Inspection on 08/11/05 for Bethesda House

This inspection was carried out on 8th November 2005.

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

Bethesda House 08/01/09

Bethesda House 07/12/06

Bethesda House 13/05/05

Bethesda House 09/02/05

Bethesda House 09/09/04

Bethesda House 01/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Bethesda House Derry Hill Calne Wiltshire SN11 9NN Lead Inspector Alison Duffy Unannounced Inspection 09:30 8 November and 2 December 2005 th nd 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 Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 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. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bethesda House Address Derry Hill Calne Wiltshire SN11 9NN 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) 01249 816666 01249 758877 The Gospel Bethesda Fund Miss Rebecca Wheeler Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (12), Physical disability (1) of places Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 12 service users over 65 years of age no more than 1 male service user with physical disability Date of last inspection 13th May 2005 Brief Description of the Service: Bethesda House is registered to provide care to thirteen older people, one of whom may have a physical disability. The home is one of five throughout the country that is run by the Gospel Standard Bethesda Fund. The Fund is a registered charity that mainly provides care to members of Gospel Standard Churches. It is the choice of residents to adhere to certain beliefs and Bethesda House is run in accordance with these. Residents are expected to attend chapel services and to meet together in the lounge for prayer on a daily basis. Bethesda House is a purpose built detached property. It has one twin and eleven single rooms on the ground floor. All except one of the rooms have ensuite facilities. There is a comfortable lounge and separate dining room. Pleasant, well maintained gardens surround the property. Staffing levels are maintained at a minimum of two care staff on duty during the waking day. At night one member of staff undertakes a waking night and another provides sleeping in provision. Catering and housekeeping staff are also deployed. Bethesda House is not registered to provide intermediate or nursing care. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of two days. The inspection initially commenced on the 8th November 2005 between the hours of 9.30am and 2.30pm. Miss Wheeler was on annual leave and therefore senior carer, Rachel Honeysett assisted the Inspector as required. A tour of the building was undertaken and the Inspector spent time with residents in the communal lounge and within private accommodation. Staffing rosters, the fire log book, care planning information and residents’ daily records were also viewed. A second day was arranged in order to meet with Miss Wheeler and discuss previous requirements and recommendations. Training and supervision formats were also viewed during this time. Unfortunately due to Miss Wheeler being on sick leave it was not possible to conclude the inspection until 2nd December 2005. This took place between the hours of 11.10 and 1.30pm. Throughout the inspection staff were friendly, attentive and hospitality was evident. Residents’ feedback was generally very positive with terms such as ‘absolutely excellent in every way’, ‘perfect’ and ‘marvellous’ used to describe the service received. An increase in external activity and greater consultation processes were suggested as ways in which the home could be developed. What the service does well: What has improved since the last inspection? Since the last inspection attention has been given to the storage of hazardous substances. Rather than being left in bathrooms and unsecured rooms, all materials are now stored securely. Health and safety information including risk assessments has been revised and is now in a clear, well written format. The fire log book demonstrated the satisfactory testing of all systems. Fire drills are also taking place as required which was a requirement identified at the last inspection. Faults are also being documented when rectified. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 6 Eight staff have completed a dementia care training programme and all members successfully passed the related assessment. This enables greater awareness regarding the needs of residents with dementia. Formal meetings have been developed following a requirement at the last inspection to ensure consultation with residents. 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. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 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 Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents have a clear assessment before admission in order to ensure a successful placement. Although intermediate care is a key standard, such provision is not provided within the home and therefore not relevant at this time. EVIDENCE: Discussion took place with one resident who has recently been admitted to the home. It was reported that visits to view the accommodation were available before admission although these were declined due to an awareness of the home. The resident felt totally satisfied with the service received and believed all her needs to be met. Such assessment documentation was viewed and detailed information was apparent. Within the information, medical history was noted and included some medical terminology for conditions. In order to give greater understanding, such terms would benefit from greater explanation including a portrayal of symptoms relevant to current need. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 Although many care plans are detailed and up to date, some additions are required in order to ensure all needs are fully identified and met. Systems are in place to ensure residents’ rights to privacy are upheld. EVIDENCE: A number of care plans were viewed and in general, all were detailed, easy to read and up to date. It was evident within one plan however that one resident has an ulcer. A nutritional and pressure care management assessment had been undertaken and both highlighted risk. Detail within the plan of care however did not fully reflect this. Such detail only included the use of creams and encouraging a healthy diet. There was also a suggestion that the resident was losing weight yet food intake and the management of meals were not evident. Within another resident’s daily record ‘can be reluctant to eat’ was highlighted although the eating and drinking section of the plan described the resident as eating well. Another resident was identified, as at risk of developing a pressure sore, yet such information was not given attention within documentation. Miss Wheeler was therefore advised to ensure that all documentation such as assessments correspond with individual plans. Intervention in relation to specific need must also be identified. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 10 During the serving of lunch, there was an incident in the dining room. Due to the complexity of the situation, staff were unsure regarding the most appropriate way to resolve the situation. The matter was discussed and to ensure consistency, it was evident that such guidelines should be agreed within a review setting and documented within the resident’s plan of care. Some photographs of residents are available within documentation although not all are apparent. Miss Wheeler reported that photographs of all residents have been taken yet have not been processed. A requirement has therefore been made to address this matter. During the inspection, the inspector was able to tour the building unattended and speak with residents both in communal areas and private accommodation. It was noted when entering individual rooms, all staff either knocked or called out to the resident before entering. Residents were asked to undertake personal care in a respectful manner and this was given appropriately, in a private manner. Residents reported that staff are excellent and respect wishes of wanting to spend time alone. It was also reported that there is never any pressure to join in activities or go to the dining room for meals if you don’t want to. The medication systems were not viewed on this occasion. At the last inspection however it was noted that the homely remedies policy had not been signed by a GP and some hand written instructions had not been countersigned. Staff have addressed the countersigning of medication although the homely remedies list is still awaiting a GP’s signature. Miss Wheeler reported that the list was ready for the GP’s attention on his next visit. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 Significant attention is given to residents’ spiritual needs and this is greatly appreciated by residents. Additional organised activity is limited yet residents appear content with following their solitary interests. Greater external activity and consultation is in need of development following individual requests of residents. Visitors are welcome yet avoiding times of services is expected. EVIDENCE: Through discussion it was evident that the spiritual aspect of the home continues to be extremely important. A service took place, as is usual practice, during the morning of the inspection with attendance of both residents and staff. Residents continue to be able to listen to services in their own rooms and transport is provided to church on a regular basis. Activity is generally centred on spirituality although on the morning of the inspection a craft morning was also being held. A volunteer reported that attendance is optional although many residents enjoy the social occasion as well as the tasks undertaken. Products made within the session are then sold within coffee mornings in the home. Residents appeared happy with current arrangements for in house Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 12 activities, stating that solitary interests such as reading are also important and followed enthusiastically. It was reported however that greater external events would be of benefit. A number of residents enjoyed a trip to Westonbirt Arboretum earlier in the year yet a trip into town or around the villages was suggested as an option. One resident highlighted that the home has its own transport and therefore increasing its usage would not be too difficult. This was discussed with Miss Wheeler and it was evident that such trips required volunteers and a driver, which at times were not plentiful. To address such issues, smaller groups were advised. A drive, as suggested by some residents, would also require fewer resources. Miss Wheeler reported that she would investigate options available. At the last inspection, a requirement was made to develop communication systems with residents as it was reported that this aspect was lacking. During this inspection, some residents who were asked reported no change. Miss Wheeler stated however that a number of informal meetings over coffee had taken place and records demonstrated such. Miss Wheeler was therefore advised to give consultation greater profile and display meeting meetings and further agendas on the notice board. It was also suggested that residents could be given their individual copy of the minutes. Within the inspection discussion took place with a relative of a resident. Feedback was extremely positive and it was reported that visitors are always made to feel welcome. Family contact is encouraged and visits to family homes are promoted. The home has a visiting policy, which states that visitors are welcome although are encouraged to avoid Sundays due to various services and the need for residents to rest in between. Meal arrangements were not assessed on this occasion although through discussion many residents gave positive feedback about the food provided. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a detailed complaint procedure yet the development of residents’ meetings would give residents greater opportunity to raise any issues and feel they are being listened to. While adult protection policies have been updated, some staff have not undertaken adult protection training. This compromises residents’ safety in terms of staff recognising signs of abuse. EVIDENCE: The home has a detailed, up to date complaints procedure, which is available on the notice board in the office. Miss Wheeler confirmed that there have been no formal complaints since the last inspection. As stated earlier in this report, further development of residents’ meetings would enable greater opportunities for consultation and the sharing of views. This would develop the culture of residents feeling that they are being listened to, which was raised as an issue at the last inspection. The home has a suggestion box in the entrance area of the home. Any issues can therefore be placed anonymously. Within the inspection, a relative reported, in the unlikely event of dissatisfaction they would be able to talk to Miss Wheeler as required. The relative continued to state that all staff are extremely approachable and therefore any difficulties with raising issues were not envisaged. Since the last inspection Miss Wheeler has revised the home’s adult protection policy. The policy now incorporates multi-agency working and contact details are clearly stated. Miss Wheeler has undertaken formal adult protection Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 14 training and has facilitated some in house training sessions for staff. Additional sessions are planned in order to ensure all staff are targeted. Residents are encouraged to manage their own financial affairs for as long as they are able although some have given the responsibility to family members or other representatives. A small amount of money is kept for safekeeping on behalf of some service users. Balance sheets contained two signatures with all expenditures and numbered receipts as appropriate. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 25 The home is comfortable, clean and furnished to a good standard. Attention to radiators covers has ensured residents’ protection yet the absence of individual temperature controls on all hot water outlets create potential risks to residents. EVIDENCE: A tour of the accommodation was undertaken and all areas were noted to be clean, homely and furnished to a good standard. All residents’ private accommodation was individually furnished and reflected personal preference and style. Televisions however are not permitted in private accommodation. At the last inspection it was noted that the slope leading up to the communal areas from private accommodation proved difficult for some residents. This matter has been addressed within individual plans of care as appropriate. The building appeared well maintained and covers have been fitted to all radiators accessible to residents. At the last inspection Miss Wheeler reported that individual fail-safe devices had been ordered for all hot water outlets. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 16 Although purchased, Miss Wheeler has had difficulty in finding a plumber to fit such and therefore hot water remains, at this time, controlled at a central point. Miss Wheeler reported that a recent quote highlighted fitment for the New Year and therefore the requirement made at the last inspection has been repeated with a new timescale. The home has assisted bathrooms and a walk in shower. Within one bathroom however it was noted that a prescribed barrier cream for a named individual was unopened and stored on the windowsill. There were also a number of old, cracked bars of soap and a nailbrush. Miss Wheeler was informed of the need to store the barrier cream appropriately in order to ensure the identified resident’s sole use. Miss Wheeler was also advised to remove the nailbrush and soap in respect of infection control guidelines. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 Staffing levels are being maintained as required by the previous Registration Authority. While training is given priority within the home, additional topics such as sensory loss would give staff greater knowledge and understanding of some residents’ conditions. EVIDENCE: During the waking day there continues to be two care staff on duty. There are also domestic staff and a cook. At night one member of staff undertakes a waking night and another provides sleeping in provision. At the last inspection it was noted that Miss Wheeler undertakes a significantly high level of care shifts as part of the working roster. Miss Wheeler reported that this was not a usual occurrence and was only for a temporary basis. However within this inspection the situation remains the same. Miss Wheeler confirmed that designated management time is readily available and usually only a proportion of her shifts are involved in care provision. All residents spoken with were extremely positive about the staff. Comments such as ‘nothing’s too much trouble’ and ‘they make you feel better through giving you time’ were views given during discussion. At the last inspection it was noted that personnel and training records did not demonstrate the training that has been undertaken. A requirement was therefore made to ensure all information was up to date and was evidenced Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 18 through certificates. Miss Wheeler reported that this matter has been addressed although personnel files were not viewed on this occasion. Mrs Honeysett reported that eight staff have recently undertaken dementia care training and each member passed the related assessment. All staff are up to date with their mandatory training and the NVQ programme is progressing well. Miss Wheeler confirmed that at present 35 of the team have NVQ level 3 and 52 have NVQ level 2. Within a resident’s plan of care it was recorded that a resident’s hearing was at times selective. It was apparent that the resident could hear sounds such as an organ, the wind or an aeroplane but not voices. This was discussed with Miss Wheeler and rather being selective, the resident could be responding to certain tones. The home has not had any recent sensory loss training and therefore this was recommended in order to ensure greater understanding. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 and 38 Although the home has a quality assurance system, this has been neglected and requires further implementation. Satisfactory systems are in place to manage small amounts of residents’ money for safekeeping. The home has an established formal supervision system yet most benefit appears to be gained from informal supervision on a daily basis. While attention is given to health and safety matters, greater clarity is required within a number of situations to ensure the individual safety of residents. EVIDENCE: The home has a quality assurance system although Miss Wheeler reported that recent work has been limited. As the end of year is busy, Miss Wheeler reported that she is planning to send out questionnaires to residents, their Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 20 families and interested parties after the New Year. A self-audit of the home will also be undertaken at this time. On this occasion, as the work is planned a requirement to address such, has not been made. Shortfalls however at the next inspection will result in an agreed timescale for action. Residents are encouraged to manage their own financial affairs for as long as they are able although some have given the responsibility to family members or other representatives. A small amount of money is kept for safekeeping on behalf of some service users. Balance sheets contained two signatures with all expenditures and numbered receipts as appropriate. Miss Wheeler has recently reviewed all training information and now ensures that this is linked to formal supervision sessions. One supervision record as an example was viewed although on this occasion, detailed attention to a number of records was not given. Miss Wheeler reported that formal supervision was working well for many although informal supervision on a daily basis, due to the size of the home, was used as a forum to discuss potential difficulties. The home appears well maintained and health and safety is given considered attention. Following a requirement at the last inspection, accident reports now contain more information and risk assessments have been updated in a clear, concise format. Hazardous substances such as bathroom cleaner are now securely stored and the sluice was locked appropriately. Within a resident’s daily notes it was evident that soaking alone in the bath was enjoyed. Miss Wheeler confirmed that control measures had been identified although the assessment had not been documented. Miss Wheeler was therefore advised to formally assess such and keep the assessment under review. The fire log book was viewed and all checks had been satisfactorily recorded. A fire drill had taken place as required and all fire instruction was up to date. A recommendation made at the last inspection to ensure that any problem identified with the fire safety equipment, is recorded once rectified has been addressed. Within a tour of the accommodation it was noted that one resident has cot sides in place. Miss Wheeler has undertaken a risk assessment although specialist input has not been gained. Mrs Honeysett reported that the cot sides are an integral part of the bed and staff use fleeced material to minimise any possible injury with the structure of the rails. This was acknowledged although a professional assessment is required to ensure full safety. Within documentation it was evident that one resident is at times disorientated and may wander around the home. The documentation highlights that the resident cannot be observed throughout the 24hour period and the back door is highlighted as a risk. The record continues to explain that the door cannot be alarmed due to its access to staff and tradesmen. This matter was discussed with Miss Wheeler and it was reported that the door is no longer an Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 21 issue with any resident. The matter must however be kept under review and be addressed accordingly. Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X 3 2 X STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 X 2 Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 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 OP7 Regulation 15 Requirement The Registered Person must ensure that any risk highlighted within an assessment is fully addressed within the individual resident’s plan of care. The Registered Person must ensure that written guidelines are available to staff in relation to the identified incident. The Registered Person must ensure that each resident has an up to date photograph on his or her care plan. The Registered Person must ensure that residents are safeguarded from the risks of hot water by fitting individual temperature controls. This was identified at the last inspection and although the controls have been purchased, fitment is required. The Registered Person must ensure that barrier creams are stored appropriately to enable single use of the intended resident. The Registered Person must DS0000028561.V261435.R01.S.doc Timescale for action 31/01/06 2. OP7 15 31/01/06 3. OP7 17 Schedule 3, 2 13(4) (a)(c) 31/01/06 4. OP25 31/01/06 5. OP26 13(3) 02/12/05 6. OP38 13(4)(c) 13/01/06 Page 24 Bethesda House Version 5.0 7. OP38 13(4)(c) ensure that a specialist health care professional assesses the identified cot sides and fully documents the agreement for their use. The Registered Person must ensure that a documented risk assessment is developed in relation to residents being in the bath unattended. 13/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP9 Good Practice Recommendations The Registered Person should ensure that all medical terminology is explained giving a portrayal of symptoms, which are relevant to current need. The Registered Person should ensure that a GP signs the homely remedies list. This was identified at the last inspection. The Registered Person should ensure that consideration is given to the options available to maximise residents’ external activity. The Registered Person should ensure that resident meeting minutes are displayed on the notice board and a copy is given to all residents. The Registered Person should ensure that consideration is given as to how residents may have access to single use soap and nailbrushes. The Registered Person should ensure that all staff undertake sensory loss training. 3. 4. 5. 6. OP12 OP12 OP26 OP30 Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bethesda House DS0000028561.V261435.R01.S.doc Version 5.0 Page 26 - 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. 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