Inspection on 18/05/06 for Caldene Rest Home

This inspection was carried out on 18th May 2006.

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

Caldene Rest Home 09/10/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Caldene Rest Home 27 Beeches Road West Bromwich West Midlands B70 6QE Lead Inspector Mr Jon Potts Unannounced Inspection 10:35a 18th May, 13 June & 14th June 2006 th 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 Caldene Rest Home DS0000066350.V297844.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. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caldene Rest Home Address 27 Beeches Road West Bromwich West Midlands B70 6QE 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) 0121 500 5664 Richmond Court Nursing Home Ltd Vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability (1) of places Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user (female) identified in the variation report dated 14.4.05 may be accommodated at the home who is 52 years and over. This will remain until such time that the service users placement is terminated. 22/12/05 Date of last inspection Brief Description of the Service: Caldene comprises of a traditional property that has a large extension (exceeding the size of the original property) built on. This means the majority of the property is built for purpose as a care home and offers a number of communal areas with some well-proportioned bedrooms. There are a range of adaptations available as would be necessary for the care of older people. The home is sited close to the centre of West Bromwich and is easy to reach by public transport or car, as transport links and main roads are close by. The majority of the accommodation offered is for long term stays although the home has offered short term and emergency care when requested. A Private company has recently purchased the home with a manager still to be registered to run the home on a day-to-day basis (this position currently covered by the provider and other registered managers from the companies homes in the near vicinity at the time of the inspection). The home is supported by a number of senior carers and care assistants as well as ancillary staff (i.e. cooks, domestics). The current range of charges for accommodation reflects the local authority rates paid for accommodation of local authority funded placements. Private funding rates would be comparable to these. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector over two and half days and consisted over assessments of the homes performance against key minimum national standards. Evidence was drawn from case tracking the care of three residents, this involving looking at all their care records, the premises in respect of their individual needs, discussion with staff in respect of the care provided and any other records that had a bearing on the way the home provided care and ensured their well-being. Time was also spent in looking at other records including staff files, training plans, quality assurance systems, health and safety documentation and in discussion with management. The residents and management/staff team are to be thanked for their ready assistance with the inspection process. What the service does well: What has improved since the last inspection? A number of requirements from the previous inspection have now been addressed this including development of a better pre admission assessment form, improvement in risk assessment (in respect of individual residents), systems for the safe administration of medication, better documentation in respect of water temperatures and addressing a number of hazards previously identified in respect of the premises. An issue identified in respect of inappropriate staff attitude has also been resolved promptly. Care planning and Individual risk assessments, whilst still in need of further improvement, have improved significantly since the last inspection as has the Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 6 generally cleanliness of the home, this helped in part by some recordation but more due to the efforts of domestic staff. The provider, whilst having only purchased the home earlier this year, has a proven track record of providing good quality care in a number of homes in the Sandwell area and the expectation is that the service in Caldene will improve further prior to the next 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. Caldene Rest Home DS0000066350.V297844.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 Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 The outcome for this group of standards is judged to be adequate but improving. Prospective residents have the information needed to choose whether Caldene is suitable for their needs, albeit verbally and through pre admission visits, but not always in written form. They have their needs assessed and revised contracts, which clearly tell them about the service they receive, are been issued to them. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home has revised its statement of purpose and service user guide since its recent change of ownership and this is improved over the document that was previously available. After taking into account the information within both these documents as a whole there are some omissions, which need to be included, as follows: -The address of the company’s head office -The experience of the company and the directors -Reference to where the homes fire procedure can be found or a copy of the same -The arrangements for contact between residents and their relatives, friends and representatives. -The size of the rooms in the home -The views of the residents accommodated at the home in respect of the service they receive (for example a summary of the findings from quality assurance questionnaires). The only recent admissions to the home have been from some of the companies other homes, although all the necessary pre admission assessments were found to be in place (the home’s assessment documentation revised and improved since the last inspection). Discussion with two of the residents who have recently moved in indicated that they had chance to look around before making any decisions concerning a move to the home, with both positive about the subsequent move. Neither stated they had received a service user’s guide however and the home is advised to document when these are issued to residents/relatives. Feedback via comment cards indicated there were conflicting views as to receipt of contracts with 4 out of 6 saying they were in receipt of such a document. The provider was however clear that the company was in the process of reissuing these following the recent purchase of the home. A copy of the contract to be issued was seen by the inspector and judged to be acceptable. It was pleasing to see reference to resident’s social and cultural traditions within the contract. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The outcome for this group of standards is judged to be good. The health and personal care, which a resident receives, is broadly based on the care plan that is in place. Whilst there is still room for improvement in respect of care planning, it is evident that these are much improved since the last inspection. With few exceptions residents received the health care that they need and the principals of respect, dignity and privacy are put into practice. EVIDENCE: The formats for the resident’s care plans have been subject to revision since the time of the last inspection and are now much improved. The care plans were judged to be easy to follow yet covering the majority of the needs in respect of those three residents whose care was tracked. There were also risk assessments on case files in respect of a number of salient areas (including moving residents, tissue visibility, nutrition, falls etc). Tracking of the plans (including discussion with residents) did evidence that they were generally accurate and implemented, with a few exceptions (i.e. plan referred to cot side Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 11 no longer in use, preferred activities for one resident differed, no writing board for one resident as documented in plan) that suggested review and update had not always taken place, this the result of inconsistent monthly review. On a more positive note, it was pleasing to see that the management were encouraging the staff to have involvement in updating the plans rather than taking control of these themselves. Whilst this approach may lead to some difficulties whilst staff adjust to new documentation the desired end result of increased involvement of staff in, and their understanding of care planning is to be encouraged. The recommencement of one – to – one supervision would support this process. Residents have rights of access to health care services and the homes policies and procedures support this access. Evidence from case tracking showed that residents are supported to have this access to health services with the exception of regular dental checks for some. There was evidence that some residents have had this access but not all, although some residents spoken to were clear they would not want to see the dentist unless there was an immediate issue with oral health. These choices were not however documented. There was evidence in the plans of reference to nutritional, tissue viability and other health related assessments, although there was some inconsistency in respect of all residents being weighed or having their weight monitored by other appropriate methods on a regular basis. The home was seen to have an appropriate medication policy and a recent pharmacists audit raised one issue for action by the home this as detailed below: - Limited life medicines need to be double-checked. Assessment of the home’s system for the safe administration, storage and handling of medication by the inspector gave rise to a few other issues that need to be addressed by the home these as detailed below: - All staff that administer or witness the administration of medication must have appropriate accredited training. It was pleasing to see that residents are given the option of self medicating and whilst there was no risk assessment in place for one of the residents that did so at the time of the inspection, the documentation has been put in place prior to this report been written, this risk assessment signed by the resident in question. Staff spoken to were aware of how to promote the privacy and dignity of the residents and there was policies and procedures in place to further support this approach to care. Residents spoken to also confirmed that care attention was paid to delivering privacy and dignity during personal care tasks. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The outcome for this group of standards is judged to be good. Residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectation. Residents receive a healthy, varied diet according to their assessed needs and choice. EVIDENCE: The routines of the home are planned around the residents needs and wishes and residents spoke of having self determination in respect of when they get up, go to bed, what clothing they wear and how they organise their day. The home encourages residents to take control of their lives and systems are been developed to actively involve them in the running of the home. Residents have stated that they have the confidence to raise any issues with staff. Sufficient staff resources are provided to allow time for activities and stimulation with support given to assist residents with individual activity or allowing them the freedom to pursue personal interests. The home operates a key worker system this which the intention of providing closer staff – resident relationships where likes, dislikes and aspirations are shared, this to help life planning. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 13 The home has a communal notice board where a menu, and information about activities is displayed and accessible to residents. Residents spoken to referred to community activities that they maintained. Family and friends feel welcome and know they are able to visit at any time. Staff always offers hospitality. The home offers seating areas next to the communal areas where people can see visitors in private, in addition to use of their own room. Maintaining independence and enabling residents to make their own decisions about home they wish to live in is a key objective of the home, residents stating that this aim is addressed. Residents are encouraged to have some responsibility for their own financial affairs wherever possible, this usually with the support of relatives. There was clear evidence that the home has assisted some of the residents to contact and use advocates in the recent past. Residents are clearly encouraged to bring personal items into the home with them, evidence of this seen in a number of bedrooms when some residents held discussions with the inspector. The homes policies indicate that residents should always have the right to access any information that the homes keeps about them, although residents spoken to showed little interest in this option at the time asked. Food and meal times are treated as an occasion and something to be looked forward to. An experienced cook is responsible for providing quality nutritional meals that meet the cultural and dietary needs of the residents. The cook is available to residents and stated when possible does ask them what their choices are, although daily choice of menu is usually offered by care staff. The cook was familiar with the dietary requirements of those residents case tracked and provides a diet that meets their needs. Discussion with the cook evidenced her knowledge of how to supplement a residents diet by such as adding milk and cream to potatoes as opposed to over reliance on supplements. The home has a number of Afro Caribbean elders and the cook is able to offer appropriate cultural diets as and when requested. Care staff are sensitive to the needs of those residents who find it difficult to eat and give appropriate assistance. Tables are set attractively. Residents enjoy flexible meal arrangements and can eat in their own room if they wish. Regular drinks are available and staff will make beverages as needed. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The outcome for this group of standards is judged to be adequate. Residents have easy access to the homes complaints procedure although there have been occasions where its effectiveness has been compromised by the handling of concerns by some staff. There are systems in place to protect residents from abuse and residents feel safe at the home. EVIDENCE: The service has a complaints procedure that meets the national minimum standards and regulations, this available within the home. Residents and relatives spoken to were aware of how to make a complaint and felt confident in doing so. There was however evidence of a complaint raised during a review not having been dealt with appropriately in that it was not recorded as a complaint, and the staff member that took the complaint was unaware that some of the issues had already been addressed (as established by the inspector not from a complaint report). This does indicate that some staff have a lack of awareness as to the steps they should take, this as detailed within the homes policies. The fact that the concerns were not documented as a complaint meant there was no clear outcome or complaint resolution documented. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 15 The policies and procedures regarding protection of residents are satisfactory and have been reviewed recently, reflecting local guidance in respect of the protection of vulnerable adults, a copy of the latter also readily available. Within the policy it is clear when incidents need external input and who to refer the incident to. The staff spoken to had a good understanding of what constituted abuse and steps that should be taken in accordance with procedures, this evidencing that some guidance/training had been provided, although there is a need based on training records for all staff to receive this training. There have been no referrals in respect of vulnerable adults protection issues since prior to the time the new owners have taken on the running of the home. Residents indicated that they feel safe living at Caldene. Caldene Rest Home DS0000066350.V297844.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22,25,26 The outcome for this group of standards is judged to be good. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which in encourages independence on some but not all occasions. EVIDENCE: The service provides a homely environment although there is no documented rolling programme to improve the decoration, fixtures and fittings. Discussion with the new provider did however centre around plans they have for improvement of the facilities on offer and some minor decorative/safety works have been carried out, of particular note the improved cleanliness of the building. The overall design of the building does lend itself to the meeting of residents needs. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 17 Residents spoken to stated they were happy with accommodation, whether communal or private, although there was an issue for one resident where due to a stroke the reversal of the rooms layout would have assisted with their independence (as would electrical sockets further up the wall as opposed to skirting board height), this an issue the management were made aware of. There was sufficient hot water available and a number of bathrooms and toilets, these accessible to bedrooms and communal areas. Radiators are all guarded or low surface temperature, with hot water taps thermostatically controlled to ensure safe. There was some concern, this shared by the new provider, that a number of areas in the home need to be lighter whether by brighter lighting or lighter décor, this of particular note in some of the corridor areas. There have been no recent outbreaks of infection and procedures in respect of hygiene management are available. Liquid soap and paper towels as well as staff protective wear was seen to be readily available. Some of the commodes in the home were found to be substandard and the provider stated they would carry out an audit of these and replace where needed. Caldene Rest Home DS0000066350.V297844.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The outcome for this group of standards was good. Staff in the home have received some training input although do need more in specific areas. They are however available in sufficient numbers to fulfil the needs of the current dependency and numbers of residents at the home. EVIDENCE: Residents are generally satisfied that the care they receive meets their needs and that staff are generally available to assist them when needed although there was reference from some of having to wait a short while for help at times. Residents spoken to were confident in the staff’s abilities to care for them. Comments made by residents included the following: “ Carers very kind” “Looked after well enough” “Staff are good at basic care” The provider recognises the importance of training, and list of staff showing what staff had what training was made available, this indicating that there is a need for input in some areas. The provider stated that the company was working towards providing the same. Whilst no new staff have been employed recently, there was evidence of the induction for staff meeting TOPSS (training organisation now superseded by skills for care) standards but needing revision in accordance with the revised Skills for Care induction standards. It was Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 19 pleasing to note that 50 of the staff have achieved their NVQ level 2 (vocational qualification) or above in care. There was no direct evidence at the time of the inspection of recruitment practice as no new staff have been employed since the provider purchased the home. Recruitment procedures and discussion with the provider evidenced that the provider was fully aware of the steps to take to protect residents through this process and this is further supported by the provider’s good recruitment practices in other homes carried on. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The outcome for this group of standards was judged to be adequate. The management and administration of the home was lacking at the time of the inspection due to the lack of a dedicated registered manager, although the provider has, with the support of other home managers worked hard to address any issues that have arisen as a result. The provider is aware of the need to develop an effective quality monitoring system and was found to be open about any shortcomings of the service, and identified areas that required work to the inspector. The provider has a good awareness and understanding of equalities and diversity. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 21 EVIDENCE: At the time of the inspection the home did not have a dedicated manager, but was monitored by managers from the provider’s other homes on a daily basis, as well as the provider themselves. An application for registration for a dedicated manager was however received by CSCI following the completion of this inspection, and it is hoped that this will address concerns that have been expressed by residents and relatives as to the lack of the former (this mostly not having a central point of contact to talk to), this if the manager is successful in respect of their application. The provider has a good understanding of equality and diversity and is keen to ensure that this is presented through the service delivery to residents of differing cultures. The home does not currently have a quality monitoring system, although the provider is aware of the need to develop such a system to build on the methods of consultation that are currently been put in place (residents meetings, formal monitoring of the home by the provider etc). Appropriate policies and procedures are in place in respect of safeguarding resident’s valuables and finances. There was however concern that there was not always a documented inventories of individual resident’s property in place and that transactions involving resident’s monies in safe keeping were not ratified by at least two signatures. The home does not act as an agent for any of the residents. The supervision of staff on a formal one – to - one basis has lapsed with the absence of a registered manager and must be recommenced. The home has a health and safety policy that meets health and safety requirements and legislation although there were areas where work needs to be undertaken as detailed within the requirements in this report, this including training of staff, developing some areas of risk assessment and outstanding areas from the last Environmental services visit. Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X 3 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 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 X 2 X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 1 X 2 Caldene Rest Home DS0000066350.V297844.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 OP7 Regulation 15 Requirement Care plans must be consistently reviewed monthly. This is a repeated requirement that has been partly met. 2 OP8 13 To ensure that there is documented evidence of residents having access to a dentist on a regular basis. To ensure that all residents are weighed or their weight monitored by other appropriate methods on a regular basis. All staff that administer medication must have accredited training. This is due to be provided and must be completed for any staff that administer or witness the administration of medication 5 OP16 22 To ensure that all concerns are documented appropriately and there is clear evidence to show that they are followed up. DS0000066350.V297844.R01.S.doc Timescale for action 30/09/06 30/09/06 3 OP8 13 30/09/06 4 OP9 13 & 18 30/11/06 30/09/06 Caldene Rest Home Version 5.2 Page 24 6 OP19 23 The provider must develop a plan for the on-going refurbishment and redecoration of the property that shows forward planning. This is a repeated requirement. This is to include an audit of all commodes and replacement of any that are substandard. 31/10/06 7 OP29 17(2) Sch 4 18 Details of employee’s full working history must be detailed in their files. Dates for all staff training identified as needed within the homes training plan must be detailed within the said plan. The dates for training of staff in adult protection, moving and handling and first aid are to be supplied to the CSCI. 31/10/06 8 OP30 30/09/06 9 OP33 24 An effective quality assurance 30/11/06 system must be developed in accordance with the expectations of the National Minimum Standards. To ensure that there are 30/09/06 documented inventories of residents property consistently in place. To ensure that transactions involving resident’s monies in safekeeping are ratified by at least two signatures, one of which may be the residents. Any monies temporarily removed to aid purchases must be entered in at the time they are withdrawn without fail. 30/09/06 10 OP18 13 11 OP35 13 Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 25 12 13 OP36 OP38 18 24 The formal supervision of staff must be recommenced. The homes fire risk assessment must be completed and reference made to the use of multipoint adaptors. To continue with risk assessments in respect of safe working practices at the home. To liaise with Environmental Services in respect of the outstanding requirements from their last report dated 23.3.06. 30/11/06 30/09/06 14 OP38 24 30/09/06 15 OP38 16(2)j & 24 30/09/06 Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 26 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 OP1 Good Practice Recommendations The homes statement of purpose and service user guide must be reviewed in accordance with the comments within the body of this report (in respect of additional information). The home should gain evidence of the resident and their representatives having a copy of the homes statement of purpose/service users guide through documenting their receipt of the same, preferably by their signature. Residents pre-admission visits to the home should be documented as part of the homes initial assessment procedure. To ensure that resident’s or their representative’s sign their care plans to evidence their involvement and agreement. To continue with consultation to gain the views of residents in respect of the social activities offered at the home and assess their suitability on an on-going basis. To give relatives, friends and representatives of the resident written information about the home’s policy on maintaining their involvement with the resident, this at the time the resident moves into the home. To ensure that the lists of furniture available in residents rooms is accurate. To give consideration to the layout of R.T’s room in respect of their individual needs. Staff should sign the homes policies and procedures to indicate that they are aware of, and understand them. 2 OP1 3 4 5 6 OP5 OP8 OP12 OP13 7 8 9 OP24 OP24 OP31 Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Caldene Rest Home DS0000066350.V297844.R01.S.doc Version 5.2 Page 28 - 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!