Inspection on 31/08/06 for Blackthorns

This inspection was carried out on 31st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Blackthorns 23/05/07

Blackthorns 18/01/06

Blackthorns 09/06/05

Blackthorns 14/03/05

Blackthorns 20/10/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Blackthorns 21-29 Dooley Road Halstead Essex CO9 1JW Lead Inspector Kay Mehrtens Final Unannounced Inspection 07:30 31st August 2006 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 Blackthorns DS0000017771.V300600.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. Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blackthorns Address 21-29 Dooley Road Halstead Essex CO9 1JW 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) 01787 472170 01787 476342 Runwood Homes Plc Manager post vacant Care Home 44 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (44) of places Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 44 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 23 persons) The total number of service users accommodated in the home must not exceed 44 persons Staffing levels will be monitored over the first six months and will be reviewed with the inspectors six months after the date of the registration The registered person must not admit persons subject to the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 18th January 2006 Date of last inspection Brief Description of the Service: Blackthorns provide residential care for thirty-nine residents within a four units. The home has a large lounge for all service users and each of the four units has its own communal area. The home is purpose built; recent building work has increased the number of registered rooms to 44. The home also provides accommodation for 5 people on a short-term respite basis. Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 31st August 2006 lasting 10 hours. The inspection process included: discussions with the senior member of staff on duty; the deputy manager, (Terena Doyle), who came in as the acting manager was on leave; the providers’ representative (Emerson Kupfwa), care staff, cook, service users, six relatives/visitors and feedback from four returned service user surveys; a tour of the premises and inspection of a sample of policies and records. The key standards were covered. Of the four requirements, from the last inspection, only one was addressed. The remaining outstanding requirements are commented upon in this report. The staff were welcoming and helpful throughout the inspection. The fees, for the home, range from £407.58 to £429.03. There are additional costs for activities, trips, hairdressing and personal items. What the service does well: What has improved since the last inspection? Some of the window frames have been replaced with new double glazed windows and frames. The arrangements for respite residents has improved in that they no longer move from the home to the day care centre each day. Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 6 The staff have worked hard, through their own fundraising, to provide the residents with a pleasant courtyard garden and B-B-Q area. The provider provided new garden furniture. 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. Blackthorns DS0000017771.V300600.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 Blackthorns DS0000017771.V300600.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Pre admission assessment records contained determine a prospective service user’s needs. sufficient information to This home does not provide intermediate care and therefore Standard 6 is not relevant to this service. EVIDENCE: The Statement of Purpose needs amending to reflect some of the changes in the service if it is to meet the requirements of the National Minimum Standards (NMS). The current version does not reflect the changes in manager, responsible person, staffing structure and the additional charges to residents for activities, which are not funded by staff fundraising events. A sample of residents’ files examined contained good assessments of needs, including social, psychological, health and spiritual needs; providing sufficient Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 9 introductory information from which the home could determine whether they could meet the needs identified and commence an individualised plan of care. One resident, who had been recently admitted, was attending their placement review with their social worker and family, on the day of the inspection. They told the inspector that they “liked the home, felt well cared for, had a clean room and wanted to stay at the home, if “they will have me!” The social worker told the inspector that they “were pleased with the contract and residents placed at the home want to stay”. There was evidence that respite residents are now provided with a contract/agreement for their stay. Blackthorns DS0000017771.V300600.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. The standard of care planning across the home was not consistent. Medication administration was good. Residents stated that they were treated with respect by the staff. EVIDENCE: Care plans sampled showed a different standard with regard to content and actions to meet identified needs. Some staff would benefit from further training in care planning. The plans did contain information on some aspects of residents’ identified needs but lacked detail about what actions were required to meet their needs especially with regard to their social activities and mental health. The files contained evidence of risk assessments with regard to manual handling and falls. There was also evidence of regular nutritional assessments and weight checks. Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 11 Daily recording covered residents’ physical health needs but lacked detail about their mental health, moods and behaviours and so provided little information for an informed review of this aspect of their care. There was evidence of resident input into their initial reviews but not in their care plans. The home operates a key worker system and the staff felt that this was working well. There is also a named worker allocated to all the respite residents and this has improved the standard of the associated paperwork and a more consistent approach to meeting the needs of respite residents. The health care of residents was well recorded and there was evidence of input from relevant health specialists, as required. The home has developed good links with the community psychiatric nursing team. The deputy manager informed the inspector that the home has used their services for advice and training. The home’s medicine administration system was inspected. This was a monitored dose system (MDS). Respite residents bring in their own medication, which is kept in containers. Permission is obtained from residents to allow the home to administer their medication. Based upon the sample of records inspected the receipt, administration, storage, security and disposal of medication was found to meet National Minimum Standards. However, there was evidence of an excessive stock of some medication and the acting manager was advised of the need to regularly audit the stocks of medication held in the home. Residents were able to express their individuality by having personal possessions and photographs around them. The residents were positive about the care provided by the staff and felt that their “dignity remained intact” whenever care staff attended to their personal hygiene needs. However, the inspector did observe poor practice regarding the catheter care of a resident. The actions taken by the care staff did not maintain the residents’ dignity. The residents and visitors commented positively about the food. The meal was well presented and clearly enjoyed by the residents. The inspector was disappointed to observe some residents wearing disposable plastic aprons at the table. This is not dignified and was brought to the attention of the deputy manager. Blackthorns DS0000017771.V300600.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet. EVIDENCE: The inspector observed several good elements of practice, which included staff’s friendly and caring attitude with residents. They chatted to residents as they went about their tasks and gave gentle reminders, throughout the day, of what was happening next, which gave residents some concept of time. Further development is required to explore various approaches to appropriately engage residents in maintaining and stimulating social and recreational interests, linked to individual needs, especially of those residents with dementia. Staff have attended dementia awareness training, which has provided them with a basic level of understanding of dementia related illnesses. However, it is not sufficient to provide detailed knowledge of the needs and therapeutic approaches to care and support for people with varying levels of dementia. This was evidenced by the lack of specific activities and Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 13 time available for staff to interact with residents in a considered and appropriate way that meets their individual social and emotional needs. The home employs an activity worker but for only 3 days a week. Care staff provide other activities, when staff levels and time permit. The current staff rota indicates that staff levels decrease for the afternoon and evening periods. This clearly limits the staff available to meet the social needs of residents, especially those with dementia. The care staff work hard to fundraise for the residents’ activities and outings as no monies are provided, by the provider, for these events. The residents have access to a “shop” in the home that allows them the opportunity to purchase small items. Regular entertainment takes place in the home, funded through staff fundraising events. There was plenty of photographic evidence, displayed in the entrance hall, of fun events and activities held in the home. Relatives spoken with confirmed that the staff were always welcoming and inclusive and there were no restrictions on visiting. The chef provides good wholesome, freshly prepared home cooking in good quantities. Examination of the catering budget showed a small daily allowance, set by the provider, for each resident. The chef is aware of the budget and manages it very well. He is to be complemented on the varied, nutritious and well presented home cooked food provided for the residents. Records of daily dietary intake and monthly weight were maintained to monitor and assess health and well being. The residents were very complementary regarding the meals provided. They especially enjoyed their cooked breakfasts and homemade cakes. The individual flats provide residents and their visitors with facilities to make tea and other drinks. Blackthorns DS0000017771.V300600.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Residents have access to a robust, effective complaints procedure and are protected from abuse through the policies, procedures and practices. EVIDENCE: The commission has received no complaints or Protection of Vulnerable Adults (POVA) referrals since the last inspection. The home has a clear complaints procedure. Residents and relatives meetings are held every two months, in the home. In addition, monthly unit meetings are held with residents. The minutes of these meetings showed that residents felt able to voice to voice their opinions about different aspects of their lives in the home. Issues raised in these meetings had been dealt with by the acting manager. There were several compliments, from relatives, recorded regarding the care provided by the acting manager and staff. An adult protection policy and procedure was in place, including Whistle Blowing, providing information and guidance for staff to follow in response to a suspicion, allegation or evidence of abuse. The majority of staff had received the appropriate training in recognising and protecting vulnerable adults from abuse. The staff told the inspector that they found the training very helpful. They felt that it had raised their awareness and improved their knowledge and practice. Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 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): 19. 22 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a site visit to the service. The home had a homely environment but extended delays in repair and maintenance in communal areas, detracted from the appearance of the home. The needs of residents with hearing loss have still not been addressed. The home was generally clean and hygienic but closer monitoring is needed malodorous smells are removed from the home. EVIDENCE: The standard of maintenance and decoration was poor. The inspector had raised premises issues at the last inspections, as the previous requirements had not been addressed. The providers’ response was to inform the commission of their intention to demolish Blackthorns and rebuild on the site so repairs and refurbishment was deferred. The commission accepted this action due the impending closure. However, the providers informed the Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 16 commission, in May, of their change of plan and stated that Blackthorns was to remain and be refurbished. The maintenance schedule, seen at the inspection, indicated that the repairs and refurbishments required from previous inspections would not be completed until March 2007. This is not an acceptable timescale, as the providers have been aware of the repeat requirement timescales of 14th March 2005 and 11th July 2005, which were not met. The inspector shared her concerns regarding the maintenance plan, with the provider’s representative. They did arrange for some of the work, with regard to the nurse call system, to be brought forward, at the insistence of the inspector, due to a failure in the system that occurred during the inspection. The system was repaired during the inspection but does need urgent replacement to ensure the safety of the residents. The home does not have a “loop system” for hearing impaired residents. This too was stated in previous inspection reports and requirements. The home was clean and generally odour free with the exception of one resident’s bedroom. This was discussed with the deputy manager who stated that the provider was intending to replace the flooring, as part of the general refurbishment of the home. Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 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): Quality in this outcome area adequate. This judgement has been made using available evidence including a site visit to the service. Blackthorns care staff are trained and skilled but are not always employed in sufficient numbers to meet the aims of the home and the changing needs of residents. Recruitment checks are not sufficient to protect residents’ safety. EVIDENCE: The current staff rota showed 1 senior and 6 care staff in the morning. This reduced to 1 senior and 5 care staff in the afternoon with a further reduction to I senior and only 4 care staff between 2 to 5 pm. The afternoon and evenings have reduced staffing levels and so activities or individual support offered to residents is limited. This has been raised at pervious inspections. The provider must match the staffing levels to the dependency levels and needs of all the residents accommodated in the home. The inspector has requested detailed evidence of individual dependency levels of residents as the information provided in the pre-inspection questionnaire sent, to the commission by the home, did not reflect the level of dependency of the current resident group. The home is registered to accommodate residents with dementia and whilst their physical needs may not be scored as Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 18 “high dependency” by the home, their emotional, behavioural and mental health needs rate them as “high dependency”. Staffing levels need to be calculated against service users’ assessed needs, using a recommended tool, paying particular attention to busy times of the day and changing needs of the residents, particularly those with dementia. The inspector had noted an increase in the incidents of falls, at the last inspection, and requested monitoring and feedback. The outcome of the providers monitoring had not been completed. The inspector requested that the provider continue to monitor accidents and falls in the home and inform the commission of their findings and actions. Relatives, visitors and residents commented upon the lack of activities in the home and the low level of staff at some times of the day. The information provided by the provider indicated that over 50 of staff have achieved National Vocational Qualification level 2. The deputy manager informed the inspector that several members of staff were enrolled on the NVQ course and she was to start NVQ level 4. The staff training matrix indicated a good level of staff training. However, it did highlight the need for training with regard to infection control and Protection of Vulnerable Adults for some new staff. The inspection also highlighted the need for additional training for staff with regard to the care of residents with dementia. Further development is required in the training programme to ensure that the basic level of dementia awareness is complimented by further initiatives in areas such as communication; nutrition, social inclusion and person centred planning to enhance staff understanding of dementia care. The homes induction arrangements were not in line with National Training Organisation specification. There was no evidence of an assessment of competency or identification of training needs. The inspector discussed, with the deputy manager, the need for all new staff to be registered on a “Skills for Care” programme, the newly formed occupational training council for the social care sector, as from September 2006. The files of recently recruited staff were examined during the inspection and did not meet the required standard to ensure the safety of residents. The application forms contained gaps in employment histories; references from past care home employers and previous employers were not sought for two carers; there was no evidence of staff being given information about the General Social Care Council code of practice; the recruitment of a returning member of staff was based on their previous application form; the job descriptions did not match the post that staff had been recruited to. Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 19 The residents spoke very warmly about the acting manager and care staff. They told the inspector that they felt “well cared for…. staff were quick to respond …. laundry is good….staff polite and friendly… dignity kept intact.” Blackthorns DS0000017771.V300600.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Quality assurance and monitoring systems are in place but not completed. The financial interests of residents are protected by the robust systems that are well adhered to. EVIDENCE: The home currently has no registered manager. The provider has appointed an acting manager but no application to register has, as yet, been received by the commission. The home has previously annual audits undertaken by their quality assurance team. After which, a development plan is provided for the manager and includes information from the results of service users satisfaction surveys. However, the last audit of the home took place in September 2005. The deputy Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 21 informed the inspector that surveys of residents and relatives groups were being done and the information gathered was informative. The records of financial arrangements and support for residents were well organised and maintained. The administration and access to residents’ monies was well managed. The systems in place gave a clear audit of all transactions. The homes policies and procedures support the health and safety of service users and staff supporting them. The certificates relating to equipment and services to the home were in place and updated as required. The inspection highlighted the need for staff training with regard to infection control and for regular fire drills for all staff, especially night staff. Blackthorns DS0000017771.V300600.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X 1 X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Blackthorns DS0000017771.V300600.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 OP1 Regulation 4 Requirement The registered person must ensure that the Statement of Purpose is amended to include all of the information specified in schedule 1 and a copy provided for the commission. The registered person must ensure that the stock levels of medication are regularly audited. The registered person must ensure that the dignity of residents is respected. This refers specifically to the use of disposable plastic aprons and the failure to ensure the dignity of residents using catheters. The registered person must ensure that residents, having regard to their needs, are provided with activities and facilities. The registered person must ensure that the premises are well maintained and do not present a hazard to service users. This refers specifically to the carpets. This is a repeat requirement for the 4th time. The registered person should DS0000017771.V300600.R01.S.doc Timescale for action 28/10/06 2 3 OP9 OP10 13 12(4)(a) 28/10/06 28/10/06 4 OP12 16 (2)(m)(n) 28/10/06 5 OP19 23 28/10/06 6 OP19 12 28/10/06 Page 24 Blackthorns Version 5.2 7 OP22 23 8 OP27 18 9 OP30 12/18 10 OP30 12/18 11 OP33 10 12 OP33 24 address the shortfalls identified in the report with regard to redecoration and maintenance. This is a repeat requirement for the 4th time. The registered person must ensure that the needs of people with hearing impairment are met through the provision of a loop system. This is a repeat requirement for the 4th time. The registered person must ensure that staff levels are increased to ensure the needs of the residents, especially those with dementia, are met. The Registered person must ensure all members of new staff receive structured induction training. The Registered person must ensure that staff receive training that will enable them to develop their understanding and knowledge of care for people with dementia. This refers to the need for more focussed interaction and activities with residents with dementia. The registered person must ensure that action is progressed within agreed timescales to implement requirements identified in CSCI inspection reports. This is a repeat requirement. The registered person must ensure that an effective quality assurance and monitoring system, based on seeking the views of residents, is in place and an annual development plan is produced and actioned. The results of resident surveys and the development plan should be made available to the commission. DS0000017771.V300600.R01.S.doc 28/10/06 28/10/06 28/10/06 28/10/06 28/10/06 28/12/06 Blackthorns Version 5.2 Page 25 13 OP33 24 14 15 OP38 OP38 13(3) 23(4)(e) The registered person must 28/10/06 ensure that action is progressed within agreed timescales to implement requirements identified in CSCI inspection reports. The registered person must 28/10/06 ensure that staff receive training with regard to infection control. The registered person must 28/10/06 ensure that staff undertake regular fire drills, especially night staff. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that the standard of care planning is consistent across the home and that residents are supported in becoming involved in their care plans. Blackthorns DS0000017771.V300600.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Blackthorns DS0000017771.V300600.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. 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