CARE HOMES FOR OLDER PEOPLE
Brackley Fields Country House Halse Road Brackley Northants NN13 6EA Lead Inspector
Irene Miller Unannounced Inspection 11th April 2006 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 DS0000012716.V288743.R01.S.doc Version 5.1 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. DS0000012716.V288743.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Brackley Fields Country House Address Halse Road Brackley Northants NN13 6EA 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) 01280 704575 01280 704614 s@brackley32.fsnet.co.uk Lt Col John Richard McLennan Rayner Mrs Judith Rayner Lt Col John Richard McLennan Rayner Care Home 24 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (24) of places DS0000012716.V288743.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To include one service user over 50 years of age with Alcohol Dependence 6th October 2005 Date of last inspection Brief Description of the Service: Brackley Fields Country House is situated in a rural location on the edge of Brackley town. It stands in it’s own grounds set back from the road, with private car parking. Resident’s accommodation is in single or double rooms, either in the original house or in a single storey extension. There are currently three lounges, two conservatories, a library and a dining room. A pleasant and well-kept garden is also available The Home offers twenty-four hour personal care for up to 24 frail older people including 5 residents with a diagnosis of dementia. Fees range from £410.00 for a shared bedroom with no en-suite facility to £455.00 for a single bedroom with en-suite facilities. The home is owned and managed by Lt Col John Richard McLennan Rayner. DS0000012716.V288743.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Residents, and upon their views of the service provided. This is an overview of what the inspector found during the inspection. The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they receive through review of their records, discussions with them were possible, and with the care staff, and observations of care practices. The inspection took place over a period of approximately six hours and was carried out on an unannounced basis. Prior to the inspection taking place the inspector spent two hours planning the inspection through reviewing previous inspection reports and other documentation in relation to the home. On the day of the inspection there was twenty-three residents living within the home. The registered manager/provider was not available on the day of inspection, however the person in charge (deputy manager) was present. What the service does well:
The home has recently employed a new activity co-ordinator; who is keen and enthusiastic to promote activities for residents both internally and externally, this has a positive effect on the residents well being. The medication administration system is well managed. The District Nurse provides clinical support such as catheter care, dressings and pressure area care, information on the treatment provided was available within the individual patient records held at the home by the district nurse, and evidenced that preventative pressure area care and treatment was being provided Staff are respectful with residents and there is a relaxed and friendly atmosphere. Residents said that they were happy living at the home, that the staff were very helpful and kind, residents were pleased with the flexible visiting arrangements saying that they could see their families whenever they wish. DS0000012716.V288743.R01.S.doc Version 5.1 Page 6 A 4-week menu provides a variety of wholesome meals, residents said that they could choose an alternative to the meal on any given day if they wished, and that a selection of choice is available for lunch and the evening meal, residents said that they were happy with this arrangement. The atmosphere within the dining room is congenial; residents can choose to take their meals within their own bedrooms if they wish. The catering staff are knowledgeable of the needs of residents who have swallowing difficulties and of the importance of additional food supplements being made available where this is required. The kitchen area is well organised, cleaning schedules in place and monitoring records of fridge and freezer temperatures are kept. Policies for the prevention of cross infection are in place and Staff were observed wearing protective clothing when entering the kitchen and food preparation areas. The Commission for Social Care Inspection have not received any concerns or complaints from residents or their representatives. The management approach is open and positive and staff morale appears to be good. The staff team are trained and competent to fulfil their duties in caring for the residents living at the home and are knowledgeable of individual residents needs and capabilities, responding to residents in a caring and sensitive manner. Resident’s views are sought on the service that the home provides through an internal quality assurance system. Areas that residents viewed as good were personal care, choice, activities, friendliness and openness and food, areas the residents identified for improvement was heating and toilet facilities. What has improved since the last inspection? What they could do better:
DS0000012716.V288743.R01.S.doc Version 5.1 Page 7 The homes statement of purpose and service users guides have been reviewed, however further work is required to ensure that the information contained within these documents fully reflects the services available, for example the Service User Guide stated that there is a Residents Committee however there is at present no residents committee in place. The pre assessment documentation needs to be followed through into the care planning processes. New residents are offered a trial period of one month, however there is no system in place for a formal review meeting to take place at the end of this period, to confirm in writing to the resident that the home can meet the residents needs in respect of health and welfare. The homes has invested in a complex needs assessment tool in an effort to identify were residents require support and assistance, however the areas identified within the assessment tool did not always transfer into the care plans, written information was not consistent on how the staff were to meet the assessed needs. The care plans for residents living with dementia lacked, clear written instructions and strategies for staff to follow especially when caring for residents who display physical or verbal aggression. However when speaking with staff they clearly had the knowledge and had developed strategies for alleviating the anxiety of residents who display such behaviour. Written risk assessments need to be in place in relation to falls prevention, however, physical and environmental factors that may contribute to residents falls episodes had been taken into consideration and appropriate action had been taken to minimise the likelihood of falls occurring. Full risk assessments need to be in place for the use of bedside rails, to ensure that they are safe and appropriate for the bed occupant. The home endeavours to provide residents with comfortable, homely surroundings, however the heating system and bathroom facilities require urgent attention to ensure that the home remains fit for purpose, from the quality assurance survey conducted in November 2005 the residents identified heating and toilet facilities as areas for improvement. Attention needs to given to upgrading the two first floor bathrooms to ensure that residents have sufficient and suitable bathing facilities. The central heating system needs to be in good working order and sufficient to ensure the resident comfort throughout the home at all times. DS0000012716.V288743.R01.S.doc Version 5.1 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000012716.V288743.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000012716.V288743.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 standard 6 is not applicable to this service. Quality in this outcome area is adequate. This Judgement has been made using available evidence including a visit to the service. The pre assessment documentation needs to be followed through into the care planning processes. EVIDENCE: The homes statement of purpose and service users guides have been reviewed, however further work is required to ensure that the information contained within these documents fully reflects the services available, for example the Service User Guide stated that there is a Residents Committee however there is at present no residents committee in place. New residents are offered a trial period of one month, however there is no system in place for a formal review meeting to take place at the end of this period, to confirm in writing to the resident that the home can meet the residents needs in respect of health and welfare.
DS0000012716.V288743.R01.S.doc Version 5.1 Page 11 Resident’s contracts are in place that set out the terms and conditions of occupancy, and had been signed by the resident or their representative. Pre assessments are in use, however the care plans generated from the needs identified did not transfer over to the care plans to instruct the staff on how the assessed needs are to be met. DS0000012716.V288743.R01.S.doc Version 5.1 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This Judgement has been made using available evidence including a visit to the service. Residents may be at risk of their care needs not being fully met due to the risk assessments and care plans not fully reflecting their needs. EVIDENCE: The homes has invested in a complex needs assessment tool in an effort to identify were residents require support and assistance, however the areas identified within the assessment tool did not always transfer into the care plans, written information was not consistent on how the staff were to meet the assessed needs. The care plans for residents living with dementia lacked, clear instructions and strategies for staff to follow especially when caring for residents who display physical or verbal aggression. However when speaking with staff they clearly had the knowledge and had developed strategies for alleviating the anxiety of residents who display such behaviour.
DS0000012716.V288743.R01.S.doc Version 5.1 Page 13 Moving and handling assessments had been completed, however they had not been subject to regular reviews. The District Nurse provides pressure area care and clinical support such as catheter care, information on the treatment provided was available within the individual patient records held at the home by the district nurse, and they evidenced that preventative care and pressure area treatment was being provided. However the pressure area body charts within the care plans were not current and there was no clear written instructions for staff to follow on the prevention and management of pressure area care. The accident reports for one service user, indicated frequent falls, there was no record of a falls prevention assessment being put into place. However on speaking with staff physical and environmental factors, which may have contributed to the falls episodes were taken into consideration and appropriate action taken, such as medication reviews being undertaken by residents General Practitioner and the relocation of furniture to prevent tripping hazards within the residents bedroom environment. Risk assessments for the use of Bedside rails were not in place, the need for risk assessments for this equipment was discussed with the person in charge and a copy of the Medical Devises Agency guidance on the safe use of bedside rails was made available to assist with implementing individual risk assessments in relation to the bed occupant and compatibility of the equipment. At the beginning of each shift the staff receive a verbal handover, on the dayto-day changes in the needs of residents. The medication administration records were well managed, however a security chain needs to be purchased to ensure that the medication storage is fully secure. Staff were observed being respectful with residents and there was a relaxed and friendly atmosphere. DS0000012716.V288743.R01.S.doc Version 5.1 Page 14 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 & 15 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to the service. The home aims to provide activities for residents that match their individual expectations and preferences. EVIDENCE: The home has recently employed a new activity co-ordinator; who is keen and enthusiastic to promote activities for residents both internally and externally. Residents were invited to a film evening that was taking place at the local church, the theme of the film to be shown generated discussion and debate amongst the residents and staff. Holy communion takes place on the first Thursday of each month; residents said that they have visiting lay preachers from within the local church. On speaking with residents they said that they were happy living at the home, that the staff were very helpful and kind, a were pleased with the flexible visiting arrangements saying that they could see their families whenever they wish. Records within the resident’s daily notes indicated when residents had received visitors and outings.
DS0000012716.V288743.R01.S.doc Version 5.1 Page 15 A 4-week menu provides a variety of wholesome meals, residents said that they could choose an alternative to the meal on any given day if they wished, the afternoon catering assistant was observed visiting residents and offering a choice of meals for the evening meal, residents said that they were happy with this arrangement. The lunchtime meal on the day of inspection was pork steaks with boiled or mashed potatoes and fresh vegetables, the portions were of a good size and the meal was well presented. The atmosphere within the dining room was congenial residents chatted during the meal saying how much they enjoyed the food available at the home. For residents who have swallowing difficulties food is puréed, the cook was knowledgeable of the needs of residents who require their food presented this way and the importance of additional food supplements being made available. The kitchen area was clean, tidy, and well organised, cleaning schedules were in place and there were records of fridge and freezer temperatures and policies for the prevention of cross infection. Staff were observed wearing protective clothing when entering the kitchen and food preparation areas. DS0000012716.V288743.R01.S.doc Version 5.1 Page 16 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 & 18 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to the service. Service users can be confident that their complaints will be listened to taken seriously and acted upon. EVIDENCE: The service User Guide stated that the full complaints procedure was available within the lobby/entrance into the home. The complaints procedure available outlines a twenty-eight day period for any complaints to be addressed by the responsible individual. There is a comment and complaints book available within the front lobby/conservatory of the home, on viewing this book there was a single entry contained within which complimented the staff on the care they provided. Since the last inspection the commission for social care inspection had received one concern in relation to staff recruitment, the commission for social care inspection was satisfied that the provider dealt with the concern promptly. There were no records of any concerns or complaints that had been raised by residents or their representatives since the last inspection. The home has written guidance to follow in the event of an allegation of suspected or actual abuse taking place, which follows the protocol of the Northants Inter Agency Reporting and Investigation Procedures, staff training
DS0000012716.V288743.R01.S.doc Version 5.1 Page 17 records demonstrated that this is an area which is included in staff induction and on-going staff training. DS0000012716.V288743.R01.S.doc Version 5.1 Page 18 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): 19,20,21,22,23,24,25 & 26 Quality in this outcome area is poor. This Judgement has been made using available evidence including a visit to the service. The home endeavours to provide residents with comfortable, homely surroundings, however the heating system and bathroom facilities require urgent attention to ensure that the home remains fit for purpose. EVIDENCE: On the day of inspection the weather was particularly cold and changeable, the heating was not sufficient to fully heat the home, the thermostatic valves on the radiators were not fully functioning. Residents were complaining of feeling cold, the person in charge temporarily dealt with the situation by putting into place portable fan heaters around the home. The residents were very pleased with the prompt action of the person in charge. On talking with residents they said that they sometimes felt that the temperature within the home at night was not adequate, the inadequate
DS0000012716.V288743.R01.S.doc Version 5.1 Page 19 heating in the home was an area that had been identified for improvement in the residents quality assurance satisfaction survey conducted in November 2005. Within the homes policies and procedures file there was a schedule for staff to follow on the evening shift, this schedule indicated times for radiators to be switched on and off, in particular within the dining room area and within residents bedrooms. This was discussed with the person in charge who explained that the heating system struggles to work effectively if all the radiators are switched on, however if a resident wished to spend time within their own bedroom she assured the inspector that the heating would be switched on to ensure the residents comfort. A shared bedroom was viewed which was pleasantly decorated and contained items of personal belongings, and privacy screens were available. Bedside rails had recently been purchased for one of the residents who occupy the room, who was at risk off falling out of the bed. No risk assessment was in place for this equipment the need for a risk assessment to be in place was discussed with the Deputy Manager and a copy of the Medical Devises Agency guidance on the safe use of bedside rails was made available. The home is situated in a rural location, set within pleasant grounds and gardens; there are single and double rooms within the original house and in the single storey extension. The communal areas of the home seen were well maintained and furnished to an acceptable standard. The residents and staff lavatories were clean and tidy, however the lack of privacy within the two bathrooms on the first floor was unacceptable, the windows although not overlooked, did not have frosted glass and had no curtains up at the windows. The enamel on the two baths within the first floor bathrooms was scratched and chipped. In general the bathroom environment within the two first floor bathrooms was very unwelcoming. On speaking with staff they said that they did not use the two first floor bathrooms for the reasons as outlined above. Choosing to use the ground floor bathroom, which was pleasantly decorated, had a frosted glass window and net curtains, but still no curtains available to draw across to give more privacy. Specialist pressure relieving equipment is prescribed through the district nurse, and there is such equipment was seen to be in use. There is a stair lift to rooms situated on the first floor; maintenance records for this piece of moving and handling equipment were seen. DS0000012716.V288743.R01.S.doc Version 5.1 Page 20 Fire alarm test are conducted weekly, however the records of these tests were not up to date, no records were available to view for the month of April. At the top of the stairs there is a sound activated door holding device, and literature on the operation and maintenance of this piece of equipment was available within the policies and procedures file. It was noted that the door at the top of the stairs did not fully close in order to create a seal; this was brought to the attention of the person in charge for urgent attention. DS0000012716.V288743.R01.S.doc Version 5.1 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to the service. The staff team are trained and competent to fulfil their duties in caring for the residents living at the home. EVIDENCE: On the day of inspection the registered individual was on holiday, there was twenty-three residents within the home, the staff on duty consisted of a deputy manager, two care assistants, one activity co-ordinator, two cleaners, one cook, one kitchen assistant and one maintenance worker. Staff induction and training records were seen to include copies of certificates that demonstrated that training has taken place on dementia care, health and safety, food hygiene and moving and handling. A senior member of staff is qualified as a National Vocational Qualification (NVQ) Assessor; arrangements are in place for this member of staff to spend time off duty, one day a week in supporting staff through the process of achieving their NVQ Level 2 award. Three staff recruitment files were looked at which contained the information required to demonstrate that equal opportunities and thorough recruitment practices are in place. DS0000012716.V288743.R01.S.doc Version 5.1 Page 22 The person in charge anticipated that following recent interviews that new care staff were soon to be recruited, and was fully aware of the importance of protecting residents, prior to and upon employment commencing, through ensuring that robust vetting and recruitment procedures are followed and that ongoing supervision and support was provided for staff. Staff spoken with said that they felt well supported by the management and that training was provided, when asked what training they had undertaken over the past year they said that they had attended training on Moving and Handling, Health and Safety, Food Hygiene, Parkinson’s, Diabetes and Dementia Care. The staff morale appeared to be high, interactions observed between staff and residents were light hearted and friendly. The Staff were knowledgeable of individual residents needs and capabilities and responded to residents in a caring and sensitive manner. DS0000012716.V288743.R01.S.doc Version 5.1 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33 & 38 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to the service. Residents are cared for by a loyal and dedicated staff team, however the health, safety and welfare of residents is placed at risk due to care plans not having the residents full range of needs identified within them, and an inadequate heating system in place. EVIDENCE: The management approach is open and positive and staff morale appears to be good. There continues to be a dependency on staff being verbally updated on the changing needs of residents, the registered individual has made some attempt to ensure that information relating to the residents health, safety, personal and social care is documented within the individual resident care plans, however
DS0000012716.V288743.R01.S.doc Version 5.1 Page 24 further work is required in this area. This has been an area were requirements have been issued following the last three inspections of 7th July 2004, 30th September 2005 and 30th November 2005 a further requirement has been issued with a timescale for action 31st May 2006. Resident’s views are sought on the service that the home provides; documentation was seen on the most recent quality review that was carried out in November 2005. Areas that residents viewed as good were personal care, choice, activities, friendliness and openness and food, areas the residents identified for improvement was heating and toilet facilities. On talking with residents they said that they sometimes felt that the temperature within the home at night was not adequate, the inadequate heating system in the home was an area that had been identified for improvement in the residents quality assurance satisfaction survey conducted in November 2005. Within the homes policies and procedures file there was a schedule for staff to follow on the evening shift, indicating times for radiators to be switched on and off, in particular within the dining room area and within residents bedrooms. This was discussed with the person in charge who said that the heating system struggles to work effectively if all the radiators are switched on. The registered provider/manager was away on holiday on the day of the unannounced inspection-taking place, the importance of ensuring that the home is consistently heated to a comfortable level for residents was discussed with the person in charge, who promptly put in place temporary heating arrangements to ensure the residents comfort. The systems in place to safeguard residents financial interests were not available to view on the day of inspection, due to the registered person/manager not being available. DS0000012716.V288743.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 1 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 2 DS0000012716.V288743.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Residents care plans must be formulated for all identified needs, to include specific guidance on how these needs are to be met. The care plans must be made in conjunction with the residents or their representative. Previous timescales of 07/11/04, 30/09/05 and 30/11/05 not met. Individual risk assessments must be in place for service users who are identified as being at risk of falls. The incidence of pressure sores, their treatment and outcome must be recorded in the service users care plan and reviewed on a continual basis. When not in use a security chain must be in place to secure the medication trolley to a wall or alternatively stored in a secure area within the home. The two 1st floor bathrooms must have the chipped enamel bath surfaces repaired or the baths replaced.
DS0000012716.V288743.R01.S.doc Timescale for action 31/05/06 2 OP7 13 (4) (a)(b)(c) 15 31/05/06 3 OP8 31/05/06 4 OP9 13 (2) 30/04/06 5 OP21 23 (2) (c) 30/06/06 Version 5.1 Page 27 6 OP25 23 (2) (p) 7 OP38 13 (4) (a) (b) The thermostatic radiator valves 30/06/06 must be in good working order and the central heating system must be suitable to heat all parts of the home accessed by service users. Individual risk assessments must 31/05/06 be in place for the use of bedside rails and their suitability with the bed occupant. 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 OP1 OP4 Good Practice Recommendations The registered person should regularly review the homes Statement of Purpose to ensure that the information contained within is factual. The registered provider should introduce a system for a formal review to take place with the service user and/or their representative, following the ‘trial period’. To confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of health and welfare. Moving and handling assessments should be regularly reviewed. Weekly fire alarm system tests, and checks on the selfclosing fire doors should have written documentation to evidence when these checks have taken place. . The two 1st Floor bathrooms should have privacy screening at the windows. 3 4 OP7 OP19 5 OP10 DS0000012716.V288743.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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