Inspection on 07/11/07 for Bungay House

This inspection was carried out on 7th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bungay House 07/05/08

Bungay House 11/04/07

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOMES FOR OLDER PEOPLE Bungay House 8 Yarmouth Road Broome Bungay Norfolk NR35 2PE Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 7th November 2007 09:30 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 Bungay House DS0000067514.V354505.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. Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bungay House Address 8 Yarmouth Road Broome Bungay Norfolk NR35 2PE 01986 895270 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) Bungay House Ltd Ms Sally Ann Gravestock Care Home 12 Category(ies) of Dementia (12), Mental disorder, excluding registration, with number learning disability or dementia (12) of places Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 12 Mentally Disordered people may be admitted if 50 years of age or older. 11th April 2007 Date of last inspection Brief Description of the Service: Bungay House is situated in the village of Broome on the border of Suffolk and Norfolk. The entrance to the home is signposted from the road. The home can accommodate 12 people aged over 50 years with either mental health illness or dementia. There are 2 double and 8 single rooms on the ground and first floor; none of these rooms have en-suite facilities. There is a separate dining room, sitting room and a small area that can be used as a quiet area or for activities. There is a pleasant small courtyard garden to the front of the premises with a large covered area for those residents who wish to smoke. There is limited parking to the side of the home. The home is supported by the local GP surgery and other professional agencies. The range of fees charged are £404 to 695 per week. Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over eight and a half hours and was conducted by two inspectors. Although the manager had stated that she had sent the Annual Quality Assurance Document it had not been received by the Commission; because of this the Commission was unable to survey relatives and residents as the relevant information had not been forthcoming. The day was spent with the Provider and manager looking at records that included care plans, personnel files, maintenance records, medication records, training records and staff rotas. Those service users who were able and members of staff on duty were spoken with. A tour of the premises was also undertaken. The Commission has been concerned for some time about the quality of the service provided at Bungay House. This inspection has shown that whilst the owner and manager have made some progress, poor record keeping continues to be a major weakness. What the service does well: Bungay House has a homely feel that is promoted by the staff. Those service users who made comment during the inspection process were broadly favourable about the care home and the staff. The home has a staff group who appear committed to providing a quality of care to the service users that helps to maintain its homely atmosphere. Meals at the home provide choice for service users. Bungay House DS0000067514.V354505.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. Bungay House DS0000067514.V354505.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 Bungay House DS0000067514.V354505.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although there has been some improvement in the formulation of an assessment document this does not give sufficient detailed information in order to construct a full assessment of needs; this has the potential to place service users at risk particularly in relation to meeting their needs and keeping them safe. Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 9 EVIDENCE: The admission records were examined for two residents who had been admitted since the Random Inspection in August 2007. Whilst there is now a format in place for the assessment of potential residents it is lacking in reference to particular mental health needs. The assessment records were lacking in any clear assessment of the mental health needs; for example one resident had a history of suicide and was at high risk because of this but nothing was mentioned in the assessment about this. This lack of information therefore has the potential to place service users at risk if the home has not assessed all their needs adequately. In such cases, it is difficult to understand how the home can establish that needs can be met, especially with sometimes very complex needs. No reference was made to medication, which can be an indication into the diagnosis of certain individuals. It was difficult to ascertain from these how care plans can then be formulated. Bungay House DS0000067514.V354505.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users health and mental health care needs are not clearly set out and kept up to date following changes in care needs; this continues to put the service users at risk. Poorly completed medication records and what appears to be a lack of knowledge in relation to the administration and handling of medication continues to put service users at risk. EVIDENCE: Five care records were examined two of which were those of the two most recent admissions to the home. It was disappointing to note that the care plans for the three residents who had been in the home for some time still had not got any detail in relation to meeting their mental health care needs. Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 11 One resident has a leg ulcer that is being dressed by the district nurse. However, there is nothing in the care notes to ensure that the home carries out other care in relation to this such as having a care plan in place to promote healing and keeping the leg elevated. This resident also has numerous falls, there is no new risk assessment or care plan in place to address these health care needs; although a risk assessment had been in place it indicated that there was no change in the original assessment. Another resident has some care plans in place and the review stated ‘as above’ with no indication to what this referred to. In the daily notes for this resident it was stated that this person had a sore groin, however no care plan was in place to prescribe the care for this, if it had been monitored, or if it had been resolved. One of the new admissions had three care plans in place but none that addressed the mental health needs; these care plans had also not been evaluated since admission on 28th of September 2007. One service user had a history of attempted suicide, however there were no therapeutic plans of care in place to deal with this, or indeed how to manage this persons medication under these circumstances. It was also noted in the daily notes that this person had complained of depression. This service user also had complained of having trouble with passing urine, was seen by GP but no care plan was activated to monitor fluid intake or output. Although GP had asked for a urine sample to be obtained one was not sent for investigation until three days later. This person had also complained of sweating a lot and feeling very low; still no care plans were in place to prescribe care or even to monitor temperature or ask for advice from the community nurse. Eleven days later this person was still complaining of trouble passing urine but had not been referred to GP again. This same person was still complaining a further ten days later when the home eventually asked GP to visit and the service user was consequently admitted to hospital. Another resident has a history of choking, there was no care plan to meet the needs of this resident in relation to choking and the steps needed for prevention or indeed what action to take if they did choke enough to inhibit their breathing. A random audit of medication was undertaken and medication records were also examined. It was noted that one seal of a blister pack for Priadel had been broken, the tablet was broken into two and then replaced in the blister pack; this is not acceptable practice. The audit of one service users Olanzapine revealed that although the MAR chart indicated that fifty-six tablets Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 12 had been received and eighteen had been administered, forty six were left. There is therefore an unexplained discrepancy of eight tablets. Inspection of the medication records and care plans confirmed that those service users who have p.r.n. (when required) medication did not have care plans in place to state why and under what circumstances the p.r.n. medication was to be given. It was also noted that service users who are prescribed Clazapine have no plans of care in place to deal with possible side effects. It was also noted that one service user’s MAR chart indicated different instructions from those on the prescribed medication boxes. This could lead to mistakes being made in the administration of the medication and puts the service user potentially at risk. The policy and procedure for the administration and handling of medication was examined - it did not contain very clear guidelines and there was no policy in place for ‘homely remedies’. Two experienced staff interviewed confirmed that they administered medication and had received training. One newer staff member said she had been trained but up to now is not dealing with medication. Bungay House DS0000067514.V354505.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provision of activities and outings for the service users have improved immensely; this has meant that they are enabled to get out more and lead more stimulating lives. Meals are managed well. EVIDENCE: The service users seen at the inspection were quite happy with the routines of the home despite describing some early times for getting up in the morning. One person said it was their habit to get up early. Staff confirmed that when they arrived for the early shift at 7 am some service users were already up and had had their breakfast. Others were still in bed and ate later. Service users felt that they could move around the home as they liked and stay in their rooms if they wanted to (see however comments about heating in the section for environment). Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 14 Service users thought they were offered enough baths and in general did not raise any problems with the routines of the home, though we wondered if there was not enough encouragement to stay up in the evening and that the day started too early. The manager may need to monitor this with staff. The rota was written up showing ‘activity days’ consisting of a two hourly session every afternoon from Monday to Thursday. Staff confirmed that they are spending time with the service users in the afternoons, playing cards, dominoes, and draughts. Two staff confirmed that they took service users out for walks on a regular basis and were able to give details about the last time that they had done this (the previous week). Staff also mentioned that they had had a firework display this year and also that the residents had been on a boat trip. One member of staff confirmed that she had taken some residents to the local pub and also sometimes took them shopping. The manager has also made contact with the local Good Companions club and five residents attend once a week. One resident is also able to undertake voluntary work. The residents seen at the inspection could not elaborate on the activities, however two people confirmed that they had been out and that they sometimes play bingo. One person said that they were not interested in activities or in going out although they commented that the manager did take people out. All staff spoken to said that they would like to develop the activities and assist service users to get out more. One gave an example of wanting to help someone to fish as this had been a past hobby. This is to be encouraged. We examined the menus and the home uses a four-week rotating menu. Menus looked appealing and the service users said the food was good. Fish and chips (from a local shop) was on the menu on the day of inspection together with trifle, which the service users seemed to enjoy. Corn beef hash was to be served for tea. All but one of the service users sat together in the dining room for their meal. Service users stated that they could have drink when they liked and had breakfast when they got up. There were no complaints about the food. Staff confirmed that they cater for only one diabetic diet and that they use alternatives to sugar. Bungay House DS0000067514.V354505.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and relatives cannot be sure that their concerns are listened to and dealt with. Lack of training and updating relating to safeguarding adults potentially puts all the service users at risk. EVIDENCE: We examined the home’s record of complaints and none were recorded. It is recommended that the home keeps a record of all concerns expressed by the residents and their relatives even if they are small issues; this then means that the home can demonstrate how they have listened to and addressed these issues. Those service users who were able to respond to our questions stated that they were aware of who to go to if they had any concerns. The staff also confirmed that they understood the procedure for making complaints. The home’s policy on adult protection was seen but was a social services document which although comprehensive, described the actions required of social services. The home needs to have its own policy outlining the steps it will take about allegations of abuse, where they will be referred, what staff have to do and any implications re staff employment. Two staff confirmed that they had received training on adult abuse though some time ago and new staff said that they had been instructed about abuse in their induction. The manager said that she was hoping to update the training for staff. Bungay House DS0000067514.V354505.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Despite some improvements taking place there are further improvements to be made to ensure that the residents live in a comfortable and well-maintained environment. EVIDENCE: The home on the whole is comfortable and homely and service users have made their rooms individual. The lounge and dining room are separate and can seat all service users together. Most of the bedrooms are single but there are two shared rooms; these have privacy curtains. All rooms have a call bell, a lock on their door, a locked safety box and a television point. All have a covered radiator but on the day of inspection these were turned off for most of the day making the rooms quite cold. It was accepted that the weather had become cooler recently and the manager agreed that the thermostat could be changed to ensure that room temperatures were maintained. The Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 17 Commission would expect the home to be warm with service users able to sit in their rooms as they wished and control their own room temperatures. All rooms have a pedal bin following the last inspection report ensuring better arrangements for infection control. Some items of furniture were looking worn and need updating and some of the décor needs a lift. At least one room did not have an armchair and lighting in some rooms was poor. The paintwork outside needed renovation. The garden towards the front of the house looked neat and tidy however the area behind the house needed tidying. The cupboards in the kitchen were quite bare but the manager said that she was about to do a big shop. Laundry facilities are adequate with one washing machine having the facility to wash at high temperatures. Staff confirmed that they had been instructed on policies regarding infection control and had access to aprons and gloves. They were able to discuss what actions they needed to take and how they dealt with clinical waste. Bungay House DS0000067514.V354505.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels have improved and this improvement needs to be maintained to ensure that the service users assessed needs are met. Although training has improved it is important that carers are given the opportunity to complete their NVQ level 2 training and also receive training in relation to those mental health needs of the people in their care thus enabling them to have the understanding of these needs and the ability to meet them. The recruitment system is not entirely robust so there is a risk of service users not being fully protected from the homes policies and procedures for recruitment. EVIDENCE: At the time of inspection there were two carers on duty right through then day from 7am.until 9pm. A domestic was on duty for two hours and the manager was working office hours. The manager stated that she was extra to the care staff on four days of the week but on Fridays she was part of the care team. The rota was checked and showed this to be the case with two care staff on duty on Fridays and the weekends. Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 19 Two staff interviewed at the inspection confirmed that they usually work with one other carer and the manager, but at weekends two staff are on duty all day without the manager with another staff member coming in from 10am till 1pm to do the cooking. This system has recently been implemented following criticisms at the last inspection that the manager did not have enough time to fulfil the administrative requirements of her job. For the number of service users this rota was felt to be satisfactory provided it is maintained and there are improvements in the way management tasks are handled. It was noted that there were a few very long shifts of 14 hours on the rota, which is normally regarded as too long and tiring for staff. This was discussed with the owner and manager who said it worked well for some staff. The manager needs to make sure that such shifts are monitored to ensure that the service users are not at a disadvantage with tired staff. Two staff interviewed confirmed that they had been studying for their NVQ level 2 and that it had been stalled through a fault in the trainers. However the manager was looking into how they might continue with their studies. No member of staff holds an NVQ qualification. The manager confirmed that she had completed the first two parts of her management (NVQ4) training and was expecting to go on to complete it. Certificates were seen for some training in relation to handling of medication and health and safety. Receipts for booked training were seen for a variety of courses in 2006 including working with people with mental health difficulties: however not all certificates were found and there was a lack of organisation making it difficult to evidence. Staff interviewed did say that they had received a lot of training and could describe the training on infection control, dementia and diabetes; there was no evidence to confirm that staff had had training in relation to meeting the needs of the majority of those people in their care. The new staff confirmed that they had received induction training but that they had had no training in manual handling. There were no written records for the induction training. Staff files need to contain a profile of what training staff have received so that gaps in training can be identified and a training plan for the year put in place. Examination of recruitment records revealed that one new member of staff had been employed to work in the home before the POVA check had been obtained. When asked about this the provider said that he had spoken to the Home Office and they had said this was an acceptable practice; however we explained to the provider that we were inspecting the home against the Care Home Regulations and that it was not an acceptable practice. Bungay House DS0000067514.V354505.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are management shortcomings that potentially compromise the health, safety and welfare of service users at the home. Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is currently undergoing management training. It was disappointing to note the lack of maintenance of appropriate records and the general lack of organisation of files. We found that during the inspection process the manager and provider were not always able to locate the appropriate files for examination. Although the managers supernumerary time has increased she still required to participate actively in a large number of care shifts to cover leave and sickness. It was also clear that the manager finds much greater satisfaction in direct contact with the residents rather than in carrying out her administrative duties. Despite previous requirements and the provision of a template to help with this, Regulation 26 visit reports have not been submitted to the Commission in accordance with the requirements of the Regulation. These visits are needed so that the provider can demonstrate that he is monitoring the quality of the service provided by the home. There has been no improvement regarding the documents which are associated with reviewing and proactively improving the quality of the service as required by regulations. The Commission has not received the AQAA as required from the home although the manager stated that it had been sent. However the high level of non-compliance with national Minimum Standards at the home suggests that any quality-monitoring systems that might be in place are not effective. Staff confirmed that they did have meetings with their manager (supervision) and that the manager would observe them in their work. One said she had a session the previous day with the manager. Four files were seen showing that staff had had one to one meetings with the manager where practice and their training needs had been discussed. Minutes of staff meetings were also seen showing they were held every three months and that practice issues were discussed. This also gives support to staff in their work. A sample of health and safety related information was checked. These show that there are servicing arrangements for portable electrical appliances including the bath hoist. The registered manager has acknowledged that the administrative and paperwork aspects of her job are a weakness and do, at times, let the home down. Bungay House DS0000067514.V354505.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 x 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 x x 3 2 2 Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 Timescale for action 07/12/07 2. OP7 14, 15 3. OP33 24 (1) 4. OP9 13 (2) The registered persons must review the content of all care plans on at least a monthly basis, or more frequently when needs change. Outstanding Requirement. The registered persons must 07/12/07 ensure that the care plans for each resident clearly set out a full range of needs in all areas of personal, mental health and social care. Outstanding Requirement. The home must instigate a 07/01/08 system for monitoring the quality of the services it provides to ensure that the home is run in the best interests of it residents. Outstanding Requirement. When medication is administered 07/11/07 to people who use the service it must be carefully checked to ensure the prescription matches that on the label. This will ensure that people receive the correct levels of medication. Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 24 5. OP31 10.1 6. OP16 7. OP30 8. OP33 9. OP25 10. OP19 11. OP33 12. OP9 The manager must ensure that she includes relevant professionals and seeks views of people using the services when making decisions about the home. 17 (2) All incidents of complaints must &Schedule be recorded and action taken, 4 this will ensure that service users and others feel that they are listened to. 18 (1) © All staff must be appropriately trained in the work that they perform. This will ensure the safety of the people using the service and reduce the risks related to their care. 24 The home must establish a comprehensive system for ensuring the quality of care provided at the home, and supply the Commission with a report (AQAA) of this review. 23 (2) (p) The manager must ensure that all parts of the home are suitably heated; this will reduce the incidence of hypothermia. 23 (d0 (o) All parts of the home must be reasonably decorated and the premises outside kept in a good state of repair. 26 The provider must carry out visits in accordance with the regulation 26, in order to determine the quality of the service. Outstanding requirement. 13 (2) People who use the service must have medicines prescribed on a prn (as required) basis given to them by staff only when clinically justified and this can be demonstrated by record keeping practices. 07/01/08 07/11/07 07/11/07 07/01/08 07/11/07 07/11/07 07/11/07 07/11/07 Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 25 13 OP29 19 4 (b) (ii paras 1-7 of schedule 2) All staff must be recruited to the standards required by the regulations, shortfalls in the system for recruitment can place service users at risk. 07/11/07 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 OP19 Good Practice Recommendations It is recommended that all rooms have suitable furniture to meet the required needs of the service users. 2. OP30 It is recommended that consideration be given to reorganising all training records. Bungay House DS0000067514.V354505.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Bungay House DS0000067514.V354505.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!