CARE HOMES FOR OLDER PEOPLE
Barnfold Cottage 400/402 Blackburn Road Westend Oswaldtwistle Lancashire BB5 4LZ Lead Inspector
Mrs Pat White Unannounced Inspection 27th September 2007 10:00 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 DS0000009428.V345383.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. DS0000009428.V345383.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Barnfold Cottage Address 400/402 Blackburn Road Westend Oswaldtwistle Lancashire BB5 4LZ 01254 381348 F/P 01254 381348 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) Mrs Diann Judith Webster vacant post Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (13) DS0000009428.V345383.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The care home may provide a service for : Up to 13 service users in the category OP (Old Age) 1 service user in the category MD (Mental Disorder under 65 years) 5th July 2006 Date of last inspection Brief Description of the Service: Barnfold Cottage is situated on the main road between Oswaldtwistle and Blackburn. There are garden areas on both sides of the building and a tarmac patio area to the rear. There is parking at the rear of the premises and on the road at the front. The home is close to local shops, and on a bus route to the town centres of Blackburn and Accrington. The home provides accommodation in 10 single bedrooms and 2 double bedrooms. There are two communal lounges, a smoking lounge and a dining room. The accommodation and facilities are on two floors that are linked by a stair lift. The weekly fees charged at the time of this inspection were between £295 and £355, with additional charges for hairdressing, magazines and newspapers. The home had a Statement of Purpose and a Service User Guide providing information about the care provided, the qualifications and experience of the owner and staff and the services residents can expect if they choose to live at the home. DS0000009428.V345383.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection site visit was carried out on the 27th September 2007. The site visit was part of an inspection to determine an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Older People, and checking the progress made on the matters that needed improving from the previous key inspection. The inspection included: talking to residents, touring the premises, observation of life in the home, looking at residents’ care records and other documents and discussion with the registered manager. Seven residents spoke about their views on the home. In addition survey questionnaires from the Commission were sent to residents, relatives, staff and health professionals asking them for their opinion of the home. Five residents, eight relatives, two doctors and six members of staff returned these questionnaires. Some of the views of these people are included in the report. In addition the home provided the Commission with written information about the residents, staff and services provided, and some of this is also included in the report. What the service does well:
Residents told the inspector that staff were “ very kind” and that, “we are very well looked after”, and one said, “you couldn’t wish for a better place”. Residents who were spoken with at the visit to the home and those who completed questionnaires said that the staff were attentive and available when needed. Residents were satisfied that the home’s routines were flexible enough to suit their individual preferences. Residents could get up and go to bed at times of their choosing, and eat their meals when and where they chose. There was some useful written information about what staff had to do to look after people and about how people wanted the care to be provided. There was also good written information about people’s preferred routines and “likes and dislikes”. Most residents praised the meals that were served, and one stated that staff went to the trouble of cooking her favourite meals. Residents appreciated the choice of two main courses and desserts at the main (midday) meal. There was also a good choice for breakfast, including a cooked option. DS0000009428.V345383.R01.S.doc Version 5.2 Page 6 The home was comfortable, clean and homely. Residents spoke favourably about their bedrooms. The manager, deputy manager and some of the care staff had worked in the home for a number of years. This meant that a group of staff, familiar to the residents, understood their needs and knew how to look after them. The home’s training courses for staff were being developed to make sure that staff were properly trained to look after the people who lived in Barnfold Cottage. The home was a safe place for the residents to live in, and all the necessary parts of the premises and equipment had been maintained and serviced. What has improved since the last inspection?
The way that residents were admitted to the home had improved and the manager had made sure that no one had been admitted to the home without meeting them first, and finding out if they could be properly looked after in the home. The information added later about how people needed to be looked after had also improved so that staff had some information about all the matters for which people needed assistance and also about things that people could do for themselves. The practices followed when giving people medication had been made safer so that residents received the right medication at the right time. There were a number of further improvements to the premises. One bathroom had a new bathroom suite and the dining room had been decorated and refurnished. The outside areas had been re-designed and tidied and had attractive ornaments and plants. There was a pleasant seating area for the residents to enjoy in good weather. The training that staff were doing had improved and more staff had the qualifications recommended for people working in care homes. This included National Vocational Qualifications for people working in care and training in dementia. This enabled staff to understand the residents’ needs and look after them better. The way the residents’ finances were managed had improved - better records were kept and any money belonging to the residents was stored more safely. DS0000009428.V345383.R01.S.doc Version 5.2 Page 7 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. DS0000009428.V345383.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection DS0000009428.V345383.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedures, including pre admission assessments and visits to the home, helped to ensure that the staff could meet people’s different needs. EVIDENCE: There was useful information about the home – The Statement of Purpose and the Service User Guide – which met legal requirements, but the Statement of Purpose still did not fully explain the pre admission assessment procedures and emergency admissions. In the questionnaire surveys residents and most relatives felt that they had enough information prior to moving into the home and had enough info to help them make decisions. The records viewed of two residents admitted since the previous site visit to the home showed that satisfactory pre admission assessments had been undertaken including a moving and handling assessment and an assessment of the risk of falling. The relatives had looked around the home before a decision was made to help establish whether or not the home was suitable. For one
DS0000009428.V345383.R01.S.doc Version 5.2 Page 10 younger resident a comprehensive mental health assessment had been undertaken prior to admission, as well as an in house assessment, in order to ensure that the home could meet this person’s needs. The registered person had confirmed in writing that the home could meet the needs of prospective residents. Residents indicated that in general the home was meeting their needs. Those spoken with stated that they were well looked after and that staff were attentive and caring. The younger person with different needs to those of the majority of the elderly residents said that he was satisfied with the support given from staff and the lifestyle he was able to lead. In the questionnaire surveys most relatives said that the care home “always” met the needs of relative, 2 said “usually” and 1 said “sometimes”. Some relatives also felt able to say that the different needs of all the residents appeared to be met and that people were able to live the life they chose. One General Practitioner who completed a survey also agreed with this view. DS0000009428.V345383.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the residents were met and in general the medication procedures and practices ensured the safe adminsitration of medication. The residents’ rights to privacy and dignity were upheld. EVIDENCE: All residents had care plans, and which had been improved since the previous inspection. They now contained some useful information about all relevant matters to assist staff understand the care and support required. There was a useful section called daily living pattern which gave information about residents preferred routines and likes and dislikes. As stated in the previous section the care plans had useful information about moving and handling requirements and how to minimise the risk of falling. However on one care plan looked at there was insufficient detail in some aspects of mental health and the support needed, and also the written assessment of risk regarding going out of the home was confusing and unclear as to what support was required to protect the resident. There was evidence that the care plans had been reviewed appropriately and updated as necessary.
DS0000009428.V345383.R01.S.doc Version 5.2 Page 12 Records viewed, discussion with the manager and the questionnaire surveys showed that residents received the health care they needed, including mental health support, and this was supported by nutrition assessments and pressure area assessments. However for one resident whose records were looked at and who was assessed as being at risk from developing pressure areas, not all the preventative care being given was written in the care plan. In the survey residents stated that they always or usually received the care and support they needed and that staff were available when needed. All the residents said that medical support was “always” available when needed. The relatives who completed the survey said the residents received the care and support expected and agreed. Both General Practitioners said that the care home followed their advice and met the residents’ health care needs. One said - “ good care of the elderly – a well managed home”. Residents’ medication in general was managed and administered safely, and a number of legal requirements from the previous inspection had been met. The home had comprehensive policies and procedures that covered all the necessary parts of medication management, and a number of good practices were followed: Accurate records of medication entering and leaving the home were kept, staff verified the medication with the GP when people were admitted and prescriptions were checked at the chemist prior to dispensing. A number of residents were prescribed controlled drugs and these were stored and administered safely. At the time of the inspection staff responsible for administering medication had undertaken suitable training. However a few improvements could be made. Although there was useful written information for when and how to administer “when required” (PRN) and variable dose medication for some residents, this was not available for all residents. Also for one resident whose records were viewed there were insufficient instructions on the Medication Administration Record about how this should be administered and whether or not it should be given on an ‘as required’ basis. For another resident whose medication was checked one tablet was missing from the blister pack and this had not yet been rectified. Residents spoken with said that staff treated them appropriately and respected their right to privacy, such as being able to stay in their bedrooms if they wished, including having their meals there. In the questionnaires a relative said that, “staff are very kind”. Another said that “staff visibly care for the residents. The two General Practitioners who completed the survey questionnaires also felt that residents’ privacy and dignity was upheld. DS0000009428.V345383.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle experienced in the home suited the needs and preferences of the residents but the choice and frequency of suitable leisure activities could be improved. Residents had sufficient choices in their everyday lives and were enabled to maintain contact with their relatives and the community. The food served was appetising and wholesome but did not suit the preferences and tastes of all the residents all the time. EVIDENCE: The routines of daily living were flexible to suit individuals’ preferences, and some of these preferences were written on the care plans. Residents spoken with stated that they could get up and go to bed at times of their choosing and that there was a choice of meals and where to eat the meals. Residents were asked at residents meetings what leisure activities they would like, and some enjoyed games of Bingo and quizzes. Residents spoken with confirmed that they enjoyed the visits of a musical entertainer. Residents’ religious preferences were observed and ministers from different churches visited the home. However of those 5 residents who completed the survey only one said there were “always” suitable activities, 2 said “usually” and 2 said “sometimes”. Also one relative was concerned that the home did not have the
DS0000009428.V345383.R01.S.doc Version 5.2 Page 14 facilities to communicate effectively with residents with hearing impairment. Another relative thought there should be more “physical exercise”. Community contacts were encouraged and visitors were welcome in the home at any reasonable time. Some residents benefited from going out with relatives. In the questionnaire survey most relatives felt that the home always kept them in touch with important matters or helped the residents keep in contact. One said the home only “sometimes” did. Residents could exercise choice in some areas of their lives. They could bring small items of furniture to personalise their rooms, and as stated above there was choice in such matters as rising and retiring times, whether or not to stay in their rooms, leisure activities and in the food served. The residents survey questionnaires showed residents were generally satisfied with the food served. Residents spoken with said that the food was good and one resident confirmed that the staff were very obliging and would make things that were not on the menu. Menus looked at showed an acceptable range of fairly traditional English dishes such as meat pie and roast dinners. There was a choice of two main (cooked) dinners and desserts each day and a choice of snack meals at tea -time. Drinks and snacks were served throughout the day. The dinners served on the day of the site visit looked appetising and wholesome. However in the questionnaires only one resident said they “always” liked the meals and 4 said “usually”. One said that they “were fed up with sandwiches at tea time”. Also some relatives commented that they felt the food could be improved. DS0000009428.V345383.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure was accessible to most residents and visitors and residents stated that they knew who to speak to if they had any concerns. There were satisfactory policies and procedures to protect the residents from abuse. EVIDENCE: The home had a suitable complaints procedure, and the questionnaire survey showed that most residents and relatives knew how to make a complaint and who to speak to if they were not happy with any aspect of the service. One resident and one relative however said they did not know how to make a complaint. Relatives also felt that the home responded appropriately to their concerns. The information supplied to the Commission showed that only one formal complaint had been made since the previous inspection and this had been investigated thoroughly. Residents that were spoken with stated that they had no complaints. The home had a “ protection of adults from abuse” policy and procedure, that included a whistle blowing policy, and that was in accordance with Government guidance. As several members of the registered persons family worked in the home, staff were encouraged to inform the deputy manager of concerns about poor practice and behaviour, to help further protect residents. There had been no allegations or suspicions of abuse within the last 12 months. Staff had undertaken relevant training as part of their “National Vocational Qualification” courses, and the homes training records showed that staff had also undertaken in house training in “adult abuse”.
DS0000009428.V345383.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): 19, 20, 23, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was comfortable, clean and furnished and decorated to a satisfactory standard. However some areas were in need of repair. Communal and private areas suited the needs of the residents. EVIDENCE: The location and layout of the home was suitable for it’s stated purpose and some aspects of the premises had been improved since the previous inspection. The dining room had been decorated and re furnished and the side gardens had been attractively landscaped with ornaments and plants. These areas were accessible to residents. The communal areas of a two part lounge and a dining area and a smoking area were adequately furnished and decorated and domestic in style, and accessible to residents.
DS0000009428.V345383.R01.S.doc Version 5.2 Page 17 The bedrooms were clean and adequately furnished and residents had brought some personal possessions with them. Residents stated they were satisfied with their rooms and were comfortable. The manager stated that regular audits of the premises were now being undertaken to identify jobs that needed doing and that these were prioritised. However several matters were discussed with the manager, including unsightly bulges in some bedroom ceilings due to a leaking water cylinder, wheelchair damage on doors and door - frames and a faulty hot water tap in the downstairs shower room. All areas of the home that were viewed were free from offensive odours and the general cleanliness of the home was of a satisfactory standard. Residents who completed the survey questionnaires stated they were satisfied with the standard of cleanliness in the home. The laundry was situated in an “out house” at the back of the property and the information supplied to the Commission said that the laundry had been made cleaner and was checked more regularly. Laundry procedures were found to be satisfactory at a previous inspection and staff had undertaken training on infection control. DS0000009428.V345383.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): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of staff on duty was adequate for meeting the physical care needs of the residents and they, and relatives, were satisfied that the staff had the right knowledge and skills to look after people. The staff recruitment procedures were sufficiently thorough to help protect residents from unsuitable staff. EVIDENCE: There was evidence from the site visit, discussions with residents and staff and the staff questionnaires completed, that the numbers of staff on duty were adequate for meeting the needs of the residents. However care staff carried out cleaning and catering duties as part of their routine shifts – there were no designated domestic hours. At the time of the site visit this arrangement appeared satisfactory for maintaining standards of cleanliness in the home and meeting the physical care needs of the residents. However there was no evidence to indicate that this staffing arrangement was sufficient to assist all the residents in fulfilling activities (see “Daily Life and Social Activity”). All residents spoken with stated that they didn’t have to wait long for staff to attend them. Four residents who completed questionnaires said, staff “were always available when needed” and one said “usually”. However one relative stated in a questionnaires that the home, “could be improved by having more staff on duty”. The manager agreed that the staffing arrangements would be kept under review as the needs of the residents changed or more residents were admitted.
DS0000009428.V345383.R01.S.doc Version 5.2 Page 19 Information given to the Commisssion prior to the site visit and staff training records showed that 75 of staff were trained to at least NVQ level 2. Records, including individual staff records, and discussion with a member of staff, showed that the staff training programme was also being developed according to Government guidelines and the needs of residents and staff. Since the previous inspection staff had undertaken training in dementia, medication and infection control. Most staff who completed the questionnaires felt that the Induction training undertaken when first commencing work, and subsequent training, was useful and relevant and gave them the knowledge and skills to look after people properly. However one member of staff stated that the training was unsatisfactory and that she only sometimes felt she had the right skills and knowledge. Relatives who completed the questionnaires were generally felt that staff had the right skills and knowledege to carry out their work. There had been no new staff recruited since the previous inspection so recruitment procedures were not assessed at this site visit. However at the last inspection these procedures were found to be satisfactory and helped to prevent unsuitable staff from working in the home. The six staff who completed questionnaires said that the required police checks and references had been sought. DS0000009428.V345383.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): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent, qualified and experienced people managed the home, and residents’ views were taken into account. The health, welfare and safety of residents and staff were promoted. EVIDENCE: The home benefited from a stable management team. The registered person worked in the home as the manager, and there was a deputy manager. Both the registered person and the deputy manager had completed the relevant qualifications and attended other relevant courses. The staff who completed the questionnaires said that the manager was supportive, and some staff said that there was a good atmosphere in the home and that the home was “a happy environment”. Regular staff meetings and residents meetings were held to assist communication within the home.
DS0000009428.V345383.R01.S.doc Version 5.2 Page 21 At the time of this site visit the home’s quality monitoring measures consisted of finding out the views of the residents mainly through informal systems such as discussions with individuals and residents’ meetings. Service quality monitoring questionnaires were sometimes used, but there was no evidence that a recent survey had been undertaken or that the views of relatives or visiting professionals had been sought. Residents’ finances were managed safely. Appropriate records were kept of the fees paid by residents and records of residents’ spending money received in the home, and spent on their behalf, were now being kept. However for one resident the records did not reflect an arrangement with the relatives and did not sufficiently protect those involved. The health and safety of the residents and staff were promoted. Members of staff had the necessary health and safety training. The home’s fire precautions and records were satisfactory. The electrical wiring and the gas appliances had been appropriately tested. There was a rolling programme of training in health and safety matters such as moving and handling, first aid and food hygiene. Since the previous inspection staff had undertaken training in infection control. However the Commission was not being notified of all “notifiable incidents” under the Care Homes Regulations, such as falls, so these could not be monitored. DS0000009428.V345383.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 2 x 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 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 x x 3 3 2 3 STAFFING Standard No Score 27 3 28 4 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 x x 3 DS0000009428.V345383.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 13(4)(c) Requirement Timescale for action 03/11/07 2. OP7 15& 17(1)(a) Sch3,3n 3. OP25 23 (2)(b) 4. OP38 37 The risk assessment regarding a resident leaving the home and the procedures to follow must be accurate and clear Following the completion of a 03/11/07 risk assessment for those residents vulnerable to pressure areas all preventative care and intervention required must be recorded on the care plans. All parts of the home must be 03/11/07 kept in sound construction and in a good state of repair including the water cylinder in the loft and the damaged bedroom ceilings. The registered person must inform the Commission when the hot water cylinder and the ceilings have been repaired. The registered person must 03/11/07 ensure that the Commission is notified of all incidents that affect the health and welfare of the residents, including falls DS0000009428.V345383.R01.S.doc Version 5.2 Page 24 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 details of the pre admission assessment procedures, emergency admission procedures and examples of how residents’ privacy and dignity are respected. The care plan should contain sufficient information about all aspects of health, personal and social care, including mental health needs, to help staff understand and provide the right care and support. The manager should ensure that there is a timely supply of all medication and that an accidental loss of tablet is immediately reported to the pharmacist and the tablet replaced. There should be written instructions for the administration of all “when required” medication which includes the signs/indicators of when this should be given as well as information about minimum and maximum doses. The registered person should review the leisure activities in the home and ensure there are suitable activities for all including those with hearing impairment. The communication facilities in the home should also be reviewed and improved if possible for people with hearing impairment. The registered person should ensure that all relatives are kept in touch with all relevant matters affecting their relative. All parts of the home should be adequately maintained and in a good state of repair including damaged doors and door frames and carpets. The registered person should ensure that the staff training programme meets the needs of all the staff. It is recommended that the home developes formal quality monitoring systems that include the views of residents relatives, staff and visiting professionals. The records kept of the spending money for one resident should accurately reflect the amount given to her. 2. OP7 3. OP9 4. OP9 5. OP12 6. 7. 8. 9. 10. OP13 OP19 OP30 OP33 OP35 DS0000009428.V345383.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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
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