Inspection on 20/09/07 for Bramble House

This inspection was carried out on 20th September 2007.

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

Bramble House 17/09/09

Bramble House 17/09/08

Bramble House 13/11/06

Bramble House 19/06/06

Bramble House 25/10/05

Bramble House 25/04/05

Bramble House 26/10/04

Bramble House 02/06/04

Bramble House 16/12/03

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

CARE HOMES FOR OLDER PEOPLE Acefield Care Home 96a & 98 Stroud Road Gloucester Glos GL1 5AJ Lead Inspector Mr Adam Parker Key Unannounced Inspection 09:50 20th September & 4thOctober 2007 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 Acefield Care Home DS0000016357.V353796.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. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acefield Care Home Address 96a & 98 Stroud Road Gloucester Glos GL1 5AJ 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) 01452 521018 Forestglade Limited Mrs Vivian Dawn Grimes Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age (2) of places Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st March 2007 Brief Description of the Service: Acefield Residential Care Home is situated on the outskirts of the city of Gloucester and is within easy walking distance of a local shopping complex. A major building project, completed last year, has joined the large detached house and an adjacent house via a link corridor. The first floor of the main house is accessed either by stairs, a shaft lift or a stair lift. In addition to the above work, by constructing a conservatory and improving the existing lounge/diner, the communal space has been increased. With another extension at the rear of the building, the home is now registered to accommodate 30 elderly residents. This extension consists of four single ensuite rooms, new office space and an assisted bathroom. To complete this work, the kitchen has been enlarged and totally refurbished and a new laundry, sluice and shower room have been built. The area that was previously the adjacent house has also been refurbished and extended to provide two extra bedrooms, one en-suite, an assisted bathroom and toilet and the small activities/quiet lounge. Access to the first floor in this half of the building is via a stair lift. There are four assisted baths and a shower within the home and there are now fourteen rooms with en-suite facilities. The home still has extensive gardens at the rear of the building and adjacent to the conservatory, with orchards, vines and fruit that the cook is able to utilise. Additional carparking space has been created at the front of the building. Information about the service to include CSCI reports is made available by the provider to prospective service users through the homes’ Statement of Purpose and Service Users Guide. At the time of inspection the fees are from £333.60 for low dependency and £400.50 for high dependency. Chiropody, hairdressing and newspapers are charged extra. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was carried out by one inspector over two days in September 2007. On the second day an inspection of medication systems was carried out by a specialist CSCI pharmacist inspector. The registered manager of the home was present for the both days of the inspection visit, which consisted of a tour of the premises and examination of residents’ care files. In addition staff recruitment and training was looked at as well as documents relating to the management and safe running of the home. A sample of residents were selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. During the inspection visit three residents were spoken to, to gain their views of the service. As part of this key inspection one of our pharmacist inspectors looked at the way medication is managed in the home (National Minimum Standard 9 Care Homes for Older People) following a previous random inspection of medication in March 2007. This included looking at some stocks and storage arrangements for medicines and some medication records. There were discussions with the manager and one care assistant. We observed the way medicines were given to some people in the home and spoke to one person about their medicines. The medication inspection took place over four hours on a Thursday. Comment cards were received from 8 relatives of resident’s and 5 from General practitioners (GPs) unfortunately no survey forms were received from residents in the home. An Annual Quality Assurance Assessment (AQAA) form was completed by the home. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: The home works to maintain the privacy and dignity of the residents also providing a good range of activities and helps residents to maintain excellent links with the local community and their family and friends. Meals are suitable to the needs and preferences of those who use the service. The home provides a generally clean and well-maintained environment. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Acefield Care Home DS0000016357.V353796.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 Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission procedure generally ensures that all service users are admitted to the home on the basis of a full assessment of their needs so that they can receive the care that they require. However written information from funding authorities has not always been obtained prior to admission. EVIDENCE: Documentation for three residents was looked at. A pre admission assessment had been completed in all cases (including a brief social and medical history) as well as a further assessment on the day of the resident’s admission to the home. This included information about nationality and first language, the latter reflecting the multi-cultural nature of the area in which the home is situated. The home had also obtained copies of the care plan produced by the local authority funding the care. However in the case of one recent admission the resident had been admitted to the home without the funding authority providing their written care plan. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 9 The home also completes a written indication confirming if the prospective resident is suitable or unsuitable for admission. The home does not provide intermediate care and so Standard 6 does not apply Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some further improvements are needed in respect of care planning documentation although the home works well to uphold resident’s privacy and dignity. People who use this service are largely protected by the home’s policy and procedures for handling medicines but the manager needs to make sure there are regular audit checks of the medicine stocks and records so as to quickly identify and deal with any discrepancy that arises. EVIDENCE: Following initial assessment, care plans are produced. Those looked at were brief in respect of the action required to meet needs but had been reviewed on a monthly basis. Care plans are arranged under set headings such as nutrition and personal hygiene. The format for the mental health care plan included an area to record whether there was involvement from a community psychiatric nurse (CPN) which is a useful method of presenting this information. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 11 One resident had a care plan to address needs around nutrition. One of the actions was for the resident to be weighed every two weeks. This had been carried out consistently with a record kept however the care plan failed to record the reason for the resident being at risk nutritionally. In respect of this the home has been making use of a set of ‘sit-on’ scales purchased since the last inspection. The care documents of another resident looked at showed evidence of family involvement both in care planning and risk assessing. A daily record is kept of personal care given as well as any checks on possible pressure area problems. In addition visits to residents from GPs, district nurses, opticians, CPNs as well as attendance at hospital appointments and dentists. Residents had risk assessments for pressure area care although these were rather simplistic and it is recommended that a recognised assessment tool should be used by staff trained to do so. Where a resident was identified as being at risk preventative care needs had not been identified in a care plan if pressure sores were to occur with a resident the home would make a referral to community nurses. Risk assessments had been completed for other residents for falling, wandering and moving and handling. We consider that the three requirements about medication made at the last inspection have been attended to. A new requirement is made and this is because of the incorrect audit counts of medicine we found. Staff who handle medicines have various levels of training and supervision to help make sure that they perform this work safely and we saw some records for this. One carer spoken to had recently completed a formal course about the safe handling of medicines and during our inspection showed a good understanding and benefit from knowledge gained from this course. There is a medicine policy available to staff that describes how they are expected to handle medicines safely in this home. This could be brought up to date to include new procedures such as administering medicines safely upstairs where a carrying case is now provided since the last inspection. A local pharmacy provides printed Medication Administration Record charts each month and these are the main medicine records kept. These help make sure each person receives the right levels of medication. Since the last inspection an additional care plan sheet for medicines has been introduced for each person so that additional information is readily available to help with giving their medicines safely. Records should also include what choices and preferences people have made about how their medicines are looked after and administered in the home. This could usefully be included on the medicines care plan sheet. One person has a prescribed emergency injection, as she is allergic to bee or wasp stings. The use of this medicine must be included on her medicine records. We made some audit checks of medicines by counting what remained in stock and comparing this with the medicine records. Some checks agreed indicating that medicines had been given correctly and accurate records made. For four people counts of eight of their medicines did not match with their records. This could indicate inaccurate records or medicines not administered correctly. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 12 We saw that the manager has records for eight audits and check counts of medicines this year but not once a week as stated in the action plan sent to us by this home after the last inspection. Much more regular checks would help to identify quickly such discrepancies and find out what has gone wrong. We strongly recommend weekly audits and checks are carried out until there is evidence that medicine records and stocks are consistently correct. We saw a member of staff administering medicines in a safe way to people living in the home. We spoke to one person where the audit count of medicines did not agree with the records. She told us that staff always give her medicines and she reminds them if they do not as she knows what medicines she needs. This could indicate that the problem identified was to do with inaccurate records. This same person said she is happy for staff to look after her medicines for her. She also told us she is well looked after and ‘staff are very kind’. Nobody in the home was self-medicating on the day we inspected. There are arrangements for this if it is a person’s choice and they are assessed as able to do this safely. We saw safe arrangements made for storing medicines including controlled drugs and there are the additional records needed for this latter class of medicines. There were high stock levels of some medicines so this needs to be managed so as to work through this stock and avoid wastage. There is also a risk of the label directions not being the most up to date if old stock builds up. There were two eye drop containers with no opening date written on the label but we were told these bottles are changed every four weeks when the new medicine charts are brought into use. Eye drops must be changed to reduce the risk of using contaminated drops so it is good practice to write the date when first opened on the label. This had been done for the four other bottles we saw in use. Staff were observed treating residents with respect and up-holding their privacy. Residents confirmed that staff knocked on doors before entering and were polite to them. One relative of a resident commented “They treat the residents with much respect and also give them privacy when they want it.” Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home takes an active role in encouraging residents’ contact with family, friends and parts of the local community. This in conjunction with a varied activities programme provides a good degree of social contact. In addition residents individual preferences are catered for in the meals provided in the home. EVIDENCE: The home has an activities coordinator working on weekdays, when spoken to she displayed great enthusiasm for her role. Two residents commented positively on the work of the activities coordinator. A mix of physical and mental activities are provided such as handicrafts, skittles, bingo, darts, quizzes and memory games. The activities for the week are planned through consultation with the residents and a weekly activities notice is produced. Trips out of the home have been organised with destinations such as Gloucester for a meal in a pub, visits to the library and a trip to the seaside. Residents have activities care plans and a life history record is made including any interests or significant events. The activities organiser is undertaking a course in providing activities in care homes. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 14 There are close links with the local church that is situated directly opposite to the home. Residents recently attended a series of art classes held in the church hall and regularly attend Holy Communion and coffee mornings. One resident also attends a local Baptist church every Sunday. There are also residents who attend the local Ukrainian club and the local Afro-Caribbean club with another working one day a week in a charity shop. The home has a policy of open visiting and one visitor was observed in the home during the morning of the first day of the inspection visit. However the home does have a policy of requesting that visitors contact the home first if they wish to visit after 8pm at night. One resident described the good relationship between his family and the staff. The home has information about local advocacy services for residents and had cause to contact one of these recently. Residents can bring in their own furniture and electrical equipment to the home and evidence of this was seen during a tour of the premises. The home has a menu that changes every four weeks; this is displayed on the wall just outside the kitchen and one resident spoken to was aware of this. There is no choice of main course at lunchtime although alternatives are catered for with individual likes and dislikes known by the staff. Soft meals are produced at lunchtime and the registered manager stated that these are produced with all the portions blended together and residents prefer this. She was aware of the practice of blending portions of meals separately and reported that this had been tried in the home without success. The evening meal consists of a choice of sandwiches or a hot snack and a soft option for those who require it. A record is kept of all meals cooked and any alternative meals prepared for individual residents. Lunch was observed being served from a heated trolley with plates covered, residents were being served drinks with their meal. Residents spoken to said the meals were “very good” and “quite satisfactory” with the “variety good” and confirmed that a choice of main courses was available stating how well the cook would accommodate individual tastes. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s policies on complaints and preventing abuse should protect service users from harm although more staff training would be of benefit to people who use the service. EVIDENCE: The home has a complaints procedure included in the service user’s guide. This is provided in each residents’ room. No complaints have been received since the last inspection and neither has the Commission received any formal complaints. The registered manager stated that she aims to see every resident on each day that she works to check if they have any concerns about the service. Although it was reported that adult protection issues had been part of discussions held with staff in the home there was been no formal adult protection training for a number of staff. Others had received training from the local adult protection unit in the past although there were no records to support this. The home has a policy on adult protection and has copies of the alerters guide produced by the local authority adult protection unit. There have been no reported incidents of abuse at the home. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the benefit of living in a well-maintained and generally clean, environment with personalised individual rooms. EVIDENCE: A tour of the premises was undertaken. The home was generally clean and well maintained and although there were slight odours in two rooms the registered manager was able to describe planned action to deal with this. Resident’s bedrooms were personalised with their own possessions and two residents spoken to confirmed that they were happy with their individual rooms. The home has communal space consisting of a lounge, a dining room and a large conservatory with a television. There are gardens at the side and the rear of the home accessible to residents with a ramp provided for those using a wheelchair. A variety of with seating is provided. The laundry had washable Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 17 floor and wall surfaces. Minor shortfalls with the arrangements for hand washing noted on the first day of the inspection visit had been improved by the second day. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although there is generally good recruitment practices and staffing levels linked to residents’ needs, the lack of staff training may affect the ability of the home to meet the needs of people using the service. EVIDENCE: Staffing in the home typically consists the registered manager with five carers in the morning and three or four carers in the afternoon depending on needs. In addition the activities coordinator works each week day. At night there are two carers in the home. Ancillary staff consist of two cleaners, a cook and a handy man. The home does not use any agency staff and it was reported that staffing levels are based on dependency levels of residents. Currently no members of care staff have achieved an NVQ although there are 5 care staff that are undergoing the training. It was reported there have been problems with accessing the NVQ assessor and this has had a detrimental effect on the progress of the qualifications. However another assessor has now been identified. Records for recently recruited members of staff were examined. All the required information and documentation had been obtained including an employment history against which any gaps in employment could be explored. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 19 However in the case of one member of staff a recent photograph had not been obtained prior to recruitment. Checks against the Protection of Vulnerable Adults list were being made as well as with the Criminal Records Bureau. As evidenced at previous inspections there is a lack of recording around staff training and this situation continues. As well as recording training already undertaken, the general training needs of staff must be assessed and a plan put in place to meet these. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home has been making use of quality assurance checks and staff supervision is being undertaken, more formalised maintenance systems need to be in place in order that the home is always run in the interests of the residents. EVIDENCE: The registered manager has a background in nursing with 12 years managing the home. She has recently completed the registered managers award with the work ‘signed off’ although had not achieved certification at the time of the inspection visit. She has also recently undergone first aid training. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 21 The home has completed a quality assurance exercise and the results were produced in February 2007. This involved questionnaires being sent to residents and their families. The registered manager reported where improvements had been made as a result of the findings of the survey such as more variety on the menu and planned changes to the operation of the laundry. The manager reported that the home does not act as an appointee for any resident’s pension and has a policy that it does not deal with any financial transactions for the residents however the home was temporarily looking after some money for one new resident admitted to the home until alternative arrangements could be made. Residents deal with their finances with support from their families. Written evidence was seen of staff supervision sessions taking place. These are carried out by the registered manager and the deputy manager and the aim is to provide six sessions a year for all care staff. Although it was reported that staff have received training in safe working practices there are still no records to support this and a requirement made at previous inspections regarding this is repeated here. However it was evident that staff had not had training in infection control and this needs to be addressed. It was reported that portable electrical appliances had undergone safety checks; however there were no records kept and although labels confirming that items had been checked were attached to some items others did not have these and had clearly not been checked. Although this work was attended to after the shortfalls were discussed, the home must ensure that checks are made on electrical equipment especially any brought into the home by residents. Maintenance checks on the electrical installation and the central heating systems as well as checks in relation to the risk of Legionella were not available in the home and will be looked at during a future inspection. The storage of cleaning materials was looked at and there was no decanting of substances from one container to another. The storage cupboard had not been locked although it is accepted that it is the normal practice to lock this cupboard. The home has a record of accidents and has used two accident books to record these. It is recommended that only one book is used in the future. Acefield Care Home DS0000016357.V353796.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Acefield Care Home DS0000016357.V353796.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 OP8 Regulation 15 (1) Requirement Residents who have needs relating to pressure sore prevention must have care plans in place to guide staff in meeting these needs. When medication is administered to people who live in the home it must always be clearly and accurately recorded and given in accordance with the doctor’s directions. This is to make sure people receive the correct levels of medication. In order to provide safeguards for residents, all staff in the home must receive training on adult protection. This requirement has been repeated from the previous inspection, the timescale for action was 28/02/07. Before a person starts work in the home a recent photograph must be obtained as specified in paragraph 1 of Schedule 2 to ensure that people who use the service are protected through robust recruitment procedures. Ensure that persons employed DS0000016357.V353796.R01.S.doc Timescale for action 31/12/07 2 OP9 13 (2) 01/12/07 3 OP18 13 (6) 31/03/08 4 OP29 19(1)(b) Schedule 2 Paragraph 1 18 31/12/07 5 OP30 31/12/07 Page 24 Acefield Care Home Version 5.2 6 OP30 18 (1) (c) (i) 7 OP38 13 (4) (a) & (c) 8 OP38 13 (4) (c) by the registered person receive training appropriate to the work they are to perform and suitable assistance including time off, for the purpose of obtaining further qualifications appropriate. This is in respect of records to confirm that staff have undertaken specific training on dementia, medication and infection control. It is also unclear as to how frequently mandatory health and safety training is undertaken by staff. This requirement has been repeated from previous inspections, the timescale for action was 31/01/07. Staff training needs must be identified and recorded in order to plan for providing training to enable residents to be cared for by a competent staff group. To ensure residents’ safety and comfort, regular checks must be made with records kept on the temperatures from hot water outlets. To ensure residents’ safety checks must be made on electrical appliances with records kept. 13/01/08 31/12/07 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations So that a full assessment of care needs can be made. The home should insist on receiving written information from funding authorities relating to a resident’s needs prior to admission to the home. DS0000016357.V353796.R01.S.doc Version 5.2 Page 25 Acefield Care Home 2 3 4 OP7 OP8 OP9 5 6 7 OP9 OP9 OP38 Where appropriate care plans should state why a resident is at risk nutritionally. A recognised pressure area risk assessment tool is used by staff trained to do so. Care plans should reflect what choices people who live in the home are given and make about how their medicines are administered and their consent to the way in which staff handle their medicines. Review the medicine policy and procedures to make sure that all aspects about the management of medication are included. Weekly audits and check counts of a random sample of medicines are strongly recommended to demonstrate that people living in the home receive their medicines correctly. It is recommended that only one accident book is used to record accidents. Acefield Care Home DS0000016357.V353796.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS8 3PF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Acefield Care Home DS0000016357.V353796.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. 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