CARE HOMES FOR OLDER PEOPLE
Canadia 41 Pearson Park Hull East Yorkshire HU5 2TG Lead Inspector
George Skinn Key Unannounced Inspection 28th 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 Canadia DS0000064770.V355830.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. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Canadia Address 41 Pearson Park Hull East Yorkshire HU5 2TG 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) 01482 341434 Mrs Heather Feeney Mrs Nicola Jayne Owens Jennifer Rose Watson Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Staffing must meet the levels set by the residential forum. The outstanding requirements must be met within four months of registration. The care home may provide care for 1 named service user with a MD To include one service user under 65 years of age. Date of last inspection 31st May 2007 Brief Description of the Service: The Canadia is a three story semi-detached building situated in Pearson Park close to the centre of Hull. It is a period property and the front of the house still gives that impression. The home is on a bus route to the city centre and a short walk from Newland Avenue shopping area. Service users can access a small area to the front garden in warmer months and there is parking space to the side of this for two cars. Service user care only is provided, to a maximum of sixteen service users and mostly in double rooms; 7 of the 9 rooms are double accommodation. Only one bedroom has en-suite facilities of a toilet and a shower. Two lounges offer a pleasant environment in each, while the dining room is extremely small, resulting in some service users having to eat at tables in the lounges and others finding it difficult to get into their places at table. The laundry is sited in a wooden garage at the side of the house. Current weekly fees are £278 per week. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered provider on an Annual Quality Assurance Assessment (AQAA); A visit to the home carried out by one inspector. Information provided from surveys. A site visit was carried out which lasted 7 hours. Service users and staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity within the home. What the service does well: What has improved since the last inspection?
The home now makes sure that people’s needs are assessed before they move into the home. This means that service users or relatives are sure the home can met their needs. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 6 The home now makes sure that people agree contracts/terms and condition before moving into the home. This means that both the service user and the home are clear about their commitments while staying at the home. The home now makes sure that all the service users have a plan of care. This means that the staff know how to care for the service users properly and the service users receive the best care possible. The home have made sure that all the staff have had the proper training to be able to giver out medication safely. This means that the service users are not put at risk by the homes handling of medication. The home has increased staffing levels and this has enabled the staff to spend more time with the service users. The home makes sure that service users maintain with relatives and friends. The home now makes sure that any compliant are recorded and investigated properly and the complainant is satisfied with the outcome. This means that complaints are dealt with properly and all those involved achieve a satisfactory outcome. Some areas of the home have been redecorated and new carpets have been fitted in the all service users bedrooms. The home makes sure there are enough staff on duty to met the needs of the service users. This means that the needs of the service users are better met and the staff have more time to sit with the service users and do activities. The home now has more than 50 of the staff trained to NVQ level 2. This means that the service user are cared for by trained staff. What they could do better:
20 requirements were made as a result of this inspection many of these are outstanding from the previous inspection so “what the home could do better” is very similar to the last inspection. The registered person must make sure the home is registered properly with the CSCI to be able to accept and care for those people who have dementia. The registered person must make sure that any one who wants to come to the home has up to date information about the home so they can make an informed choice. The registered person must make sure that good and up to date information is kept about each of the service users so the staff can care them properly and they provide the best care that the home can offer.
Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 7 The registered person must make sure that there are activities and entertainment specifically designed for those people with dementia. The registered person must make sure that the hallway and lounge carpets are replaced, and any worn or broken chairs are replaced. Areas of the ground floor, which are accessible to the service users, have been identified as being hazardous by the Environmental Health Officer (EHO) and place the service users at risk. The registered person must make sure they comply with the requirements made by the EHO to ensure the safety of the service users. The registered person must make sure that the drive is repaired and that this does not pose a trip hazard to both service users and relatives. The registered person must make sure that staff receive mandatory training around the health and safety of the service users to prevent them being put at risk of harm. The registered person must make sure that the staff are fully checked before working at the home and the proper checks are done with the Criminal Records Bureau (CRB) so service users are not put at risk of harm or abuse. The registered person must make sure that the service users, relatives, friends and any visiting GPs or nurses are consulted about the running of the home, this will ensure that the service users live in a home which is run in their best interests. The registered person must make sure that they visit the home regularly to make sure that home is being run properly by the manager and consult with service users to gain their opinions; from this they have to complete a report which indicates any areas for improvement, or development. This will make sure that every one who is involved with the home has a say about how it is run and the service it provides. 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. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 8 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 Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 9 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): 1, 2, 3 and 6. People who use this service experience poor quality outcomes in this area. Information provided to service users is not up to date and is misleading. Service users needs are assessed prior to moving into the home. Service users are admitted outside of the registration category of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some of the service users’ primary needs are of those people with dementia and the home actively encourage the admission of people with dementia; this is outside of the registration category. The registered person must submit an application to vary the homes registration, this will ensure that the home is operating within the legal requirements of the Care Standards Act 2000. It was identified at the last inspection that not all newly admitted service users had their needs assessed prior to moving into the home. All service users files were looked at during this site visit including newly admitted service users. It
Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 10 was found that all had community care assessments, which had been undertaken by the placing authority, and basic assessments undertaken by the home. That Statement of Purpose has not been updated since the registered person recruited a manager and does not reflect the staffs’ or manager’s qualifications or the service provided at the home for those people with dementia. This would enable prospective service user, or their relatives, make an informed choice about whether the home could meet their own, or their relatives, needs At the last inspection it was noted that newly admitted service users had not agreed a contract with the home. Copies of agreed contracts/terms and conditions were on the service users files. This ensures that both parties understand their responsibilities with regard to the service users stay at the home. A relative of a newly admitted service user was spoken with during the site visit. He commented that he had looked around three homes before deciding on the Canadia; he confirmed that he was able to visit the home and that the manager had visited the service user prior to her being admitted to the home. He could not remember seeing a Statement of Purpose or anything that indicated what service the home offered. The home does not admit service users for intermediate care. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience adequate quality outcomes in this area. All of the service users have a plan of care which has been agreed and sets out their needs. Service users have regular access to health care professionals. The service users are protected by the home medications procedures, staff are appropriately trained. Service users are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the service users plans were looked at as part of the inspection. It was found that these contained assessments undertaken by the placing authority and basic assessments undertaken by the home. The homes assessments were generic and identified areas of strengths and those areas where the service user needed assistance. Risk assessments were undertaken around falls, daily living tasks, mental health and nutrition. The updating of these risk
Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 12 assessments was variable and it was not possible to always find when these had been updated or changed along with the changing needs of the service users. One-service users nutritional needs had changed significantly. Their nutritional risks assessments had been updated but it was not possible to find a clear audit trail of when the change was first identified, how this had been monitored, who had been involved and what the outcomes were for the service user and how the home could provide the best care possible for the service user. It was identified at the last inspection the recording of information around nutrition and weight was variable, this was still the case. Evidence on service user files indicated that they had not had their weight monitored or their nutrition assessed for some months. One service user’s bathing record indicated that she had not had not had a bath or a shower since 06/09/07. The home have a key worker system, when interviewed the staff who are key workers commented on just completing the daily notes and not formulating the service user plan of or being involved with this process. At the last inspection it was identified that the manager had been undertaking regular reviews of the care plans. These had lapsed and where found to out of date. Service users continue to have access to health care professionals some service user visit their own GP independently others are supported by the home. There was evidence of other health care professionals visiting the service users. The homes medication is handled appropriately and records were up to date and accurate. At the last inspection the home were required to ensure that all those staff administering medication had received accredited training; staff files indicate that this had been complied with, and staff confirmed this when interviewed. The staff were observed to treat the service users with dignity and respect, they were courteous and addressed the service users using their preferred form of address at all times. Conversations were relaxed and respectful and service users seemed to be used this interaction responding appropriately to the staff. One of the service user has been deaf from birth, observation made during the site indicated the staff were communicating with him very well, they commented that he did not use British Sign Language but communicated his needs very well to them. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience adequate quality outcomes in this area. Service users’ life style matches their expectation and cultural needs, further development could be made for those who have dementia. Service users have contact with relatives and friends. Service users can exercise choice and control over their lives. Service users receive a well balanced diet and have a choice of meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation made during the site visit indicated that the staff have a good relationship with the service users and interaction has improved since the last inspection. Staff were seen to be sitting with the service users and engaging those with dementia well. Those service users who are more able and independent continue to engage well with the staff and were able to go about their daily lives and exercise choice. Those service users who are able to leave the building independently are supported to do this and service users go out with relatives.
Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 14 At the last inspection it was noted that those who are dependent on the staff were not stimulated well and had limited opportunities for activities. Observation made during this site visit indicted that this had improved, service users were occupied and there was lots of interaction with the staff. Service users were engaged in making posters and the staff were singing and entertaining the service users. At the last inspection it was noted that the time the staff had to spend with the service users was limited due to having to undertaken other tasks like cooking. Staff stated that they now have more time to spend with the service users since the employment of a full time cook and domestic. There was no evidence that there were no activities specifically designed for those with dementia; however the manager stated that there are plans for staff to attend training on how to work better with those people with dementia. The service users’ records indicate their interests or if they are to be encouraged to join in activities; some records indicated that some service users did not what to join in activities. The home encourages contact with relatives and friends; those relatives spoken with during the site visit confirmed that they are made to feel welcome and visit at any time. Service users were observed to be interacting well with each other and conversations were friendly and relaxed. The food continues to be of an acceptable standard. The cook commented on an improvement in the provision of food for the service users and she was able to provide a greater choice. The service users commented positively on the quality of the food comments included “the food is very good” “there’s plenty of it” “they always ask me what I want” “can’t fault it”. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience adequate quality outcomes in this area. Service users knew who to complain to. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection the home were required to improve the way complaints are recorded, this has been done. Evidence in the complaint file indicated that there is a record of the complaint, what the home did about it, the outcome and whether the complainant was satisfied with the outcome. No complaints have been received by the CSCI or investigated by the Local Authority since the last inspection. The home had received one complaint since the last inspection this was found to have been dealt with appropriately using the above procedure. The home have a complaints procedure this is included in the Service User Guide and displayed around the home. Staff interviewed during the site visit confirmed they knew the home had a complaints procure and what this entailed; they confirmed that they had received training on the Protection Of Vulnerable Adults (POVA) and this was recorded in their files.
Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 16 Those service users and relatives spoken with during the site visit new that they could complain and to whom that complaint should be made. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience poor quality outcomes in this area. Service users live in a home which is generally clean and tidy. Service users do not live in a home which is routinely refurbished. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some redecoration of the home has been undertaken this was as a result of registered person successfully obtaining a capital grant for improvement from the Government. The communal areas have been redecorated and new carpets laid in all of the service users’ bedrooms. Some chairs have been replaced in the lounge but some remain shabby, worn, broken and ripped. The carpets in the lounges and entrance hall have not been replaced and continue to be dirty and worn. Following a visit from the EHO some areas of the ground floor accessible to the service users pose a potential risk and remedial action is required.
Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 18 The service users have access to the garden to the front of the building; this is used as a smoking area for the service users and staff. The garden continues to be generally tidy. It was noted at the last inspection that the drive is made up of uneven paving slabs which cause a trip hazard to the service user and visitors. No work has been done in this area and this remains the same. There was no evidence of a routine maintenance record to ensure the building is maintained and refurbished as required. The home was generally clean and tidy laundry facilities are located outside of the building in a shed. Staff were seen to be using protective clothing when entering the kitchen and dealing with the needs of service users. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience poor quality outcomes in this area. Service user needs are met by the numbers of staff on duty Service users re not protected by the home recruitment and selection practise. Staff are receiving the relevant training to be able to acre for the service users appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home have increased staffing hours since the last inspection, this means that staff are provided in enough numbers to meet the needs of the service users. At the last inspection some concerns were raised that the care staff have to undertake other duties such as cooking which takes them away for caring for the service users. Staff confirmed that the employment of a regular cook and cleaning staff had help to ease this and they were able to spend more time with the service users and undertake caring tasks. At the last inspection concerns were raised about staff taking lunch breaks leaving the home short staff for periods of time. This had particular impact on the night staff as there are only ever 2 staff on duty, consequently leaving the home staffed by 1 member of staff for 2 hours during the night. This has been
Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 20 addressed and night staff are now paid through the night and day staff are paid for the time they are in the home and have the option of taking a lunch break or not dependent on the needs of the service users. New contract have been agreed with staff. When spoken with staff confirmed that this is a much better arrangement and means that they are not neglecting the service users needs. Files for all staff employed at the home were looked at. The majority contained the required information including CRB checks and references. It was identified at the last inspection that some files included photocopies of CRB checks undertaken by previous employers, one file contained no evidenced of a CRB check, this was still the case. the manager stated that these had been sent for but could not provide any evidence to confirm this. A staff member confirmed that she had applied to the CRB and had paid the fee to the registered person. The registered person needs to provide evidence that this has been undertaken and the manager was asked on the day of the site visit to provide this within one week. The registered manager continues to audit the staff training and those areas which need updating have been identified; she has accessed the local authorities training programme and stated that staff are booked to attend training on dementia and diabetes. The manager stated that 7 members of staff, including her, had achieved the NVQ level 2 in caring and were awaiting their certificates. This will mean that over 50 of the staff are trained to NVQ level 2 standard. Relatives spoken with during the site visit commented on how well trained they thought the staff were and how caring they were. One said, “ I would not have let my wife stay here if I did not have confidence in the staff or their ability”. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use this service experience poor quality outcomes in this area. Service users live in home which is managed by someone who is fit to be in charge. The home is not run in the best interest of the service users. The health and safety of the service users is not promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is registered with the CSCI, she has limited experience in managing a residential home but has managed changes within the home well, and she currently does not hold the Registered Managers Award equivalent to NVQ level 4.
Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 22 At the last inspection there was no evidence that the registered person undertakes regular supervision with the manager, this is now done and written evidence is kept on the managers file. The manager had also identified training which she would like to attend this included equality and diversity; she stated this would be accessed via the local authority-training diary. At the last inspection it was noted that the registered person does not undertake visits in line with the requirements of Regulation 26 of the Residential Care Homes Regulations 2001. This was still the case and no evidence was seen that these visit are undertaken or the required reports compiled. At the last inspection it was noted that the manager had developed a limited Quality Assurance system (QA) within the home. There was written evidence, in the form of minutes taken, that service user meetings had taken place. There was no evidence however that the QA system included the views of other stakeholders for example visiting GPs and other health care professionals or that there is an annual development plan for the home. The QA system did not include the views of relatives or staff. At the last inspection it was noted that the homes policies and procedures are not updated in line to changes in legislation or good practise guidelines issued by the Department of Health, local health authorities, and specialist professional organisations. This was still the case, a recent inspection undertaken by the EHO identified that the home had no environmental risk assessments, or risk assessment to ensure the safety of the service users. At the last inspection it was noted that the staff have not received regular mandatory training and that this had not been updated as required. Staff files indicate that they had received some mandatory training, but a few still needed updating. The manager stated that she had system which flagged up when this was required; staff spoken with were aware of what needed up dating and when this was to be done. The registered person is required to complete a self-assessment prior to the site visit taking place (AQAA). The evidence in the AQAA was poor and did not fully demonstrate how the home had identified areas of weakness and how they were intending to improve these. Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 23 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X X X 1 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 1 Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4, 5 & 6 Requirement Timescale for action 07/03/08 2 OP1 4, 5 & 6 The registered person must submit a variation to include registration for those service users with dementia. The registered person must 07/03/08 ensure that the Statement of Purpose is updated to include the change in management, the qualifications of the staff and service the home provide for those with dementia. This will enable prospective service user to make an informed choice about whether the home can meet their needs. Outstanding requirement previous time scale not met 30/08/07 The registered person must 07/03/08 ensure that the service users’ care plans meets relevant clinical guidelines produced by the relevant professional bodies concerned with the car of older people. This will ensure the service user receive the best care possible. The registered person must 07/03/08 ensure that the service user plan is reviewed by the staff in the home at least once a month, updated to reflect the changing needs of and current objectives
DS0000064770.V355830.R01.S.doc Version 5.2 3 OP7 15 4 OP7 15 Canadia Page 26 for health and personal care, and actioned. This will ensure that the service users receive the best care possible 12, 13, 18 The registered person must & 19 ensure that any significant changes in service user health needs are recorded in their care plan and there is clear audit trail about when it was identified, what was done, who was involve and what the outcome was for the service user. 5, 12, 16 The registered person must & 23 ensure that service users are given the opportunities for stimulation through leisure and recreational activities, particular consideration should given to people with dementia and other cognitive impairments. Outstanding requirement previous time scale not met 30/08/07 The registered person must implement a programme of routine maintenance and renewal of the premises is produced and implemented with records kept. Previous time scale not met (30/05/06, 01/01/07, 30/07/07) new time scale set. The registered person must make, as priority, plans for renewal of furniture, carpets and redecoration of the lounges and hallway. Outstanding requirement previous time scale not met 30/07/07 The registered person must ensure that the drive is made
DS0000064770.V355830.R01.S.doc 5 OP8 07/03/08 5 OP12 07/03/08 6 OP19 16, 17 & 23 07/03/08 7 OP19 16, 17 & 23 07/03/08 8
Canadia OP19 16, 17 & 23 07/03/08
Page 27 Version 5.2 safe and dose not pose a trip hazard to service users or visitors. Outstanding requirement previous time scale not met 30/07/07 The registered person must ensure that any requirements set by the Environmental Health Officer is complied with within the time limits given The registered person must ensure that the staff have received essential training to meet the needs of the service users. Outstanding requirement previous time scale not met 30/07/07 The registered person must ensure that there is robust and effective recruitment and selection procedure to ensure the safety of the service users. Outstanding requirement previous time scale not met 30/07/07 The registered person must ensure that all relevant recruitment checks are undertaken to ensure the safety and protection of the service users. Outstanding requirement previous time scale not met 30/07/07 The registered person must ensure that prior to employment a CRB check is undertaken for all staff, and a CRB is obtained for any current staff who do not have the appropriate checks. It is unacceptable for staff to be
Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 28 9 OP19 16, 17 & 23 07/03/08 10 OP27 18 07/03/08 11 OP29 18 & 19 07/03/08 12 OP29 18 & 19 07/03/08 13 OP29 18 & 19 07/03/08 employed on the strength of a CRB check undertaken by a previous employer whatever the time scale. Outstanding requirement previous time scale not met 30/07/07. The registered manager must demonstrate that he/she has undertaken periodic training to up their knowledge, skills and competency while managing the home including the registered managers award. 14 OP31 4, 5, 18 & 19 07/03/08 15 OP33 Outstanding requirement previous time scale not met 30/08/07 4, 5, 6, The registered person must 14, 15, ensure that there is an annual 17, 21, 22 development plan for the home, & 24 based on systematic cycle of planning-action-review, reflecting aims and outcomes for service users. Outstanding requirement previous time scale not met 30/09/07 4, 5, 6, The registered person must 14, 15, ensure that the views of families’ 17, 21, 22 friends and of stakeholders in & 24 the community (GPs, chiropody, District Nurses) are sought on how the home is achieving gaols for service users. Outstanding requirement previous time scale not met 30/08/07 4, 5, 6, The registered must ensure that 14, 15, policies and procedures are 17, 21, 22 regularly reviewed in light of & 24 changing legislation and of good practise advice form the department of health, local health authority, and specialist/
DS0000064770.V355830.R01.S.doc 07/03/08 16 OP33 07/03/08 17 OP33 07/03/08 Canadia Version 5.2 Page 29 professional organisations. Outstanding requirement previous time scale not met 30/09/07 The registered person must ensure that visit required by virtue of regulation 26 of the Residential Care Homes Regulations 2001are undertaken and reports available for inspection. 18 OP36 10, 18, 19, 24 & 26 07/12/07 19 OP38 Outstanding requirement previous time scale not met 01/07/07 10, 12, The registered person must 13, 16, 17 ensure that all staff receive & 37 mandatory training. Previous time scale not met (30/05/06, 01/11/07) new time scale set 10, 12, Environmental risk assessments 13, 16, 17 must be completed and reviewed & 37 on a regular basis. Previous time scale not met (30/05/06, 01/01/07, 30/09/07) new time scale set. 07/03/08 20 OP38 07/03/08 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 Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Canadia DS0000064770.V355830.R01.S.doc Version 5.2 Page 31 - 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!
