Inspection on 15/05/07 for Bank Close House

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Bank Close House 29/04/08

Bank Close House 13/11/06

Bank Close House 06/10/05

Bank Close House 04/05/05

Bank Close House 02/12/04

Bank Close House 28/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Bank Close House Hasland Road Hasland Chesterfield Derbyshire S41 ORZ Lead Inspector Claire Williams Unannounced Inspection 15th May 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bank Close House DS0000019932.V336838.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. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bank Close House Address Hasland Road Hasland Chesterfield Derbyshire S41 ORZ (01246) 208833 01246 208833 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) Vital Balance Ltd Vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus Three (3) Day Care Places Date of last inspection 13th November 2006 Brief Description of the Service: Bank Close House is a large converted 18th Century Georgian building situated close to the centre of Chesterfield. The home is registered to provide personal care for up to 27 residents. Accommodation is spread over two floors and includes 3 double rooms. The care home is a grade 2 listed building, and many of the original features have been retained. The building is set within extensive grounds, and there is a walled garden area accessible to residents. Several communal lounge areas are located on the ground floor and include a conservatory area. There are bathroom and toilet facilities on both floors. There is a stair lift and passenger lift at the Home and a resident call system throughout the building. Information about the service is provided in the Statement of Purpose and Service User Guide; The Statement of purpose is available upon request and residents are given a copy of the Service user guide when they move into this home. The fees for the home range from £360.00 to £422.00. This information was provided on the day of the visit as the pre-inspection questionnaire had not been completed and returned before the inspection. Information about the fees is also included in the Service user guide. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and lasted 10 hours over the period of one day. Additionally, time was spent in preparation for the visit, looking at previous inspection reports and other relevant documents and preparing a structured plan for the inspection. Surveys were sent to the people living in the home in order to gain feedback about the quality of the service, and 1 survey was returned. During this visit time was spent undertaking a brief tour of the service, looking at records and speaking to the residents and staff about their experience of the home. Lunch was spent with the residents and medication was also examined. Three resident’s care files were seen. The inspector had an opportunity to talk to a pharmacy representative and 2 relatives, and their comments have been incorporated into this report. Following consultation with these people, it was agreed that they would be referred to as ‘residents’ for the purpose of this report. What the service does well: What has improved since the last inspection? Some progress has been made to address the previous requirements and recommendations, and some areas of the environment have been redecorated and pipe work has been boxed in, as part of a rolling programme. The Service user guide now includes accurate information about the accommodation fees. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 6 Specialist locks have been ordered and were due to be delivered the day after the inspection visit. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 7 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 Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 8 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, 2, 3, 4, and 5 (standard 6 not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given sufficient information and assessment to ensure they are able to choose a choice of home, which will meet their needs. EVIDENCE: There is a Service user guide and statement of purpose in place at the home, and these documents have recently been up-dated. The Service user guide is provided in written format but also contains pictures to aid the understanding of the contents, which is good practice. Both documents contained the required information to inform people about the service and facilities available, apart from the Statement of purpose, which did not refer to three elements listed in schedule 1. These items will be recommended, for their inclusion, however this information was contained in the Service user guide. All residents are issued with a Service user guide when they move into the home. When asked residents stated that they had enough information about the home, in order to make a decision about their future. Many residents also Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 9 stated that they, or their relative had visited the home before a final decision was made. One resident visited the home for a period of respite and has now decided to remain in residence as she “likes it and feels comfortable and settled”. A blank copy of the contract stating the terms and conditions of stay was examined, and this included all of the required information. The inspector was informed that all residents have copies of their terms and conditions/ contract in their main files, which are stored in a secure place separate from the care plan file. The acting manager stated that she undertakes pre-admission assessments on all individuals before they move into the home. Care managers and any other healthcare professionals that are involved in the individual’s placement also provide assessments so that the management team have the required information to make a decision if the home can meet their needs. The manager stated that she did not routinely confirm in writing that the home was able to meet the resident’s needs following the pre-assessment, but stated that she would now formally write to all prospective individuals. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have their health needs met in a respectful and dignified way although gaps in care planning and management of medicines means their well being is not fully safeguarded. EVIDENCE: Three care files were seen in detail. The manager stated that the staff team are still in the process of changing the care plans over to the new format, but confirmed that some of the old format will remain. This information combined, will provide the staff team with a person centred care plan, as it covers not only the residents support needs, but information on their life history and preferred routine and skills that they would like to maintain. The files contained information about the individuals support needs but none of the files were completed in full, and the care plan elements had not been signed or dated by either the staff member or resident. There was limited evidence to support that the plans of care had been reviewed on a monthly basis. On separate sheets there was an assessment of the residents risk of pressure sores, continence, nutrition, moving and handling, falls and general risks. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 11 There was evidence to support that when a risk was identified, the required action was recorded and the aids and adaptations identified in order to minimise any risks. There was evidence to support that residents have access to healthcare services, such as GP, opticians, dentist and chiropodist. During discussions with residents they stated that they felt they were receiving the care that they required in all areas. Comments from residents included “I’m well looked after here”, “the care is excellent”, “the staff are good they look after us well”. Relatives visiting the home also confirmed that they felt the quality of the care was “excellent ”, and the staff were “very attentive and helpful and communicated well”. There is a core stable staff team, which contributes towards ensuring that resident’s needs are well known by staff. During this visit a pharmacy representative visited the home to undertake an inspection of their medication practices and storage. The inspector spoke with the pharmacy person about the general standards and also undertook a brief inspection of the systems in place, which were generally satisfactory with the exception of the following: Eye drops had not been dated on opening, not all of the medication had been signed in, and although an error was identified in a residents blister pack, no action was taken to inform the pharmacy. Two people did not always countersign-handwritten medication instructions in order to verify them, and this had resulted in medication being written incorrectly for one resident. The inspector noted that some staff was signing the Medication record before they had administered the medication to the residents. The staff spoken with confirmed that they have undertaken the ‘boots accredited training’. There was no evidence to support that the manager has developed and undertaken a medication competency assessment in order to assess the practices of the staff following their training. Residents spoken with and feedback from the surveys confirmed that staff ‘always’ uphold their privacy and dignity and “always” knock on their bedroom door to request permission to enter. An ongoing issue in the home, which effects resident’s privacy, is the provision of locks on doors. The registered provider visited the home during the inspectors visit and stated that the locks were due to be delivered the next day and will be fitted as soon as possible to all doors. The inspector also noted that the double bedrooms did not have privacy curtains installed. Residents confirmed that staff treat them with respect and that they are able to exercise choice in the home such as what they wear and how they occupy their time. There are male staff members working in this service, and both the male and female residents confirmed that they are asked there preferences concerning which gender of the staff team they would prefer to support them in personal care tasks. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to choose their lifestyle, social activity and keep in contact with friends. Social, cultural and recreational activities meet resident’s expectations although more one to one time with staff would enhance their lifestyle. Residents receive a healthy well balanced diet. EVIDENCE: Feedback from the residents/relatives who completed the pre-inspection questionnaires and from the discussions held indicated that residents felt that enough activities were provided that met their expectations. There was a list up in the foyer detailing the week’s activities, which are facilitated on a daily basis including Saturday with Sunday being a day of rest. Residents informed the inspector of the different external entertainers they had watched, and about the outing to Chatsworth the previous week. Residents were looking forward to the annual garden fete and talked about the internal activities they enjoyed such as the Ti-chi, and bingo. One resident stated how they enjoyed working in the garden and enjoyed looking after the flowers. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 13 Resident’s confirmed that they receive visits from their respective churches, and that their relatives could visit them at anytime. The inspector joined the residents for their lunchtime meal. The food provided for that day was written on the menu board and available in the menus, which were located on the tables. Lunch was unhurried and residents were offered various drinks throughout. Residents who were unable to eat without help were given assistance, and those with reduced appetites were encouraged to eat. Observations of staff showed that they were very attentive to resident’s needs throughout. Although a choice for the main meal was not provided residents stated that they are asked their preference and if they don’t like it, then something else is prepared for them. Residents spoke positively about the food and comments included: “the food is excellent, there is plenty of choice, and alternatives are offered if I don’t like what’s is on the menu” “ The food is always nice, I enjoy it everyday”. “I really like the food it’s always tasty”. A resident informed the inspector that they had recommended the choice of the desert for that day, and everyone seemed to enjoy it, so the cook stated she would prepare it again. Another resident stated that the only improvement they could think of for the home was to warm the plates before serving the food as they felt the food would stay warmer for longer. The cook was aware of the different dietary requirements of residents, and actively sought feedback from the residents during the mealtime. A fruit bowl was situated in the dinning area to encourage residents to help themselves. An inspection of the kitchen was undertaken and all storage and systems appeared to be satisfactory. There was evidence to support that the staff involved in catering duties were suitably qualified. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the residents felt that any concerns would be listened to and acted upon, evidence supports that not all complaints are responded to. Residents are safeguarded from risk by the procedures and practices in place. EVIDENCE: The feedback received confirmed that both residents and relatives knew how to make a complaint and indicated that there is someone they can talk to in the Home. A copy of the complaint procedure was on display in the foyer and included all of the required information. The Homes’ records showed that there had not been any complaints received since the last Inspection, but there was evidence to support that an outstanding complaint may not have been responded to and this was discussed. Staff had access to adult protection procedures, which the inspector was informed links in with the Local Authority’s multi-disciplinary procedures. All three of the staff members who were interviewed were aware of the procedures and gave good response on the action to take in the event of witnessing any potential abusive practice. The inspector spoke with the catering staff and the domestic staff who are aware of the procedure but have not received any formal training. There was evidence to support that all care staff have undertaken some form of safeguarding adults training. The manager Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 15 confirmed that there have not been any safeguarding incidents since the last inspection visit. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23, and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the physical layout of the Home enables residents to live in a comfortable environment, improvements are required to make it a homely and well maintained for residents to enjoy. EVIDENCE: A full inspection of the private and communal accommodation was undertaken. All areas of the home were clean well lit and ventilated, and overall, safe and warm. The previous inspection identified several areas that required redecoration, and maintenance work to be undertaken. Although some areas have been improved there is still a lot of work outstanding. As part of the programme of refurbishment and redevelopment, the provider has ordered new communal and bedroom furniture and as stated previously new locks will be fitted. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 17 Discussions with the handyperson confirmed that work to box in the pipe work and fit radiator covers is ongoing and areas deemed high priority are completed first. The bedrooms that require redecoration are also part of the work that he intends to do as part of the rolling programme, and this includes the bedrooms that were identified in the previous inspection report. Residents and their families/representatives expressed high levels of satisfaction with their rooms and the standards of cleanliness. One resident told the inspector that they are really happy with the redecoration undertaken in their room, and they confirmed they had chosen the colour. Some comments were received about the areas that require work to be undertaken, and some residents stated that they do not have lockable storage but this will be provided when the new furniture is fitted. Residents felt that the signage was satisfactory to aid orientation in the building. Although there, is sufficient bathroom and toilet facilities, some of these areas world benefit from an upgrade. In response to the previous inspection, soap dispensers have been fitted but the inspector did note that some areas still had bars of soaps available. From discussions with both the staff and residents it was highlighted that a shower and a wet room would be beneficial to replace one of the bathrooms in the stable block that is currently not used. There have been some ongoing problems with the emergency call system, and three call leads were due to be sent to be repaired. During this period three call leads will be taken from the bedrooms that are vacant so that all residents have this facility in their rooms. The laundry area continues to be under review as it is located in a small area that is not suitable for this facility. The provider stated that he is in the process of drawing up plans and considering varying options for its relocation. The garden areas are well maintained and established providing a large area for the residents to access. Garden furniture and gazebos are available. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported by a competent staff team, and the recruitment practices ensure resident’s welfare is safeguarded EVIDENCE: At the previous inspection of this service there was issues identified around the staffing levels, due to staff vacancies. The manager stated that this situation has improved and there is currently only one vacancy, which has been advertised. Comments from the residents and their family about the staffing levels were mixed, with some people stating that the levels were satisfactory, and some felt that the levels could be improved upon. One comment in the survey stated: “Sometimes staff are not very visible or accessible but can usually be found around the home”. The staff members spoken to also stated that at times due to the dependency levels of the residents it can be difficult, as it takes two staff members to support a resident with their mobility which leaves one staff member working on the floor. The actual number of staff on duty on the day of inspection was consistent with numbers identified on the staffing rota. There was also additional support from cooks, cleaning staff and a handy person. Although mixed comments were received all residents and their family/representatives stated that there support needs were met by the staff Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 19 and positive comments were received which included: “the staff do a marvellous job”, “the staff are always very caring and do what I ask” and “the staff always put themselves out including the manager, nothing is to much trouble.” Similar comments were also seen on ‘Thank you’ cards displayed on the notice in the reception area of the home Three staff recruitment files were viewed and the required recruitment checks had been undertaken, although for one staff member it was unclear if the reason for the gap covered all of the time period identified. The provider stated that new recruitment forms would be implemented soon. The recruitment files for the existing staff still require some improvements in order to ensure they met the current required standards. The staff training is ongoing and a training plan was in place for this year. The acting manager stated that all staff have the required mandatory training in place or are due to attend a course. Training in Dementia care is part of the plan and staff stated that this would be beneficial due to the supports needs of the residents. The pre-inspection questionnaire stated that 70 of the staff have an NVQ (National Vocational qualification) level 2 or above, qualification. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed effectively and the health and safety of residents and staff is promoted, however it would benefit residents if a permanent, qualified and registered manager were in place. EVIDENCE: The acting manager has worked in this role since January 2006 and although she is experienced in this role, an application to register has not yet been received, and no progress has yet been made to enrol on a training course to achieve a management qualification. Discussions held with staff, residents and relatives/representatives during this inspection indicated their overall satisfaction with the way the service is managed. Residents stated that they are consulted on issues and meet Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 21 regularly with the manager. A quality assurance survey has recently been sent out and the inspector was informed that a report would be completed of the findings. Comments received from the surveys received included reference to how residents/relatives felt about the home and these included: “the home is well managed”, and “the manager is helpful and supportive”, “The staff are generally very helpful and there is a good atmosphere”. At the time of the visit residents/relatives and the staff team all commented on how “approachable and supportive the manager was”. The resident’s choose to manage their finances independently or request the manager to supportive them in this task. The finances storage and systems were examined and they were found to be satisfactory. Discussions with the registered provider and general manager indicated that new systems will be implemented to monitor practice and compliance with the home’s improvement/action plans and policies and procedures in place. The pre-inspection questionnaire indicated that all health and safety systems and appliances are monitored and serviced regularly and the Registered manager confirmed this during this visit. A fire risk assessment has been completed, and a hazard risk assessment is currently being completed as required in the previous inspection report. Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 22 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 3 3 2 3 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 2 17 X 18 3 2 3 3 X 3 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 2 X 3 X 3 X X 3 Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 23 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 OP4 Regulation 14 (d) Timescale for action The registered person must write 01/08/07 to the resident following the preadmission assessment to inform them of the outcome and whether the home can meet their needs. The transfer of all care planning information to the new format / files must be completed so that residents have a completed person centred plan so that the staff team can deliver the appropriate support. (previous timescale of 31/01/07 not met) The resident’s plan must be made available and developed with the resident and reviewed on a monthly and annually basis. Eye drops must be dated when opened to ensure they are not used after 28 days. Two staff members must sign handwritten medication instructions in order to ensure they are accurate with the prescribed medication. All medication must be signed in to ensure the residents have the DS0000019932.V336838.R01.S.doc Requirement 2 OP7 15 (1) 01/09/07 3 OP7 15 (2) (a) 01/09/07 4 5 OP9 OP9 13 (2) 13 (2) 01/08/07 01/08/07 Bank Close House Version 5.2 Page 24 6 OP9 13 (2) 7 OP9 13 (2) 8 OP16 22 9 OP19 13 (4) 10 OP31 9 required prescribed medication and to check for any inaccuracies. Staff must not sign the Medication record until after they have administered the medication, to the resident. An assessment of medication competence must be developed and completed on all staff members that administer medication in order to assess and monitor their practice. All complaints must be responded to in accordance with the complaints procedure, and records completed detailing the investigation undertaken and the outcome of this complaint. A programme for the ongoing redecoration, maintenance, refurbishment and installation of locks, and development of the service must be developed with clear timescales for completion of the work. The registered providers must progress the registration of a manager who is to take up relevant training qualifications. 01/08/07 01/08/07 01/08/07 01/09/07 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The Statement of purpose should include reference to how residents will be supported to attend religious services of their choice, the arrangements for dealing with reviews of the residents plan of care, and the experience and DS0000019932.V336838.R01.S.doc Version 5.2 Page 25 Bank Close House 2 3 4 OP7 OP9 OP10 5 OP15 qualifications of the manager and registered provider. Photos of the residents should be on their care file. An auditing system’s should be implemented to monitor the medication practices and systems. Discussions should be held with the individuals who share a room, to ascertain if they would a like a curtain to be installed in their room so that they have privacy when undertaking personal care tasks. Two choices of meals should be made available at all meal times. The catering staff should warm the plates before serving the food as requested by the residents. Consideration should be made about installing a shower in the home. Individual bars of soap should not be left in bathroom areas and liquid soap dispensers should be available. (Repeated from the previous inspection) The staffing levels should be reviewed based on the current dependency of the residents. All personnel files should be reviewed and information obtained were possible so that all files meet the current National Minimum Standards and regulations. Staff should access in training in Dementia care to assist them in their role. A fire risk assessment for the Home should be reviewed and implemented. A hazard analysis of the premises should be completed and an action plan established. 6 7 8 9 10 11 12 OP21 OP26 OP27 OP29 OP30 OP38 OP38 Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. Extracts may not be used or reproduced without the express permission of CSCI Bank Close House DS0000019932.V336838.R01.S.doc Version 5.2 Page 27 - 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!