Inspection on 21/04/08 for Autumn House Nursing Home

This inspection was carried out on 21st April 2008.

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

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 06/04/09

Autumn House Nursing Home 03/10/07

Autumn House Nursing Home 11/10/06

Autumn House Nursing Home 09/08/05

Autumn House Nursing Home 13/04/05

Autumn House Nursing Home 08/09/04

Autumn House Nursing Home 27/04/04

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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 2 Station Road Worsbrough Dale Barnsley South Yorkshire S70 4SY Lead Inspector Michael O`Neil Key Unannounced Inspection 21st April 2008 09:20a 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 Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Autumn House Nursing Home Address 2 Station Road Worsbrough Dale Barnsley South Yorkshire S70 4SY 01226 243057 01226 247651 autumn.house@hotmail.co.uk None Mrs Nurjahan Hossain Mrs Vijay Kumari Singh Post Vacant Care Home 35 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) Category(ies) of Old age, not falling within any other category registration, with number (35) of places Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 60 years and above with the exception of three persons who can be 55 years or over. Of the 35 beds registered, all can be used for personal care. Twenty of these can alternatively be used for nursing care. 3rd October 2007 Date of last inspection Brief Description of the Service: Autumn House is a care home providing personal and nursing care for up to 35 older people. The home is situated in a residential area of Worsborough Dale, close to all local amenities and bus routes. Accommodation is provided over two floors served by a passenger lift and stairs. The home has 23 single and six double rooms, three of the double rooms have en-suite facilities. Communal accommodation consists of two lounges and a dining room. Sufficient bathing facilities are available, with aids and adaptations in place. A central kitchen and laundry serve the home. The home is in an elevated position in its own grounds, and is reached by a steep tree lined driveway. Car parking is available. Fees were £351.50 for residential care and £452.50 for nursing care. Hairdressing, toiletries and newspapers were not included in the weekly fee and were charged separately. This information was provided on 21st April 2008. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This was an unannounced key inspection carried out by Mike O’Neil, regulation inspector. This site visit took place between the hours of 9:20 am and 4:10 pm. Garry Guest is the manager and was present during the visit. Garry has submitted an application to the CSCI to become the registered manager. Prior to this visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of this report. Chris Rolt, regulation inspector, also carried out a random inspection at the service on 24th January 2008. The random inspection was to check the progress made, particularly relating to people’s health and welfare, since the last CSCI key inspection on 3rd October 2007.Findings from this visit are also included in this report. On the day of this site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the service, check the services policies and procedures and talk to six staff, one relative and seven people who live at the home. We checked all key standards and the standards relating to the requirements outstanding from the services last inspections in October 2007 and January 2008. The progress made has been reported on under the relevant standard in this report. We wish to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There had been positive action on the requirements listed within the last inspection report. The majority of requirements and recommendations had been acted upon and resolved. Information such as the statement of purpose, service user guide and the latest inspection report were being made available to people and visitors to the home. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 7 The detail and consistency of recordings made in peoples care plans has improved. People’s health was also being monitored more closely. One person said “It’s a different place in the last 4 months, its so much better, the care, everything”. There has been an improvement made in the medication procedures at the home. People said the frequency of activities had increased. Issues raised as concerns by people living in the home were now being recorded together with the action taken to resolve the issues. Since the last inspection refurbishment of the lounges and dining room has occurred. These areas are now bright and cheerful. Touches have been added to make Autumn House feel more homely. The lighting is softer, a small aquarium has been purchased and new televisions have been bought for the lounges. People said they were really pleased with the cleanliness and the refurbishment of the communal areas. Recruitment practices had been improved. A manager has now been appointed to the service. People said he was approachable, friendly and will sort out any issues quickly. What they could do better: Peoples care plans need to be improved so that they contain sufficient detail to ensure that people receive a consistently high standard of care. People and/or their relatives must be involved in drawing up and reviewing their care plans. Staff could be come more involved in activity programmes. Staff could look at providing a much more person centred approach to care delivery and arranging activity programmes for people. The paintwork on large sections of the corridors is damaged and needs redecoration. Also the carpet in some areas of the corridor needs cleaning or replacing. The bathrooms and toilets in the home are all in need of refurbishment. Some of the baths/showers are damaged and all the rooms are very stark and clinical with the floor covering badly stained in some areas. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 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 Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including random and key inspection visits to this service. People are assessed before moving into the home to make sure it is the right place for them to live. Pre admission information ensured the home was able to meet peoples health, social and care needs. This service does not provide intermediate care. EVIDENCE: There was information on the three files checked that people were informed in writing that the home could meet their needs. The statement of purpose, service user guide and the latest inspection report were displayed in the main entrance. The manager said that people living in the home had copies of the service user guide in their bedrooms. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 11 Three peoples files were checked and each contained a copy of their full needs assessments. Prior to admission taking place, professionals and staff from the home assessed people. Evidence was seen that the staff at the home were regularly consulting with and requesting reviews from health professionals when the person’s needs were quite complex and had been changing. The service does not provide intermediate care. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including random and key inspection visits to this service. Each person had a plan of care, however these did not include sufficient detail to ensure that peoples individual needs were being met. People were however treated with respect and said they were satisfied with the care they received. Medication procedures did not fully protect people’s health and welfare. EVIDENCE: Three peoples care plans were checked. The peoples care plans checked were good in that they contained some details about the person’s biography, personality and their preferences and choices. Comprehensive risk assessments were included within the documentation and included moving and handling, nutritional, skin integrity, and other risk factors. These risk assessments had also been reviewed. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 13 Some previous requirements made at the last inspection had been addressed in that the plans were being regularly reviewed and the changes in people’s health were being more closely observed and recorded. In the main the care plans showed significant improvement. Staff were keen to improve the documentation further and both inspectors spent time with the manager discussing how the records could be further enhanced to provide more person centred planning. Monitoring charts, relating to people’s health needs, had improved and provided clear instructions and consistent information e.g. diabetic monitoring charts. Accident forms were available on people’s files and 72-hour monitoring sheets were being used. Care plans were up to date, signed and dated. The care plans however were still inadequate because: Inventories of people’s personal possessions were recorded but staff had not signed the documents or dated when the inventory was checked. Information relating to a persons care was being recorded on different documents and books that did not form part of the care plan. Information relating to peoples care needs to be condensed and recorded in the persons individual care plan. There was no evidence recorded to show that people and/or their relatives were involved in drawing up and reviewing the care plans. The plans did not contain detailed enough information as to how the persons’ physical health and personal needs could be fully met. More specific information is required. As already highlighted under standard 3 the care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People looked clean, well dressed and appeared to have received a good level of personal care. People who use the service and relatives expressed their views, during the visits: ‘The care is good’. ‘Its nice here they look after us very well’. “The staff are very friendly and they are great” Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 14 “I’m very satisfied with the care” “I’m happy and content” “It’s a different place in the last 4 months, its so much better, the care, everything” Medicines were securely stored in locked trolleys within locked cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. A requirement/recommendation made at the previous two inspections had not been met. Some handwritten MAR sheets checked did not contain General Practitioners or two members of staffs’ signatures alongside any directions regarding the dosage of the medication or the time the medication was to be given. Staff were aware of the need to treat people with dignity and respect and were observed interacting in a friendly and pleasant way. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including random and key inspection visits to this service. People were able to make choices about daily living and be involved in some social activities. To improve choices and maintain interests, activities need to be more individualised to peoples assessed needs and preferences. The home had an open visiting policy, which assisted in maintaining good relationships with people’s representatives. Meals served at the home were of a good quality and offered choice to ensure people receive a balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives said they were able to visit at any time and were made to feel welcome. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 16 Throughout the day friends and family were seen visiting the home and there seemed to be a very friendly and welcoming feel in Autumn House. People said that there were some activities planned such as bingo, a monthly trip to a local club and entertainers visiting the home. People said the frequency of activities had improved since the last CSCI visit. People were observed to be sleeping for long periods during the morning and afternoon and some people said that they just watched television for most of the day and would welcome the opportunity to undertake simple activities or talk to staff or other people in the home more frequently. The manager and inspector discussed ways that staff could be come more involved in an activity programme. Also it was discussed how staff could look at providing a much more person centred approach to care delivery and arranging activity programmes for people. A small information board was sited in the corridor of the home. The information on the board did not contain sufficient detail that may help people with orientation. The only detail displayed was the date and that films were being shown on the TV. Information in larger brighter print such as the weather, a news item may help the residents with orientation to time and place and provide more stimulation. The mealtime experience for people in the home was very positive. Tables were set nicely with cloths, condiments and matching crockery. Staff were supporting people with their meal in a polite and discreet way. People said “We always get a good meal” “The food is very good, with a lovely variety”. The cook was aware of peoples special dietary needs and said that people were asked each morning what they wanted for lunch. People said that they always received a good choice of food. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including random and key inspection visits to this service. The service had a complaints procedure and it was operating according to the company policy, this provided confidence that complaints were taken seriously and acted upon to address any shortfalls in care or service provision. Safeguarding adults training made staff aware of their responsibility regarding the protection of vulnerable adults. EVIDENCE: People and their representatives had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People said that they felt very comfortable in going to the manager knowing that any concerns they may have would be addressed without delay. The complaints book was checked and there were no complaints. However, as part of the home’s quality assurance, issues raised by people living in the home were recorded together with the action taken to resolve the issues. This Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 18 showed that the home listened to what was said and was proactive in ensuring that people’s needs and wishes were being met. Regarding safeguarding adults, the safeguarding policies and procedures were available to the staff. Staff had undertaken Safeguarding Adults training, and the manager was able to evidence this by producing the training records. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including random and key inspection visits to this service. The home was clean, pleasant and hygienic although some areas of the home are in need of redecorating and refurbishing. EVIDENCE: The home was clean and tidy and no unpleasant odours were noticeable. Lounge and dining areas were domestically furnished to a good standard. Since the last inspection refurbishment of the lounges and dining room has occurred. These areas are now bright and cheerful. Touches have been added to make Autumn House feel more homely. The lighting is softer, a small aquarium has been purchased and new televisions have been bought for the lounges. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 20 Staff showed a real pride in the home and were keen to show me around the recently refurbished areas of the home. People said they were really pleased with the cleanliness and the refurbishment of the communal areas. Some people said how they were much more comfortable now they had been provided with new lounge furniture. The service must be commended on the real transformation of these areas. Other areas of the home however are in need of refurbishment and redecoration. Some bedrooms are being redecorated and new carpets laid. The refurbished rooms are bright and airy. This rolling programme of bedroom refurbishment should continue. The paintwork on large sections of the corridors is damaged and needs redecoration. Also the carpet in some areas of the corridor needs cleaning or replacing. The bathrooms and toilets in the home are all in need of refurbishment. Some of the baths/showers are damaged and all the rooms are very stark and clinical with the floor covering badly stained in some areas. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including random and key inspection visits to this service. Staff were employed in sufficient numbers and recruitment procedures promoted the protection of people. People receive care from a generally well-trained staff team. EVIDENCE: People spoke highly of the staff team and said staff always listened and acted on what they said. People said that staff were “always” or “usually” available when needed. Staff and the manager confirmed that staffing levels were adequate. Currently the home is not at full occupancy and has 18 empty beds. The manager confirmed that staffing levels would increase again as more people were admitted to the home and added that he was monitoring the staffing situation closely. Staff files were checked at the random visit, January 2008 to ensure that the relevant documentation was included. All documentation was in place. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 22 Three staff files were checked at this visit. The files contained a range of information including two references and a declaration of health and identification. The staff had undertaken a criminal record bureau check (CRB), at the enhanced level. For members of staff recently recruited documentation demonstrated that a Protection Of Vulnerable Adults check had been carried out before they commenced employment. This confirmed thorough recruitment practices were in place, which was sufficient to safeguard people. On examination of the staff training records there were records that indicated the staff had received moving and handling, fire training and other relevant clinical training. Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff were able to talk about the various training courses that they had attended. Over 50 of the staff team had achieved their NVQ Level 2 or above and others were due to commence this training shortly. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including random and key inspection visits to this service. The procedures and ethos of the home ensure that the home is run in the best interests of people who use the service. The homes procedures promote the health, safety and welfare of people who use the service and the staff. EVIDENCE: A manager has been appointed to the service. His position had been discussed with the CSCI.He has submitted an application for registration to become the registered manager. (Previous requirement met) Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 24 The manager has many years experience within the nursing and caring profession. He is committed to ensuring that people staying in the home were consistently well cared for, safe and happy. People staff and relatives said they were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that he would respond to them appropriately and swiftly. The home had a quality assurance system. There was evidence of internal auditing of the homes environment, services and records. Staff meetings were held and minutes of these meetings were seen. The responsible individual visited the home on a regular basis, a report was written following the visits. People who use the service met with the management of the home. A meeting was due to be held next week and this was advertised in the home. These quality assurance systems will help to ensure that the service is operating in the best interest of the people who live there. A sample of monies that was looked after on behalf of people living at the home was checked. Records were kept and money tallied with the records. The fire risk assessment had been reviewed in January 2008. No issues requiring attention were highlighted in the review. Staff said they had received recent fire safety and other health and safety training .A sample of records showed that staff were receiving this statutory training. At the time of the visit fire exits were clear and hazardous products were safely stored in the home. This will promote the safety and welfare of the people. Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 17 Requirement An up to date inventory of each person’s personal furniture, equipment and other belongings must be recorded on their personal file. The information on file must be dated and signed by staff. Previous timescale of 02.04.07 not fully met. Peoples care plans and risk assessments must contain sufficient detail to ensure that people receive a consistent high and safe standard of care. People and/or their relatives must be involved in drawing up and reviewing their care plans. Where handwritten entries are added to medication administration record charts, these must be signed and dated and all relevant information must be included i.e. quantity of medication received. Previous timescale of 25.01.08 not met. A programme of renewal of the fabric and decoration must be produced, and work started to DS0000006470.V362502.R01.S.doc Timescale for action 01/06/08 2. OP7 12,15 01/07/08 3. 4. OP7 OP9 12,15 13 01/07/08 01/06/08 5. OP19 23 01/12/08 Autumn House Nursing Home Version 5.2 Page 27 implement the plan. (Corridors and bathrooms/toilets) 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 OP7 Good Practice Recommendations As a sign of good practice all information relating to people’s needs should be condensed and collated into individual files and the files used as working documents. Previous recommendation. All the people who live in the home should be given the opportunity for stimulation through suitable leisure and recreational activities. Previous recommendation. More and clearer information should be provided to help orientate people to date,time and place. Continue with the rolling programme of redecoration. Toilets and bathrooms should be redecorated and touches added to make them more domestic in style and so less clinical. 2. OP12 3. 4. 5. OP12 OP19 OP21 Autumn House Nursing Home DS0000006470.V362502.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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