CARE HOMES FOR OLDER PEOPLE
Carshalton Nursing Home 28 Salisbury Road Carshalton Surrey SM5 3HD Lead Inspector
Alison Ford Key Unannounced Inspection 31st January 2007 10:30 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 Carshalton Nursing Home DS0000019081.V328997.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. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Carshalton Nursing Home Address 28 Salisbury Road Carshalton Surrey SM5 3HD 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) 020 8669 2592 020 8669 9558 sweethomes@aol.com Sweet Homes Ltd Care Home 33 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A maximum of 10 service users may be in the DE (E) category. Date of last inspection 8th August 2006 Brief Description of the Service: Carshalton Nursing Home is registered to provide care for up to thirty-three older people who may have dementia however; reluctance by the local authority, to place clients in shared rooms has lead to a decrease in the number of residents in the home. As an existing care home some of the facilities would not meet the requirements of a newly registered home. A large proportion of the accommodation is provided in shared rooms, without en-suite facilities and they are smaller than would now be acceptable. There is only one lounge/dining area and this is in the form of a conservatory, which despite fans is sometimes uncomfortably hot. There is a shaft lift to ensure accessibility throughout the home and the conservatory overlooks the rear garden. There is limited off-street parking however the home is in a quiet road and close to public transport links. At the time of this inspection fees range from £525 - £550 per week. A copy of the homes Statement of Purpose, Service User Guide and the latest inspection report can be obtained from the homes Registered Providers or the latter can also be obtained from the Commission For Social Care Inspection. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second key inspection visit as part of the inspection process for the year 2006/2007 and was unannounced. Consideration has also been given to other information gathered throughout the year such as comment cards from those using the service, complaints and documentation required to be kept by the home as well as conversations with residents, their relatives and members of staff. On the day of the visit there were 17 residents in the home. Two trained nurses were on duty with 4 care staff and a cook, laundry assistant and domestic assistant. The Registered Manager has recently retired and the registered providers are in the process of recruiting a suitable applicant to fill this post. A partial tour of the premises was undertaken; a sample of care plans were assessed and several of the residents were spoken to. No complaints have been received about this service since the last inspection. What the service does well: This home aims to provide a caring homely environment for older people, the majority of whom have advanced stages of dementia. Staff turnover is very low which contributes to a stable and familiar environment and one of the staff members commented, “ it was like being a part of a big family “. There is always at least one trained nurse on duty in the home supported by care staff, in sufficient numbers to ensure that resident’s needs are met and to enable carers to spend time talking with them. A key worker system encourages a close relationship between the residents and individual staff members At the time of the inspection, residents, the majority of whom were sitting in the lounge, looked clean well cared for and comfortable. Those who could express an opinion commented on “how kind the staff were” and “how well looked after they were”. They all agreed that the food served in the home was “always nice” and “they had lots to eat” Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 6 Pre-admission assessments undertaken by a senior member of staff ensure that residents can be confident that their healthcare needs will be met and all of them receive a contract and Service User Guide when they move into the home. All residents have an individual plan of care, setting out the support and interventions that are needed and these are reviewed regularly to ensure that they reflect the care that is currently required. The majority of the staff have received training in dementia and its associated problems, which has heightened their awareness of the healthcare needs of the residents and during the visit they were seen to be interacting well with residents. Activities are provided which suit the remaining capabilities of the residents although, several choose not to join in and a physiotherapist visits weekly to help to maintain their mobility. Visitors would always be made welcome into the home. The home is run in accordance with current health and safety legislation, equipment and services are regularly maintained and complaints and concerns would always be taken seriously and acted upon. What has improved since the last inspection? What they could do better:
While it is acknowledged that the redecoration and refurbishment programme has started in the home, there is still no sign that the problem of the excessive heat in the lounge in the summer has been addressed. There was a plan to replace the glass roof to help with this and this will need to be put in place before the warmer weather.
Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 7 The Statement of Purpose, which sets out the objectives and philosophy of the home and The Service User Guide, which gives residents information about life in the home and the services that they can expect, both need to be updated in line with current legislation and changes that have occurred within the home. These documents provide information to potential residents about whether the home will suit their needs and allows them to measure how well the home fulfils its aims. Without them, residents cannot be certain that this home will meet their expectations. All of the residents have an individual care plan, which identifies the areas in which they require help and support. These have been thoughtfully written however; the interventions that are needed are not always identified. This would make it difficult for any member of staff, not fully conversant with the resident, to care for them in the way that they preferred and was most appropriate. There must also be some indication in the plans that the wishes of residents in the event of them becoming unwell or of their death have been discussed and noted. One new member of staff has been appointed since the last inspection however, there was no indication that relevant clearance had been obtained from The Criminal Records Bureau. The Registered Provider was contacted and reminded of his responsibilities in this matter and he agreed to send a copy of this information, which was being held centrally. These checks are made to ensure the protection of residents and in future, evidence that they have been completed must be available at inspection visits. Concerns were raised about the use of keys to unlock fire doors. Any door through which people may need to pass in the event of a fire must be able to be opened easily without the use of a key. If staff are worried that a resident may open the door and wander off, an alternative method must be found of locking the doors. Despite a previous requirement, a method to gain the opinions of the people using this service has still not been introduced. This mean that their views are not being used to influence the services that are being provided and that they are not being offered an opportunity to contribute to the running of the home. Although it is acknowledged that residents have a limited ability to participate in this process the majority have representatives or relatives who could do so. In addition other health care professionals visit the home on a regular basis and could be asked for their views. The Registered Provider visits the home on a regular basis however there is no record of these visits or of whom he spoke with. Records of these visits would also contribute to this monitoring. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 8 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. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 9 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 Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 10 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): Standards 1,3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a pre admission assessment process in place to ensure that the home and the services that it provides will meet residents assessed needs however, written information that is given to them needs to be updated so that they can be sure that the placement will suit them. This home does not offer intermediate care. EVIDENCE: The local authority funds the majority of the current residents and the care manager’s assessments, determining the level of support that is required were seen in care plans that were assessed. In addition a senior member of the homes staff will visit a potential resident to make certain that their needs can be met. A standard form is used to record the information although it was suggested that this could be developed further to include more detail. It is
Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 11 acknowledged however, that potential residents are often frail and confused and it may difficult to obtain the relevant information from either them or the hospital staff. A combined Statement of Purpose / Service User Guide is available in resident’s bedrooms. This now needs to be amended so that there are two distinct documents. A clear Statement of Purpose must be available for the home, which complies with Regulation 4 of The Care Homes Regulations and identifies the objectives and philosophy of the home. In addition, a written guide to the home, which will include a summary of The Statement of Purpose and a description of the services being offered, must support this and be made available to residents. Information relating to fees must also be included in this in line with Regulation 5 and it must reflect the current situation in the home with regard to staffing. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents all have an individual care plan so that staff know how to meet their health care needs and regular review ensures that they reflect the interventions and support currently needed. Staff attitudes within the home respect the privacy and individuality of residents and allow them to retain their dignity. Medication policies and procedures, designed to protect residents and ensure their safety, are in place within the home. EVIDENCE: All residents have an individual care plan of which four were seen. These included those of two of residents recently admitted to the home. They are based on a nursing model; ”Ropers Activities of Daily Living” and include risk assessments, assessment of skin integrity, nutritional screening and the identification of those most at risk from developing pressure sores.
Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 13 Careful thought has obviously been given to making sure that all of the relevant problems have been identified however; the interventions and support that are needed are not always clearly stated. This would make it difficult for any staff member who did not know the resident to care for them in the way that they prefer. Staff must also work with residents and their relatives to document their wishes in the event of them becoming seriously unwell or their death. Photographic evidence is used to monitor wound healing and pressure-relieving equipment was seen in use throughout the home. It was recommended that to safeguard both the home and the resident a consent form should be signed by the resident or their representative prior to this being done. The staff also explained that residents are sometimes admitted into the home with bruising or pressure sores that they had not been made aware of beforehand. It was recommended that they should develop an assessment tool or body map, which they could complete as soon as possible after a residents admission. This would provide evidence of both their condition at that time and allow staff to monitor improvements. Advice is sought from the Tissue Viability Nurse Specialist as needed for the best treatment of pressure sores and there is also evidence in the care plans of visits from other members of the multidisciplinary health care team. A physiotherapist visits the home weekly to encourage and maintain the mobility of the residents. Staff were seen interacting with residents in a kind and respectful manner and they were able to spend time talking with them. Most resident’s sit together in the lounge and this creates a very homely atmosphere. Medication records and storage was seen and appeared to be in order. Trained nurses administer all of the medication in the home and they were reminded that opened bottles of eye drops should be labelled on the bottle rather than the box in order to minimise the risk of any errors occurring. The nurses in the home are interested in keeping a stock of “homely remedies “ and discussed ways to arrange this. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 14 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): Standards 12,13,14,15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents find that the lifestyle in this home matches their needs. They are encouraged to exercise as much choice over their lives as they can and to maintain contact with their families and friends in order to promote their independence. The well-presented meals served in the home provide a balanced and nutritious diet, which is suited to the needs of the residents and provides variety in their daily lives. EVIDENCE: The advanced stages of dementia of many of the residents in this home can lead to restrictions on the amount of choices that they can make although their care plans illustrate that they are encouraged to do so. Recreational activities are provided in the afternoons by care staff and outside entertainers also visit. It was recommended that a book should be kept to show which activities had been offered on various days and which residents had participated in them. A relative that was visiting the home was spoken with and confirmed that she was always made to feel welcome in the home.
Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 15 The lunchtime meal was served during the inspection and looked appetising and well presented. All the residents were given a drink with lunch and there were sufficient staff to help those who required it. Several residents require their food to be pureed and this, too, was presented in an attractive way. Menus were also seen which appeared varied and well balanced and a book now reflects the food actually served on the day. The cook is made aware of resident’s particular preferences and dislikes and a choice of meal would always be offered. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 16 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): Standards 16,18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A robust complaints policy, which has been made available to residents and their relatives in this home, ensures that they are aware of the procedures to be followed if necessary. Appropriate procedures to deal with abuse and discrimination ensure that residents feel safe living in this home. EVIDENCE: There is a clear complaints procedure in use in the home; it is outlined in the service user guide, a copy of which is in all the residents’ rooms. Any complaints would be recorded in a book, which was seen at the inspection visit Previous inspections have provided evidence that Criminal Records Bureau clearance had been received for all members of staff and the records of the one new staff member were also checked for this. In the file there was only a copy of the criminal Records Bureau clearance from a past employer. The Registered Provider was contacted and he agreed to send a copy of the new check to the Commission for Social Care Inspection office. In future there must be evidence held in the home and available for inspection, that this check has been completed. Staff have previously received training in issues around adult abuse however this has not been updated for some time and it was recommended that a training session should be provided.
Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 17 Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 18 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): Standards 19,26 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. A programme of redecoration and refurbishment is now underway to make sure that the home provides a pleasant homely environment for residents to live in. However, their safety cannot always be guaranteed in the event of a fire. EVIDENCE: A tour of the premises was undertaken. Previous inspections highlighted a need for a redecoration and refurbishment programme for the home, which is now underway. Bedrooms and communal areas have been repainted and new carpets are being laid. New armchairs are in the lounge. Once this has been completed new bedroom furniture and curtains will be coming. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 19 All designated fire doors are fitted with automatic closers, which operate in the event of a fire to maintain the health and safety of residents however, serious concerns were raised about the fact that the fire exit door and the front door both need to be opened with a key. This could pose a risk to both staff and residents if there was a fire in the home. If these doors need to be locked, because some residents may have a tendency to wander out of the home, an alternative method must be found so that they are easily openable in the event of a fire. The garden has now been tidied up and all of the rubbish removed. The provision of some furniture will make it a pleasant area for residents to sit in when the weather is fine. There are plans to replace the glass in the conservatory / lounge roof so that it will not be so hot for residents in the summer months. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 20 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): Standards 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents can be sure that there are sufficient numbers of appropriately trained staff on duty in the home to ensure that their needs will be met and that recruitment procedures are in place to protect them. EVIDENCE: The off duty rotas were seen and showed that there were always trained nurses on duty in the home and they are supported by enough care staff to be able to meet the residents needs and, in addition, laundry and domestic staff are on duty. The majority of staff have undertaken a distance-learning package in dementia care and in infection control. Statutory training has been provided although, as detailed in relation to Standard 18, staff would benefit from an update in issues concerned with adult abuse and protection. All staff training is recorded in a book which was seen however, it was recommended that an easier system could be used to identify which staff members had attended which courses and so identify any future training needs.
Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 21 A previous requirement, to produce an induction package for new staff members, has still not been addressed although only one new person has been employed on a bank basis. This must now be put in place. Recruitment procedures had previously judged as being satisfactory with appropriate checks being made on new staff to maintain the safety of residents. On this occasion, as detailed in Standard 18, there was no evidence that a new Criminal Records Bureau check had been obtained for a new member of staff. The Registered Provider agreed to forward evidence that this clearance had been done, to the Commission for Social Care Inspection office and in future this documentation must be available to be seen at inspection visits. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 22 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): Standards 31,33,36, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no evidence that residents or their relatives are able to influence the services that they receive or contribute to the running of the home and some working practices do not ensure that resident’s health and safety are fully protected. EVIDENCE: The home is currently without a Registered Manager, the previous manager having recently retired. The Registered Providers are currently in the process of appointing a new person to this position. Despite previous requirements there was still no evidence that any form of quality assurance monitoring is undertaken in the home. A system to measure
Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 23 the satisfaction of those living in the home and their relatives must be introduced and the results used to influence the provision of future services. The Registered Provider visits the home on a regular basis however no records are available of these visits. Written reports of these visits must be prepared in accordance with Regulation26 and made available for inspection. Supervision of care staff is still not occurring in the home on a regular basis. This must be introduced so that staff are given the opportunity to discuss their development and practice and to identify any training needs that they may have. Safe working practices are generally in place however, as detailed in Standard 19, some concerns were raised about the safety of residents and staff in the event of a fire. The Registered Providers must ensure that any door through which people may have to pass when escaping from the building are easily openable from the inside without a key. A selection of certificates showing that equipment is appropriately maintained was seen and there was no evidence that electrical safety checks or portable appliance testing had been done. Evidence that these checks have been undertaken must be available in the home for inspection. Kitchen records and hot water temperature records were all in place and satisfactory and records showed that all accidents since the last inspection had been minor. Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 24 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X 1 X 2 Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4 and 5 Requirement The Responsible Person must ensure that there is a clear Statement of Purpose available and that this is supported by a Service User Guide so that residents are made aware of the services that are provided and can measure the homes success in meeting its objectives. The Responsible Person must ensure that residents care plans identify both the problems experienced by them and the interventions required to support them. The Responsible Person must ensure that resident’s preferences in the event of their death or their becoming unwell are identified and documented so that everyone is aware of them. The Responsible Person must ensure that there is evidence of satisfactory clearance from the Criminal Records Bureau for new staff members available for inspection. The Responsible Person must ensure that the covering on the
DS0000019081.V328997.R01.S.doc Timescale for action 30/05/07 2. OP7 15 30/03/07 3. OP7 15 30/03/07 4. OP18 19 31/01/07 5 OP19 23(2)(b) 30/05/07 Carshalton Nursing Home Version 5.2 Page 26 lounge roof is replaced or removed. (Previous timescale 08/11/06 not met) The Responsible Person must ensure that all designated fire doors through which people may need to pass in the event of a fire are easily opened without the use of a key at all times. The Responsible Person must develop the staff induction programme so that it becomes a more useful learning tool for new staff. (Previous timescale 08/11/06 not met) The Responsible Person must ensure that an appropriately experienced and qualified person is put forward for registration as the manager for the home. The Registered Providers must ensure that there is documented evidence of visits undertaken in line with regulation 26. (Previous timescale 08/11/06 not met) The Registered Providers must ensure that there is documented evidence of a quality assurance programme in place within the home. (Previous timescale 08/11/06 not met) The Registered Manager must ensure that there is documented evidence that all staff are receiving regular supervision. (Previous timescale 08/11/06 not met) The Responsible Person must ensure that there is evidence
DS0000019081.V328997.R01.S.doc 6 OP19 23(4)(b) 31/01/07 7 OP30 18(a) 30/05/07 8 OP31 8 (1) 30/05/07 9 OP33 26 30/05/07 10 OP33 24 30/05/07 11 OP36 18(2) 30/05/07 12 OP38 13(4)(c) 30/05/07
Page 27 Carshalton Nursing Home Version 5.2 available at inspection visits to show that all equipment and services have been regularly maintained and checked. 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 OP7 Good Practice Recommendations It is recommended that a tool should be developed which will illustrate the physical condition of any new resident and provide evidence of future improvements or deterioration. It is recommended that consent be obtained from residents or their representatives before any photographic evidence is collected, in order to protect them. It is recommended that the home should keep a record of the activities undertaken by individual residents to provide evidence that they are encouraged to participate in activities that will entertain and stimulate them. It is recommended that staff should receive a training update in issues concerned with recognition of adult abuse so that they are aware of current guidelines and reminded of their responsibilities in this. It is recommended that a training needs analysis should be developed to make it simpler to identify further training required by individual staff members. 2 3 OP8 OP12 4 OP18 5 OP30 Carshalton Nursing Home DS0000019081.V328997.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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
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