Inspection on 12/07/05 for Autumn House Nursing Home

This inspection was carried out on 12th July 2005.

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

Autumn House Nursing Home 18/09/07

Autumn House Nursing Home 14/08/06

Autumn House Nursing Home 16/12/05

Autumn House Nursing Home 24/01/05

Autumn House Nursing Home 21/07/04

Autumn House Nursing Home 02/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Autumn House Nursing Home 37 Stafford Street Stone Staffordshire ST15 0HG Lead Inspector Lynne Gammon Announced 12 July 2005 9:00am 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 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. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Autumn House Address 37 Stafford Street Stone Staffordshire ST15 0HG 01785 812885 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Waverley Care Homes Ltd Mrs Lesley Barbara Powell CRH 67 Category(ies) of DE(E) - 6 registration, with number MD(E) - 6 of places OP - 31 PD - 31 PD(E) - 31 Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Physical Disability (PD) minimum age 50 years on admission - Nursing Care 31 Physical Disability (PD) minimum age 60 years on admission - Nursing Care 4 Physical Disability (PD) minimum age 50 years on admission - Personal Care Date of last inspection 24 January 2005 Brief Description of the Service: Autumn House is a care home providing personal care, nursing care and accommodation for up to 67 elderly service users. The home is registered with the Commission for Social Care Inspection to care for service users with the following needs: - dementia, mental disorder (excluding learning disability or dementia), old age, (not falling within any other category) and physical disability. The home is owned by Waverley Care Homes Limited who also own the other care home located on the site. The home is located on the outskirts of the town of Stone in Staffordshire. Amenities, including those in Stone town centre are situated within walking distance. The home consists of two floors, the ground floor is home to service-users requiring personal care and the first floor is dedicated to those needing nursing care. There is a passenger lift installed serving both floors. Most bedrooms have en-suite facilities, with some double rooms available. There is a patio area with tables and chairs and a substantial car-parking area at the front of the home. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced visit was made on the 12th July 2005 at 9.30 a.m. The inspection was carried out by two inspectors who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 13hrs. The registered care manager, Director of Care Services, Lesley Powell, was in charge of the home on the day of the inspection plus the care manager, trained nurses, care assistants and a range of support service staff including administrative staff, domestics, catering, laundry and maintenance staff. The numbers, skills and experience of staff on duty were adequate to meet the needs of those service users living in the home that day. The inspection included a tour of the building, inspection of records, observation, and discussions with service users and staff, and also with visiting health professionals. Since the last inspection on 24th January 2005, no complaints nor any incidents or reports of abuse of any kind had been received. One requirement against the regulations and the minimum standards was outstanding from the last inspection report and has been raised again as a requirement at this inspection. All aspects of care had been addressed well and service users were able to make a decision about the home following an assessment and invitation to visit the home. Care plans were generally well written but not all were reviewed monthly and some risks assessments had not been reviewed at all. For those that had been completed in a comprehensive and detailed format, it was evident that health, personal and social care needs were being met well. All aspects of service user privacy, dignity and choice were recorded and supported by staff. Service users spoke highly of the quality of care provided by the staff and said that they were treated respectfully and politely. The home itself, overall, was generally well maintained, bright, and clean. It provided a safe and secure environment for the service users and staff. The bedrooms and communal areas were decorated to a satisfactory standard, clean, warm and tidy. Menus were balanced and nutritious, with choices available to meet a range of needs. Staff training had been recorded well. Service users were able to make their own choices and decisions about the day-to-day activities within the home. Satisfactory systems were in place to safeguard service user’s health, safety and welfare. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Care planning processes were generally good but the care plans should be reviewed every month to ensure that staff were clear about the current needs of the individual service users and how to meet those needs. To address this problem, the home had allocated a senior member of staff to review and update the care planning processes and other key processes within the home and the Commission will monitor the outcome of this review. It is important that staff are clear about service user requirements in all aspects of care, including their end of life needs. It is necessary to consult with service users, their relatives and their GP to be sure that their death is handled with dignity and courtesy, and their spiritual needs are observed. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 7 Recruitment and selection processes also need to be reviewed to ensure the protection of service users. Staff files should be audited to identify if there are any gaps and if so, this should be rectified without delay. Some service users felt that they needed more stimulating activities within the home and it is a requirement of this report that service users are consulted about the existing activities to identify what changes could be made to make life more interesting for some of them. It was observed that most meals contained frozen vegetables and it is recommendation that fresh vegetables are provided more often and also a recommendation that fresh fruit is available each day, in the afternoon. One of the bedrooms on the residential floor had a strong malodour and it is required that this is addressed to ensure that the premises are kept clean, hygienic and free from offensive odours. The upstairs sluice window also needed attention and oxygen cylinders must be secure when on trolleys in service user’s bedrooms. It was also noted throughout the inspection that door wedges were used and these must be removed and replaced with door retainers for the protection of service users. These should not be fitted untill the home have had approval from the Fire officer. 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. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5 Potential service users received an initial assessment to determine their needs and confirmation that those needs would be met. Trial visits were available to enable prospective service users and their relatives to assess the quality and suitability of the home. EVIDENCE: The registered care manager of the home and the care manager on the residential wing carried out the pre-admission assessments for prospective service users. Needs were clearly identified and written confirmation given to the service users that these needs could be met. The registered manager confirmed that service users and their relatives were invited to visit the home before admission to assess the suitability of the home. Some service users spoken to said that they had visited the home before moving in. A trial period of 6 weeks also enabled the service users to decide if the home was the right place for them. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7, 8, 9, 10 and 11 The assessed health and personal care needs of service users were, overall, well documented but reviews of care plans should take place more frequently to ensure needs were being met at all times. Good standards of care were being delivered. There was a safe system for the receipt, storage, and administration of medicines. Service users were treated with respect, privacy and dignity, during the inspection. EVIDENCE: Several service users, and relatives spoken to by the inspectors, commented very positively about the care being provided on both the nursing and residential floors. The service user plans and relevant documentation were generally well written and reflected the current condition of service users followed through case tracking. However, some care plans were only reviewed on a two monthly basis, which was raised as a previous requirement, and some risk assessments had not been reviewed at all or updated on the residential floor and it is a requirement of this report that care plans are reviewed monthly and risk assessments are reviewed and updated for all service users. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 11 The documentation seen by the inspectors evidenced that health and personal care needs were being well met and the staff and relatives confirmed this too. Signatures of relatives were evident within the care records. Care records were stored securely within the nursing office/clinical room and care manager’s office. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. One inspector spoke to the rehabilitation nurse and the palliative care nurse whilst they visited service users in the home and they confirmed that they were happy with the care being provided to the service users. A local GP practice and a local pharmacist serviced the home, and there was a good working relationship with them. Records of their visits and outcomes were seen documented. The medicines within the home and medication administration records were all checked and no errors were noted. However, a requirement was made to secure oxygen cylinders on trolleys in service users bedrooms. Throughout the inspection the inspectors observed that privacy and dignity were being afforded to service users, and there was very good interaction with staff. All staff were seen knocking on doors before entering. Several service users told the inspector that they were treated with respect, and that the staff were all very kind. One stated ‘this is a fantastic place – the care, the food – everything!’ It was noted that end of life care plans did not contain suitable consultation with service users, family and GP and it is a requirement of this report that this is undertaken for all service users in an appropriate manner. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The home provided a variety of activities to satisfy the needs of some service users. For others, they required more stimulation and challenge. Service users were encouraged and supported to see family and friends and to make decisions and choices about their lives. Menus were balanced and nutritious. EVIDENCE: The home employed an activities co-ordinator for 3 mornings a week who was supported by a senior carer in providing activities and organising outings for the service users. These included bingo, dominoes, armchair ‘aerobics’, flower arranging and trips to Trentham Gardens, Llandudno and into Stone to the local public house by the canal to relax, have a drink and watch the boats. Religious needs were attended to and a Holy Communion service was held every month. The inspectors did not talk to the activities co-ordinator on this occasion but one inspector did speak to a number of service users about the activities provided within the home. They were very complimentary about the staff and said they were ‘extremely friendly and attentive’, but wished to have more opportunities for activities within the home, which would provide more stimulation and interest. One service user said ‘They give you lots of love and care, but we need more than that’. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 13 Another of the inspectors witnessed a bingo session being held in the lounge with several service users taking part. They appeared to be enjoying the session with lots of friendly banter taking place. Service users also commented on the recent cheese and wine evening that had been held at the home for service users and relatives, which had been a great success and enjoyed by a number of people. However, it is a requirement of this report that service users are consulted about the activities arranged by the home to determine if they are meeting service user’s expectations, preferences and capabilities, and to provide activities to meet those needs as required, as far as possible. The home had an open visiting policy for relatives and friends which was observed throughout the inspection. Service users confirmed that they could see their visitors whenever they wished to in the privacy of their own rooms. They also informed the inspector that they could get up and go to bed when they wanted to, and could stay in their own rooms or mix with others in the lounges or outside on the patio when they wanted to have company. Inspection of the kitchen evidenced that all documentation was in order and the kitchen was very clean. The storeroom was warm but the fridge temperatures were satisfactory. Food was correctly stored and cleaning schedules were in order. Four weekly menus were examined and found to provide a variety of choice to suit all needs. However, it was also noted that frozen vegetables were provided on most days throughout the week. The inspector discussed the option of providing more fresh vegetables for the service users with the chef, who confirmed that this would not be a problem. The inspector suggested alternate days to start with and also that service users be given the opportunity to try out fresh fruits cut up and prepared for them, perhaps during the afternoons. It is a recommendation of this report that fresh vegetables are used more often to replace frozen vegetables and also a recommendation that fresh fruit is prepared and cut up for service users during the afternoons. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 and 18 Complaints were listened to and documented in the form of an incident and resolved. The home policies, most procedures and the staff training, protected service users from aspects of abuse. EVIDENCE: An examination of the incident reports, the relevant policy and procedure documentation, and a discussion with staff and service users, evidenced that complaints were listened to and dealt with in the correct manner. Since the last inspection no written formal complaints had been recorded but several incidents were documented. Thank you and complimentary cards were seen. No incidents of neglect or abuse of any kind had been reported. The policy documentation seen, and a discussion with staff confirmed that service users were protected from all forms of abuse. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 24 and 26 The home provided a safe and adequately maintained environment for service users. The home was clean and tidy, and although the home had a clinical atmosphere, communal areas were more homely. Bedrooms were comfortable and contained personal items of the individual service users. EVIDENCE: At the front of the home significant building work was taking place. 16 residential properties and an extension to the adjacent home were being built causing some disruption for service users in terms of the storage of building supplies and noise. However, barriers were in place around the home for the protection of the service users and the registered manager had undertaken risk assessments for the service users regarding the building work and these were examined and found to be satisfactory. Communal areas were comfortable and contained satisfactory furnishings and fittings. There were four lounge areas – on the residential floor, the dining room also had a small lounge area within it. Also within the home was a hairdressing salon and smoking room. It was noted that there was limited Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 16 storage space for wheelchairs on the residential floor. Outside, there was a large patio area overlooking a large car park. The inspector had a discussion with the registered manager about the possibility of providing some sort of screening to this area with planters etc to improve the setting for the service users and to provide improved safety. The registered manager had already considered this as an option for the future. It is recommended that this be put into place as part of the ongoing maintenance schedule. Most areas were exceptionally clean and tidy; bedrooms were well organised and personalised with individual items. During a tour of the home it was noted that one bedroom on the residential floor had a malodour and this needs to be addressed. It is a requirement of this report that the home is kept free of offensive odours. Most bedrooms had en suite facilities and all rooms had locked drawers. The decoration within the home was overall satisfactory with some areas needing some slight attention. It is a requirement of this report that the window in the sluice upstairs is made good. The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked by the inspector had a good knowledge on infection control issues, and discussed the relevant documentation. Adequate hand washing facilities were available throughout the home. Fans were situated throughout the home to reduce the temperature for the comfort of the service users and staff. The laundry was inspected and found to be well organised and all washing was undertaken at the correct temperatures including soiled linen in the appropriate red bags for easy identification. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The assessed needs of service users had been met by an adequate number of suitably trained staff. Staff files and recruitment procedures needed to be audited to ensure the protection of service users. Staff training had been given a high priority. EVIDENCE: On the nursing floor, staffing levels were maintained, as the previously issued Staffing Notice of 1st April 2002 and following a discussion with the Director of Nursing and her staff it was agreed that the shift cover was adequate for the existing service user’s needs. Staffing rosters were checked and were in order. There were two trained nurses and seven care staff on each morning shift, one nurse and five care assistants on each evening shift, and one nurse and four carers on each night shift. Adequate ancillary staff had been provided each day. The records seen evidenced that the home employed thirteen nurses, fifty care assistants. 40 of carers were trained to NVQ level 2 or above and 20 will complete training in August 2005. The homes recruitment policy, procedures and documentation were examined and recruitment issues were examined. Most staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. One member of staff who had returned to work at the home had not got a current CRB check and it is a requirement of this report for all recruitment procedures to be updated and staff files to be reviewed and audited to ensure all staff Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 18 have the appropriate checks prior to employment. Staff asked stated that they had job descriptions and contracts of employment. Training had been given high priority and the training records of individuals were seen. The records evidenced that care assistants had benefited from ‘in house’ and external training which had covered the needs of the registered client group. Staff told the inspector that they had been encouraged to study. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38 The service users’ financial interests were safeguarded by the systems in place within the home. Procedures were in place to promote and protect the health, safety and welfare of both service users and staff. EVIDENCE: Some service users looked after their own financial affairs and for those that required some assistance to do this, the procedure for dealing with management of monies was operated. A sample of service users financial records were inspected and found to be correct, corresponding with the amounts detailed in the individual ledgers. The health, safety and welfare of those living and working in the home were protected by the range of required policies and procedures held within the home and the on-going training that takes place for staff, e.g. manual handling, fire instruction, food hygiene etc. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 20 Records were examined and evidenced that all tests relating to portable appliance testing, fire safety and food safety etc were up to date. However, during the tour of the environment, it was observed that door wedges were in place and it is a requirement of this report that these are removed and door retainers provided. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 x x x 3 x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 2 Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 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 OP 7 Regulation 15 (2) (b)(c) 13 (2) 12 (3) Requirement Care plans to be reviewed monthly and risk assessments reviewed and updated for all service users. Secure oxygen cylinders on trolleys in service users bedrooms. To undertake consultation with service users, family and GP in an appropriate manner regarding end of life care requirements. Service users to be consulted about the activities arranged by the home to determine if they are meeting service user’s expectations, preferences and capabilities, and to provide activities to meet those needs as required, as far as possible. To Keep the home free of offensive odours. To make good the upstairs sluice window. All recruitment procedures to be updated and staff files to be reviewed and audited to ensure all staff have the appropriate To remove all door wedges from the fire doors (and replace with retainers door guards) if to be kept open in consultation with Timescale for action Immediate and ongoing Immediate and ongoing Immediate and ongoing 30.09.05 2. 3. OP 9 OP 11 4. OP 12.1 16 (2) (n) 5. 6. 7. OP26 OP 19 OP 29 16 (2) (k) 23 (2) (b) 19 (1) (b) (i)) 23 (4) Immediate 30.08.05 Immediate 8. OP 38 Immediate Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 23 the fire officer.. 9. . 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. 2. 3. Refer to Standard OP 15 OP 20 OP 15 Good Practice Recommendations Fresh fruit is prepared and cut up for service users on a daily basis.. To provide a screened area with planters to the large patio area overlooking the large car park to improve the setting for the service users and to provide improved safety. Fresh vegetables to be used more often to replace frozen vegetables. Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Autumn House Nursing Home E51-E09 S22309 Autumn Hse V233253 12.07.05 Stage 4.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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