CARE HOMES FOR OLDER PEOPLE
CARTLIDGE HOUSE CHARLTON STREET OAKENGATES TELFORD SHROPSHIRE TF2 6BD Lead Inspector
JANET ADAMS 25
TH Announced APRIL 2005 09.30 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 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. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service CARTLIDGE HOUSE Address CHARLTON STREET OAKENGATES TELFORD SHROPSHIRE TF2 6BD 01952 618293 01952 616149 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) ACCORD HOUSING ASSOCIATION LIMITED MRS J DICKENSON CARE HOME 54 Category(ies) of 36 DEMENTIA registration, with number 18 OLD AGE of places CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: The home may accommodate a maximum of 54 service users. The home may accommodate up to 54 Elderly Persons of whom 36 may be suffering from Dementia. Date of last inspection 21ST DECEMBER 2004 Brief Description of the Service: Cartlidge House is situated in Oakengates, Telford and is registered to provide personal care to a maximum of 54 older people, 18 of whom may have dementia. The home is separated into six units each of which has its own lounge/dining room, bathroom and small kitchen. In order to maintain consistency of care each unit has its own staff team. The home operates a key worker system with nominated care staff having responsibilities for individual service users. Accord Housing owns the home and the registered manager is Mrs Jean Dickenson, she holds the registered manager’s award. A refurbishment of the accommodation and facilities started in November 2004 and will take up to 12 months to complete. Up to nine service users at a time are moved on a temporary basis to other premises and move back when a section of the refit is completed. In order for this to happen, the home has no plans to admit any residents on a respite basis until the refurbishment is complete. At this inspection, it was seen that the refurbishment project was running smoothly ahead of schedule. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was announced and commenced at 9.30am lasting seven and a half hours. It included observing activity within the home, inspecting the premises, looking at records, ‘case tracking’, talking and listening to residents their visitors and staff working at the home in a variety of roles. The Manager and staff on duty were welcoming and helpful throughout the inspection. It was obvious a lot of preparation had been undertaken to make sure all information needed was available, and the details the home provided to CSCI (Commission for Social Care Inspection) before the inspection was most worthwhile. A variety of information confirmed what was seen at the inspection , including the results of a survey where over 66 of residents, many visitors and several visiting professionals gave information about life at Cartildge House. It was found that the National Minimum Standards assessed had been met with only minor exceptions Although the home has been in the process of major refurbishment for the past five months, it has appeared to have a positive effect on everyone involved. Comments from residents visitors and staff were unanimous that people were closer,and the team spirit of the staff had improved as everyone was working together to ensure all residents were looked after properly. All residents appeared happy, content and well cared for and those who were able expressed satisfaction with their quality of life at the home. What the service does well:
It was pleasing to only read and be told very positive information about living at Cartilage House. This is summed up in a comment received from a person who wrote ‘Cartilage House looks after me well and attends to all my needs I require within a happy and friendly environment.’ The staff on duty paid respect to the residents and were seen to be following the individual care plans, encouraging those who were able, to maintain their independence and take part in activities that they enjoy and benefit from. It was considered that the management approach towards the home refurbishment programme has created an open and positive atmosphere from which the residents continue to benefit. It was evident that there are clear lines of accountability in the way Cartlidge House is organised. The home communicates well with families, representatives and visiting professionals, and has a group of staff that have worked at the home for a considerable time.
CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 6 Good communication was confirmed by a resident who said ‘Cartlidge House is as good as it is because of the staff – they let you know what is happening. ‘ To make sure the building works at the home cause as little disruption as possible to the residents, the team have embraced many additional responsibilities and changes to their working lifestyle . In light of this they are to be commended for their efforts, especially when the amount of staff training that has also been achieved and planned for was seen. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 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 standard(s) 2,3,and 4 The policies and procedures that are in place have recently been professionally followed, to ensure that the home undertakes all necessary assessments for successful and satisfactory admissions to take place. EVIDENCE: Documentation examined for three residents indicated that individuals now have a comprehensive assessment of their needs prior to admission, which is reviewed and amended as requirements change. Before admission, when a potential resident is to be assessed, a good practice measure the home has adopted is to give the person a copy of the home contract of terms and conditions at that time so they are aware of what life at Cartlidge House entails before they move in. This gives the person plenty of time to look at it before signing it as part of the ‘moving in’ process. Observations and discussions with residents, the manager and staff on duty indicated that the home has met the individual needs of the elderly people living there in a desirable manner despite the upheaval they have experienced as part of the refurbishment. The Registered Provider, Accord Housing, and the home’s staff team are to be commended for its commitment to ensure the safety and well being of all at Cartlidge House during this time of change.
CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 9 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 standard(s) 7, 8 10 and 11 There is a good, consistent care planning system in place, which needs a few minor details to be included to confirm residents get the care they need and expect. The staff are sensitive to the individual needs of each service user and meet these in a professional manner. EVIDENCE: The care plans of four residents at the home were looked at. Most of the persons’ health, personal and social care needs were seen to be set out in their records, however, some information was needed to be brought up to date, and some new details were seen to be required in order to give a full picture of what their care needs were. For example, although a falls risk assessment was seen in records it did not address which footwear to use to minimise a person from falling. This was highlighted when a visitor was overheard discussing why the resident was not wearing the new slippers purchased to replace the old pair she was wearing that were not suitable for walking in as they were a poor fit. In another instance, a resident spoken to was having difficulty with his wheelchair.
CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 10 Although records were held about it being serviced, there was no plan of action to ensure it was fully working in between times. Also, the persons wheelchair seen had a lap strap fitted and did not have care plan records to detail how it was to be correctly used. Some records needed more detail to confirm which type of bath or hoist (including the type of sling) the person required. It was also confirmed that the home did not have the equipment to safely weigh all of its residents. As some people who live at the home cannot share this information with people, it is important it is written down. In balance of these findings, a lot of improvements to care records were seen. It was positive to see relevant details how to manage a lot of individual needs such as continence, personal hygiene and night-time preferences. The sensitive issue of caring for a person’s needs in the event of their passing away was also seen to be suitably dealt with. All residents spoken to confirmed they were fully involved with what was written about their needs. District nurse, Doctor’s, chiropodists and opticians visits were recorded well. For the second year running a local GP had written to CSCI to confirm the home was very well run. Comments from staff who had worked in the home for over two years confirmed the way they recorded the residents care information was much better. All contact with relatives confirmed that they could see their relative in private if they wish. Individual’s receiving care during the inspection were taken to their rooms or bathrooms. Staff observed during the inspection spoke respectfully to service users. All contact with residents confirmed that the residents felt safe in the home; staff treated them well, and respected their privacy. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 11 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 standard(s) 12,13 ,14 and 15 Staff work in close liaison with residents and their relatives to understand their individual lifestyles and preferences in order that these can be continued when they live at Cartlidge House. In consultation with individuals living at the home or their relatives if appropriate, choice and control over their lives is promoted where possible. EVIDENCE: It was seen that individuals were encouraged and empowered as far as it was practical to maximise their independence and be involved in choices about all daily activities in the home. The refurbishment of the home has provided a huge opportunity which has fully involved people wherever possible to encourage their opinions to be listened to and acted upon. It was seen that the ongoing building activity in the home had not had any negative effect to compromise the social pastimes in the home. Residents had recently been involved in local courses for ‘active healthy lives’, computer skills and art and crafts. A resident had recently composed a poem seen on display. Other favourable information about the range of both communal and 1:1 activities from residents, families and staff confirmed standards continue to be exceeded. For example, people were involved in making choices about
CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 12 destinations for forthcoming trips and outings. Furthermore, in order to ensure everyone’s opinion about any trips was listened to, it was reported that a ‘trip evaluation form’ was completed to record peoples feelings and comments about it. It was seen that the people of Cartlidge House regularly attended shows at Oakengates Theatre, and posters and leaflets on display confirmed the home was involved with local church parishes and the Salvation Army. The needs of people with dementia related conditions living at home were seen to be met by staff in receipt of ongoing specialist training for this purpose. Staff were seen to sit with residents spending quality time with them to help them decide what to choose for meals planned for the next day. The service, presentation and meal quality at lunchtime was of a good standard. Although a few residents commented they sometimes liked the food, the majority said they enjoyed it. It was noteworthy to be told that the home has ‘Menu Meetings’ where they can make suggestions about what to try for a change. One resident also commented that the food was ‘extremely good’. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 13 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 standard(s) 16, 17and 18. Concerns and complaints are dealt with promptly and professionally and procedures and practices are in place to ensure that individuals are protected from abuse. EVIDENCE: The complaints log seen showed the home has received three complaints in the past 12 months. Although these were recorded and seen to be managed satisfactorily, in order to make this system robust, it is recommended the pages be numbered to keep them in the right order. The home has all necessary documentation in relation to the protection of vulnerable adults and this subject is included in staff training. Due to the nature of residents’ disabilities, some of the people at Cartlidge House cannot be involved personally to manage their own affairs. In order to ensure their well being, it was reported that all of these individuals have advocates to ensure all important issues including finances were dealt with correctly. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 14 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 standard(s) 19.20.21.22.23.24.25, and 26. Good progress with the ongoing refurbishment continues to improve the living environment within the home. All necessary works have been identified and are in hand. Interim measures until its completion ensures residents have a clean, safe, comfortable and homely place to live. EVIDENCE: It was seen that considerable progress had been made with the refurbishment programme at the home and it was reported by the manager that the target date for completion had been set well ahead of schedule for early Summer 2005.Once all internal works have been completed the grounds are to be revamped to include better garden areas including a safe garden for residents with dementia related conditions to enjoy. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 15 Despite the challenges and disruption this has entailed, the home team have endeavoured to ensure the wellbeing of the people to be living and working at the home in comfortable, pleasant and hygienic surroundings. Structural and cosmetic improvements to the home have resulted in improved fire safety systems, residents bedrooms, and communal areas including the installation of specialist bathing equipment. The involvement of the local fire safety officer had ensured he was satisfied with all arrangements during the building works as well as approving the installation of the new sprinkler system. It was seen that most of the works identified at the last Visit by the Environmental Health had been actioned, although some chemicals seen in use still needed correct labelling. Redecoration of the completed areas has transformed that appearance of the home. Residents confirmed they were involved in choosing the colour schemes with the help of ‘design boards’ to aid decision making. Accord Housing have also incorporated ‘good practice’ ideas such as having amenity doors and toilet doors in the building painted different colours.Attention to detail to provide pictures chosen by the residents hung in the corridors adds a homely feel. Redecorated bedrooms seen had been personalised according to the preferences of the person it was allocated to, and upgraded with many features including door locks, radiator guards, a new call bell system and washbasins. To help orientate people to their new surroundings, residents had been involved in designing signage for their bedroom doors. It was seen that any ‘teething troubles’ with any of the decor and equipment were actioned correctly. This included the edges of carpets seen to be starting to lift in the communal lounges. However, in one of the units where work was reported as complete it was seen that some hot water pipe work seen at the last inspection in a bathroom still needed to be protected. Risk assessments for the new locks were reported to be an ongoing task and were looked at when people moved back into their ‘new’ bedrooms. These details need to be included in the person’s care planning. Residents and staff were all complimentary about the improvements, and how the programme had been well planned and managed to ensure any disruption had been kept to a minimum. At the time of the inspection plans were in place to deal with the home laundry, as it was due to be refitted that week. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28,29 and 30. Residents are supported by a well trained and committed staff group who are meeting the needs of each individual in a sensitive and professional manner. EVIDENCE: The staff rotas on display and staff on duty at the time of this inspection indicated that adequate numbers and skill mix of staff are on duty at all times. The manager confirmed that there were two vacancies in the care team, although well trained staff were provided by a local agency that knew the home and the residents to ensure continuity in care. Discussion with the manager verified staffing levels remain constant with a very low turn over of staff despite the many changes the home team has had to deal with due to the refurbishment. It was positive to be told that the only leavers were those who had done so to further their care careers to be nurses. Examination of the most recent staff file demonstrated that thorough recruitment procedures had been followed, although the quality of staff photographs needs to be improved to confirm identity. Accord Housing continue to support staff to undertake their NVQ awards – 68 were reported to have the required qualifications in care, with another 5 people due to complete their course in the near future. A variety of other training has been undertaken or is planned for the near future and was seen in staff files as well as in the training information provided for inspection. It was also confirmed that more in depth training for the staff team caring for the residents with dementia related conditions had been approved and was in the pipeline. On the day of the inspection the company Dementia Care Manager
CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 17 was on site holding some training for 8 staff members. Staff spoken to were very knowledgeable about their training experiences, and showed the home has exceeded standards expected to care for the people at the home. They are to be commended for their ongoing efforts to excel in such a year of change. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33, 36, 37 and 38 The home is managed by a competent manager who leads the staff group with confidence. They are clear about their roles and responsibilities. Good systems of communication are in place to seek the views of the service users and families/representatives. Service users finances are handled appropriately. Staff are regularly supervised to enable them to carry out their work effectively. Health, safety and welfare of service users and staff continue to be improved by safe working systems in place. EVIDENCE: The manner in which Accord Housing, Jean Dickenson the manager, and staff responded to this inspection and the home refurbishment indicated that a good
CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 19 management approach is in place. - Staff are committed to ongoing improvements, achieving best practice and to developing equal opportunities. The home has an effective quality assurance system in place. Systems to make sure information about the huge changes in the home has been shared with everyone include the actions taken as a result of monthly resident and staff meetings, and the monthly issue of an eye catching ‘Cartilage News.’ CSCI recognise the planning and partnership working between Accord Housing and Telford and Wrekin Council to mange the home business during the refurbishment. The health, safety and welfare of service users and staff has been well managed with evidence of planning, preparation and informed staff knowing their roles and responsibilities. It was pleasing to see information and risk assessments around the home about the safe use of any new equipment installed, although some attention to details to the environmental risk assessments to include those for water temperature testing for Legionella were seen to be required. It was positive to see risk assessments in all care plans seen about how residents manage their money – showing the team follow the company policy for this. All staff are appropriately supervised on a regular basis. This was confirmed through discussion with staff and records of supervision being examined during the inspection. A noteworthy system to record this process seen in staff files clearly shows how it is managed. When the accident book was looked at it was seen that details to make sure all accident records contained all the relevant information, and they were in the right order was necessary to further improve this system. All other records and service certificates were seen to be satisfactory. CSCI look forward to reviewing future records to confirm successful completion of all works identified at previous inspections have been carried out once the refurbishment of the home is complete. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 4 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3
COMPLAINTS AND PROTECTION 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 x 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 x x 3 3 2 2 CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement All care plans must contain evidence to assess individuals regarding falls risk.This must include details of appropriate clothing and footwear. (Previous timescale of 27.9.04 not met) Care plans must contain evidence to demonstrate a service user’s health is promoted, and there is access to health care services to meet all the criteria of 8.1.-8.13 of this standard.(Previous timescale of 27.8.04 not met) Evidence of risk assessment and servicing to promote wheelchair safety must be included in service user plans. This must include details about the safe use of any fitted lap straps.(Previous timescale of 27.8.04 not met) Equipment needs to be provided to ensure all residents can be weighed. Timescale for action 30.08.05 2. OP8 12,13,14 30.08.05 3. OP8 16 05.07.05 4. OP8 23 (2) (n) 05.07.05 CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 22 5. OP19 16 (2) (j) All works identified by the Environmental Health officer on 3/12/04 must be met. All chemicals used in the home must be labelled as expected to fully comply with COSHH guidelines. A strategy to ensure bedroom security with relevant risk assessments is met for all service users for the present time, the transitional time, and the permanent outcome of the home refurbishment. (Previous timescale of 27.8.04 not met) Pipe work, including the new plumbing in Ashdale unit and radiators must be guarded.(Previous timescale of 27.7.04 not met) The home’s record systems must be streamlined and developed to contain all of the required elements of the National Minimum Standards, including record keeping for accidents, care plans and environmental risk assessments.(Previous timescale of 27.8.04 not met) An up to date Legionella risk assessment with appropriate management plan to manage it needs to be implemented. 02.08.05 6. OP19 13 (4) 05.07.05 7. OP24 23 (1) (a) 05.07.05 8. OP25 23 (2) (p) 05.07.05 9. OP37 17, Schedule 3 30.08.05 10. OP38 13 (4) (a) 30.08.05 CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 23 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. 2. Refer to Standard OP16 OP29 Good Practice Recommendations That the pages of the complaints log are numbered in order to validate it contains every complaint received. Photographs in staff files to be provided tobe legible enough to identify the person. CARTLIDGE HOUSE E56 S20542 Cartlidge House AI V186248 250405 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn, Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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