered Person must ensure that staff working at the home receive fire training on a regular basis This will help staff to follow safe procedures and take appropriate action in the event of fire 30/11/2008 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 The Registered Person should develop a detailed plan of care for each person using the service. Care plans should clearly identify the problem/need and detail care, assistance and treatment required. Care plans should include capabilities and limitations of the person using the service to help to ensure that care needs are met Care plans should be evaluated on a monthly basis and include any deteriorations or improvements made The Registered Person should ensure for each person using the service that the amount of unused medication carried over from one month to the next is recorded on the Medication Administration Chart to help to ensure accurate recording and enable auditing The Registered Person should put photographs of people using the service on Medication Administration Charts to help to assist with identification of the person The Registered Person should update the homes complaint procedure to include names and contact details of who to complain to and timescales for action The Registered Person should update the homes adult protection procedure to include action to take if abuse is suspected The Registered Person should redecorate the ground floor lounge The Registered Person should repair or replace the wallpaper border in the second ground floor lounge The homes reference request should be updated to ask the 2 3 7 9 4 9 5 16 6 18 7 8 9 19 19 27 Care Homes for Older People Page 29 of 31 referee to confirm dates of employment. This will enable any gaps in employment to be explored 10 11 31 33 The Registered manager should continue working towards achieving her NVQ Level 4 in Management The Registered Person should develop a formal quality assurance and quality monitoring system. The results of which should be made available to people that use the service and their representatives. Care Homes for Older People Page 30 of 31 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 31 of 31 - 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!