Inspection on 13/03/06 for Cambrian House

This inspection was carried out on 13th March 2006.

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

Cambrian House 03/11/09

Cambrian House 08/07/08

Cambrian House 18/06/07

Cambrian House 17/10/06

Cambrian House 01/07/05

Cambrian House 17/11/04

Cambrian House 02/05/04

Cambrian House 02/04/04

Cambrian House 16/02/04

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 Cambrian House 294 Chester Road North Kidderminster Worcestershire DY10 2RR Lead Inspector Andrew Spearing-Brown Unannounced Inspection 13th March 2006 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 Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cambrian House Address 294 Chester Road North Kidderminster Worcestershire DY10 2RR 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) 01562 825537 01562 825537 Kidderminster Care Ltd Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25), of places Physical disability over 65 years of age (25) Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st July 2005 Brief Description of the Service: Cambrian House is a care home providing personal care and accommodation for up to twenty-five older people who may have a physical disability or a mental health need associated with old age. It is located in a residential area on a main road about a mile and a half from Kidderminster town centre. The home is a large three-storey house, which has been adapted and extended for its current purpose. Accommodation for the service users is provided on the ground and first floor. On the first floor there are seven bedrooms five of which are en-suite. There are sixteen bedrooms on the ground floor thirteen of which are en-suite. There are three Parker baths and one conventional bath. There are five separate toilets throughout the building. Access to both floors is provided by a through floor lift. There are separate lounge and dining areas. There is parking at the front of the house; at the rear there is a good-sized enclosed garden with seating and tables. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by a regulation inspector from the Worcester office of the Commission for Social Care Inspection (CSCI). The inspection took place over a period lasting a total of 5 ½ hours commencing at 09.15. The last inspection at Cambrian House took place on 1st July 2005 making this inspection the second statutory visit during the 2005 – 2006 inspection year. The home had one vacancy on the day of this inspection. Part of this inspection was to assess the progress made in relation to the requirements from the previous inspection as well as assess some other key standards. Throughout the inspection the acting manager was on duty. The registered provider joined the inspection for part of the process and for the feedback session at the conclusion of the visit. A partial look around the home took place concentrating primarily on communal areas and facilities. The care documents of a sample number of residents were viewed including care plans, daily notes, risk assessments and accident records. Other documents seen included medication records, some service records and some staffing records. What the service does well: What has improved since the last inspection? Although the requirements made following the last inspection in relation to medication were all assessed as met new requirements are issued following this inspection. Requirements issued regarding some environmental matters were assessed as met. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 6 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. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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 Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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): Standards 2 and 3. Standard 6 is not applicable. An initial pre admission assessment carried out by a representative of the home provided some detail for the staff in the home. Terms and conditions need to be completed to safeguard residents individual rights. EVIDENCE: The homes Statement of Purpose and Service Users Guide were not seen as part of this inspection having been assessed as meeting the required standard in the past. These documents will however be assessed as part of future inspections and along side the acting managers application to the Commission for Social Care Inspection to become the registered manager. This application needs to be made without further delay. A pre admission assessment was viewed in relation to a recently admitted resident. In addition to this document compiled by the acting manager was a Community Care Assessment (CCA) prepared by the funding local authority. Further comments regarding this assessment are included under standard 7 below. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 9 A copy of the homes terms and conditions was held within each residents individual file. These documents were blank; the acting manager stated that she is intending to hold a review with each resident and their representatives and plans to discuss terms and conditions as part of that meeting. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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): Standards 7,8 and 9 Although not signed or dated the initial pre admission assessment carried out by a representative of the home provided some detail for the home to demonstrate their ability to meet individual care needs. The lack of a care plan following this assessment could however lead to staff having insufficient direction to carry out the care package. Risk assessments are not in place to ensure safe working practices, which include fall prevention. The lack of these assessments places both residents and staff at risk of injury. Significant improvement in medication management is needed to safeguard residents. EVIDENCE: Individual plans of care are available. As part of this inspection a random sample of care plans were viewed. The care plans were well presented in a folder with cellophane leaves. The initial care plan of a respite resident was adequate in detail and could be read alongside the Community Care Assessment (CCA) provided by the placing social worker. This initial care plan Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 11 was not however either dated or signed. Concerns were highlighted as a result of the lack of either amendments or up dates to this initial plan. Under the heading ‘history of falls’ the care plan stated ‘ lots of falls whilst at home . . . careful monitoring will be put into practice to observe’. No account of how this ‘monitoring’ was to take place was recorded. Another care plan had a falls risk assessment dated April 2005 with a review scheduled for July 2005, this review has not taken place. Other risk assessments including moving and handling and nutritional screening were not reviewed. Residents’ weights were not recorded each month. The care plans for a resident who was self caring in a number of areas was scant in detail and contained a number sections without any information even though some information was necessary. The daily notes were generally satisfactory although terms such as ‘all care given’ are insufficient if the care plan lacks detail and is not up to date. Monthly reviews of the care plan, which were not always done, need to take place on at least a monthly basis or more frequently to reflect changing care needs. The actions taken by staff in contacting the emergency services following a resident becoming unwell on the day of this inspection were appropriate and well managed. As part of this inspection the safe management of medication was assessed. Since the last inspection the acting manager has changed both the medication system as well as the supplying pharmacist. Using the current system the majority of prescribed medication is held within blister packs or MDS (Monitored Dosage System). These packs are securely held within a suitable medication trolley. Stock medication is held within a cupboard, which is also used to store medication due to be returned to the pharmacy. The supplying pharmacist has not carried out a visit to the home to review procedures since the change has taken place. The majority of the MAR (Medication Administration Record) sheets covering a four-week period, which had come to a conclusion the night before this inspection, were viewed. This process highlighted serious concerns in the records and required immediate action from the acting manager and registered provider to address these matters. A sizable number of gaps were noted on the MAR sheets whereby neither a signature nor a code was entered to indication whether medication was administered or not. It was noted that two persons had not signed hand written amendments to the MAR sheets as required. One MAR sheet was signed in pencil on one occasion. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 12 An audit of one drug did not balance. It was evident that the frequency of medication was reduced by a medical practitioner however the MAR sheet did not indicate when this had taken place and errors in recording such as gaps and an occasion whereby a signature was crossed out were seen. One resident who was in hospital for a period of time had medication signed as given when clearly it was not possible to administer the medication. This indicates that the homes own procedures are not carried out in that medication must only be signed for once administered. The section at the top of each sheet headed ‘ Allergies’ was in some cases blank. Any known allergies must be recorded here. If no allergies are known then ‘none known’ must be recorded. The controlled drugs book was viewed, it was noted that only one signature was in place for the evening of the 9th March. These records did not match the signatures on the MAR sheets, which had a gap on the 8th March, and a signature crossed out on the 10th March. One MAR sheet showed that a resident self-administers medication. No risk assessment was in place regarding self-medicating. It was of concern that a resident was prescribed antibiotic medication however the drug was not commenced until two days later. The acting manager should investigate the reason for this time delay and why no record existed regarding the delay As indicated above on the day of this inspection it was the end of the medication cycle and therefore medication not used should have been ready for returning to the supplying pharmacy. None of the medication requested for checking which was signed as refused or for a resident who spent time in hospital was available and could not be accounted for. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Some social activities are organised to provide stimulation and interest for residents these however need to be extended and more frequent ensuring that they are able to meet the care needs of residents. EVIDENCE: A list of activities, which had taken place during January 2006, was viewed and the availability of activities was discussed with the acting manager. It is evident that each month 3 different persons visit the home these activities are in relation to electric keyboard, music and movement and a craft related activity. No other activities take place on a regular basis. The acting manager should seek the opinions of residents regarding activities that staff could embark upon in addition to the ones highlighted above. Open visiting is in place. Residents are able to receive guests within their own bedroom or one of the communal rooms including a lounge area on the first floor and a second lounge on the ground floor. No food was viewed during this visit. The minutes of a recent residents meeting showed that a desire for more fresh vegetables and hot puddings. As the acting manager was not part of the meeting these matters were brought to her attention and a positive response was recorded. Although only a small sample of residents were consulted the comments regarding food were Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 14 generally positive. On the day of this inspection the mid day meal was cauliflower bake, new potatoes, tomatoes and bacon. The sweet was due to be apple crumble but as both the cook and kitchen assistant were off sick a substitute was going to be provided by the deputy manager who was cooking the days meal. The days menu was on display in one of the dining areas. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 The complaints procedure needs a minor amendment however information obtained showed that residents feel that any concerns or complaints would be listened to. The vulnerable adults procedure needs to be reviewed to ensure that it is consistent with local procedures to fully safeguard residents. EVIDENCE: Two differing complaints procedures were displayed within the care home and another different procedure was held within the complaints file. It was noted that the procedure near to the manager’s office made reference to the former NCSC as opposed to the CSCI. One complaint regarding a temporary loss of hot water was recorded and well documented with a satisfactory outcome. The CSCI have received no complaints regarding Cambrian House since the last inspection. Adult abuse training has taken place although this training remains outstanding for some employees. The homes own procedure refers to the former NCSC and makes no reference to the Adult Protection Coordinator employed by Worcestershire County Council. These amendments need to take place. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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): Standards 19, 24 and 26 Cambrian House offers a comfortable and homely environment for people to reside. A small number of areas were identified which require some improvement to further safeguard residents and staff. EVIDENCE: The majority of environmental standards were not assessed during this inspection however was noted that the home was clean and had no unpleasant odours. The home has sufficient lounges and other seating areas located around the home some of which are infrequently used. The reception area of the home, which is pleasant in appearance, is a popular sitting area with some residents. Liquid soap was provided within communal toilets however bars of soap were also noted which can be a means of cross infection. Training regarding infection control is needed for the majority of staff members. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 17 At the time of the last inspection it was noted that the treads on the stairs leading down to the cellar were in need of replacing. Since that date they have received attention however the adhesive used had come free in some places and therefore a potential trip hazard could come about. The registered provider undertook to have this attended to as soon as possible. It was noted that a freestanding wardrobe was not secured to the wall to prevent it falling over when opened. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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): Standards 27, 28, 29 and 30 The procedures for recruiting new members of staff were not sufficiently robust to fully ensure that residents are safeguarded however a sufficient number of staff were on duty and training continues to improve. EVIDENCE: The staff rota confirmed that staffing levels remain as reported within the previous inspection report. A total of four carers including a senior are on duty in the morning and three in the afternoon. Ancillary staff such as domestic staff and catering staff are also employed within the home. Carers are required to carry out domestic duties at the weekends A well-maintained file contains certificates of all training undertaken by each member of staff. It was evident that the majority of staff have received moving and handling training since the previous inspection. Ancillary staff have not received any training in relation to the safe lifting of loads. Some staff need to receive training in fire awareness, infection control and adult abuse awareness. The acting manager confirmed that currently five out of the fourteen carers hold a NVQ (National Vocational Qualification). This equates to 36 of the care term. Additional staff are currently undertaking this training and therefore the 50 level should be achieved in the near future. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 19 Documentation relating to an employee who commenced duties recently was seen. It was evident that the registered persons had not sought a Criminal Records Bureau (CRB) disclosure and Protection of Vulnerable Adults (POVA) check prior to commencing duty. A new employee may only start work once a POVA first is obtained and even then only under supervision. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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): Standards 31, 33, 34 and 38 Quality assurance systems currently in place need to be extended and the acting manager needs to apply for registration in order to develop the service offered. Some shortfalls regarding health and safety documentation and training need to be improved to assist with the safeguarding of residents and staff. EVIDENCE: Cambrian House has had an acting manager for over 12 months. An application to become the registered manager with the Commission for Social Care Inspection must be made without any further delay. A quality assurance document dated March 2005 was briefly viewed. An external person carried out the survey on the quality of the service offered. As this was now 12 months ago a similar exercise or other means of quality Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 21 monitoring needs to be undertaken. Minutes of a residents meeting attended by 6 individuals dated January 2006 was seen. The registered provider carries out regular visits to the home and prepares reports upon the conduct of the home as required under regulation 26. The certificate of public liability certificate was displayed as required. A business and financial plan regarding the home was not sought during this visit. The fire records were briefly viewed. The last testing of the fire alarm took place on the 28th February; therefore the alarm was not tested the week before the inspection. The alarm was tested in some form of sequential order however one break glass point was last tested as part of the weekly testing on 12th July 2005. In addition the regular monthly tests had not taken place during February these include the visual checking of the fire extinguishers and operation of the emergency lighting. A fire risk assessment dated November 2002 is in place at that time a number of recommendation were included within the document which are recorded has having taken place over the following 7 months. No evidence is available to demonstrate that any up date or review of this document has taken place since June 2003, which is now 2 ¾ years ago. Service records of the parker baths were not requested however a label on each bath stated that they were last serviced during February 2006. Similarly a mobile hoist also displayed a label confirming a recent service. Portable electrical appliances had a sticker on each of the plugs stating when they were last checked. The person who had carried out the checks had not signed accompanying records. A passenger shaft lift is provided to ensure that residents have access to both the ground and first floor. Due to the location of the beam on the lift a risk assessment is needed regarding the possibility of the doors closing on to a resident and failing to open automatically. Aspects of health and safety training are highlighted elsewhere within this report. A number of wheelchairs were stowed in a corridor area. Three only had 1 footrest in place while one had none. Not having footrests can be hazardous to residents when wheelchairs are in use. Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 X X X 2 Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 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 OP2 Regulation 5 (1) (b) Requirement The registered person must ensure that each resident has a copy of the homes terms and conditions, which is signed by either the resident or a representative. The registered person must ensure that residents care plans are up-dated and must accurately reflect all service users care needs. (Previous timescale of 31/01/05 and31/0705 not met. Immediate and on going action needs to take place to fully comply with this requirement) 3. OP7 13 Care plans must be signed by residents or their representatives. (Previous timescale of 31/01/05 and31/0705 not met. New time scale given) 30/04/06 Timescale for action 31/05/06 2. OP7 15(1) 13/03/06 Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 24 4. OP8 13 Risk assessments must be undertaken for nutritional and skin care needs of the service users, and must be signed and dated. (Previous timescale of 31/01/05 and31/0705 not met. Immediate and on going action needs to take place to fully comply with this requirement) The registered person must ensure that residents are assessed regarding their risk of falling and the outcome included in the plan of care with details of appropriate interventions. The home must ensure that where bed rails are in use an appropriate risk assessment is in place and fitted with protective covers. The registered person must ensure that accurate records regarding medication are completed in order that a full medication audit can be carried out. The registered person must ensure that Medication Administration Record (MAR) sheets are signed after medication has been administered to service users. The reason for any nonadministration of prescribed medication to service users must be clearly entered onto the MAR sheets. The registered person must ensure that when a variable dosages is prescribed the actual dose given is recorded. DS0000018498.V286593.R01.S.doc 13/03/06 5. OP8 15 13/03/06 6. 13, 15 13/03/06 7. OP9 13 (2) 13/03/06 8. OP9 13(2) 13/03/06 9. OP9 13(2) 13/03/06 Cambrian House Version 5.1 Page 25 10. OP9 13(2) The registered person must ensure that handwritten MAR sheets are checked for accuracy by two people and signed by both. The registered person must ensure that all records including those relating to medication are completed in pen. The registered person must ensure that policies and procedures regarding medication management, administering and recording are implemented. Activities provided in the home must take into account the individual needs and wishes of the residents. (Part met – extended timescale given) 13/03/06 11. OP9 13(2) 13/03/06 12. OP9 13 (2) 13/03/06 13. OP12 16(n) 31/05/06 14. OP18 13 (6) The registered person must ensure that all members of staff receive suitable training regarding adult abuse. The steps to the laundry room must be repaired/made safe. Items of furniture such as freestanding wardrobes must be secured to prevent accidental toppling over. All the items of furniture specified in Standard 24.2 must be provided in residents’ bedrooms. If the provision of any item of furniture poses a risk to the resident or they decline the provision this should be recorded in the residents assessment of need. (Previous timescale of 30/06/04 and 30/09/05 not met) The registered person must DS0000018498.V286593.R01.S.doc 31/05/06 15. 16. OP19OP38 OP19 23 (2) (b) 13 (4) 27/03/06 27/03/06 17. OP24 23(f) 30/06/06 18. OP26 13 (3) 13/03/06 Page 26 Cambrian House Version 5.1 19. OP29 19 20. OP30 18 (1) (c) review practices within the home regarding bars of soap in communal facilities. The registered person must ensure that recruitment procedures are in accordance with the requirements of Regulation 19, Schedule 2 and Standard 29. The registered person must ensure that an action plan covering all mandatory training is in place accounting for all members of staff. The registered provider must ensure that the acting manager makes the required application to the CSCI for registration as manager. A quality assurance program must be maintained which includes regular consultation with residents. The registered person must ensure that a suitable risk assessment is undertaken in relation to the location of the sensor beam on the passenger lift and that appropriate action is taken. The registered person must ensure that records regarding the electrical safety checks of portable appliances are signed and dated. The registered person must ensure that wheelchairs are used appropriately having both footrests in place in order to prevent entrapment or other health and safety risks. The fire risk assessment must be DS0000018498.V286593.R01.S.doc 13/03/06 14/04/06 21. OP31 9 31/03/06 22. OP33 24 30/06/06 23. OP38 13 (4) (a) 20/03/06 24. OP38 13 (4) 20/03/06 25. OP38 12 (1) (a) 13/03/06 26. OP38 13 13/03/06 Page 27 Cambrian House Version 5.1 reviewed at regular and frequent intervals, signed and dated. 27. OP38 23 (4) (c) The registered person must ensure that the fire alarm is tested on a weekly basis using break glass points in sequential order. Fire records including those regarding the visual checking of fire fighting equipment must be maintained as required by Hereford and Worcester Fire Authority. 13/03/06 28. OP38 23 (4) (c) 13/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Cambrian House DS0000018498.V286593.R01.S.doc Version 5.1 Page 29 - 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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