Inspection on 11/04/06 for Castle Court

This inspection was carried out on 11th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Castle Court 22/11/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Castle Court Arthur Street/Linton Road Castle Gresley Swadlincote DE11 9H6 Lead Inspector Claire Williams Unannounced Inspection 11th April 2006 08:45 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 Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Castle Court Address Arthur Street/Linton Road Castle Gresley Swadlincote DE11 9H6 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) 01283 223673 Derbyshire County Council Vacant Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first inspection of the service. Brief Description of the Service: Castle Court is a residential home situated in Castle Gresley. It is a purpose built home that provides personal care and accommodation for up to 41 older persons. All of the accommodation is situated on the ground floor, and all bedrooms are single apart from the provision of one double bedroom. All have en-suite facilities, and are fitted with patio doors, which lead out to a small garden area for each individual. There are three shops, which are local to the home. The home has separate lounge and dinning areas, a hairdressing room, smoke room, and an activities area. All areas are wheelchair accessible. The home was built to enable the closure of two Local Authority homes that did not meet the National Minimum Standards. Therefore two separate groups of staff and residents have been transferred to this home. The home was registered in January 2006. The fees for the home commence from £289.70 Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a Ten hour period. The inspection involved assessing key areas as defined by the CSCI. The inspector spoke with 15 residents and examined three files using the Case tracking methodology. The inspector joined the residents for their lunchtime meal and a tour of the building was undertaken. Time was spent observing residents and staff interaction, and the inspector spoke with 7 staff members and examined four files. The manager of the home was not available therefore the relief managers on duty assisted with the inspection. Following consultation with the people who live at this home, they will be referred to as ‘residents’ for the purpose of this report. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that residents have the required information such as the Service user guide to enable them to be informed about the provisions and services available at the home. The care plans for each resident must be updated to ensure they reflect their current needs and standardised so that all residents have the same system in place. Residents should be involved and consulted about their care plan to ensure that they are aware of what Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 6 information is being stored about them and to enable them to comment and to state whether they agree with the contents. In order to ensure residents healthcare needs are met staff must review all of these forms and implement new ones, which reflect their current needs, which can then be monitored appropriately. The medication practices of the management team must be assessed due to the discrepancies and issues relating to their practice in the storage and administering of medication, which could potentially place residents at risk. Although an activities co-coordinator is employed and has commenced with facilitating activities, this can at times be compromised due to the staff member having other care duties which impact on the provision of activities. This limits the time and the potential of meeting residents social and emotional needs. Residents commented that they would like the staff or the activities coordinator to be able to spend quality time with them. The staffing levels should be reviewed in accordance with the needs of the residents as comments were made that the staff are “always running around” and “never get to spend any quality with us”. The staff team also felt rushed especially during the morning, as this is a very busy time. 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. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, and 5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not currently provide the required information about the service to residents, so they are not informed about the facilities available. The home has developed a pre-admission tool, which can be used to assess resident’s needs prior to admission. EVIDENCE: Residents informed the inspector that they had not received a copy of the Service user guide since they transferred to the home, and that a Statement of purpose was not available. This was confirmed by the management team. This results in residents not having the required information in order to be informed about the facilities and services available in the home. All the residents living at this home have transferred from two homes that have closed, therefore there was no evidence of completed pre-admission assessments in their files. However the manager and the staff team are in the process of completing an assessment of all residents needs using the preCastle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 9 admission format, so that updated information is present in their files and to ensure that individual needs and aspirations can be met by the home. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes care planning system does not ensure that resident’s needs are met. The medication practices have some potential to place residents at risk. Residents felt respected by the staff team, and confirmed that their privacy and dignity is upheld. EVIDENCE: Four residents’ files were examined in accordance with the case tracking methodology. Although the files did contain some information that covered aspects of the resident’s health, personal and social care needs, this information was out of date and referred to routines and information relating to their previous homes. The files and the paperwork had not yet been standardised and two systems were in place. There was no evidence to support that residents are involved in care plans. Although nutritional, tissue viability and risk assessments were in the files, they to were outdated and not reviewed in accordance with the guidance. Although there was evidence to support that residents had six monthly and annual reviews this information was not then transferred to their care plan. Monthly reviews were not undertaken. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 11 In discussions with all the residents spoken to it was confirmed that they felt that the staff team did meet their needs and are aware of all their support needs. Residents felt that their dignity and privacy were upheld and that personal care tasks were supported in a respectful and sensitive manner. Observations of the staff team interacting and supporting individuals did on the most part confirm this knowledge. Staff are informed of residents needs or changes during staff handovers or through the use of daily case notes. Unfortunately systems for the new home have not been prepared before the move and the management team do not have access to a computer in order to develop and implement the required systems; a fax machine was also not available at the home. As result of the limited information, and resources available, this has hindered the process of the two staff teams coming together and getting to know the residents they had not worked with before, thus making it difficult for everyone to work and be supported as one home, rather than two separate groups of people. The inspector checked the daily case notes for the four people case tracked. There was no consistency in the length of time between case notes being written which resulted in long gaps of up to 13 days without an entry. When records requested for an aspect of someone’s care to be monitored this was not always completed, resulting in the records not fully reflecting the care, and support, provided or the well-being of individuals. Some records contained derogatory comments about individuals for example; it was stated that one resident “was in a mess” due to incontinence. Another resident was described as being “mardy”. The Medication storage and practices were examined and improvements are required in this area. The inspector identified gaps on the Medication administration Records (Mar chart) with no explanation or codes used, and some discrepancies were found on the chart. The controlled drugs register was incorrect as the balance was not accurate, as new medication received had not been signed in. However the medication was added to the Mar chart but these two systems could possible cause confusion on the number of tablets actually held in stock. Two people had not countersigned handwritten medication, and staff at times signed the Mar chart before administering the medication. This was due to the amount of medication that had to be administered as a method to prevent mistakes, and due to time constraints on the staff. (Please see standards 27). The inspector was informed that the management team responsible for administering medication had undertaken training in this area. A medication competency assessment has not yet been developed, which could be used to assess the staff member’s competency in administering medication. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Limitations on staff time can impact on the provision of activities and quality time spent with residents. Residents receive visitors without any restrictions, and felt that the food provided met their preferences. EVIDENCE: The home employs a staff member whose duties include activities combined with some caring tasks. The home has an activities room, which is in use at all, times. The residents commented that the provision of activities, was satisfactory and stated that they enjoyed both in-house activities and the trips out that are organised. Some residents have designed Easter bonnets ready for the Easter parade and an Easter raffle, which was supported by the local community and family, which raised funds for the home. Some residents stated that it would be nice to have some in-house entertainment such as singers or an organist, and this information was passed onto the managers. Due to the dual role of the activities co-ordinator this can at times compromise the provision of activities as she is expected to undertake personal care tasks if there are staff shortages, or if the staff are busy. Her role also includes assisting the manager on duty to administer medication, which limits her Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 13 allocated hours of 4 hours per day to 3 hours. It also impinges on one to one time with individuals who choose to remain in their rooms; consultation with residents; and preparing notices for the home detailing what activities are available on each day. Consequently there are limited records to support the provision of activities and the social needs of residents. Residents confirmed that there were no restrictions on the times visitors came and the provision of small kitchenette enabled visitors and residents to make drinks and snacks. The inspector joined the residents for their lunchtime meal. Residents informed the inspector that they always have a choice and are asked their preferences by the care staff at breakfast. The menus for the home are not displayed, and feedback confirmed that residents do not have any involvement in the menus. Some residents commented that the food was “good” and “tasty” while other comments made stated that “at times the portion sizes were not adequate” especially the soup which is served in small bowls, and is one of the alternatives available. The files examined did not include detailed lists of preferences, and only limited information was provided. Although the mealtime was relaxing, and not rushed, a resident made the following comment “we are assisted to the dinning area half an hour before the food arrives”. This is due to the number of residents that require support and the numbers of staff on duty. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents felt that their complaints and concerns were listened to and acted upon. Staff had a good awareness of the safeguarding adult’s procedures and their associated responsibilities. EVIDENCE: The complaints procedure was displayed within the home so that residents are informed of how to complain. Due to the absence of other literature this is the only way that residents and relatives are aware of the procedure. Residents commented that complaints or concerns made were always listened to and responded to. The home has received seven complaints three of which were referred to the provider from the CSCI. Some of the issues raised were concerning some problems with the systems, and the equipment within the home, due to everything being new some equipment when used with residents did not function, as it should. Other issues raised were personal to individual residents. All of the complaints have been investigated and responded to. The staff spoken with confirmed that they had undertaken training on how to safeguard adults from abuse. The staff members were aware of their responsibilities under these procedures and how to respond if they witnessed any form of abuse occurring. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is furnished and maintained to a satisfactory standard and offers homely and spacious facilities for residents to enjoy. EVIDENCE: The home is purpose built and all facilities are on one level. The building is spacious, well decorated and well maintained. Residents commented on some of the difficulties faced due to some of the systems and equipment not working properly following their transfer to this home. This had proved to be frustrating for both the staff and residents, who hope “no more problems arise”. Some residents spoke positively about their new home and the facilities available whereas some residents felt the home was too big, and were experiencing difficulties with ‘settling in’ and getting used to the new routines. Some residents commented on their dissatisfaction with being moved and the closure of their previous home, which for some was closer to their family and friends. Residents and staff felt that it was going to take time for them to get Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 16 used to this transition and change in their lives. Residents commented on how hard the staff teams had worked in assisting them with the move and how they have tried to make the move go smoothly. Residents informed the inspector that they had an opportunity to choose which bedroom they wanted, and following their invitation the inspector viewed their rooms, which were personalised to individual’s preferences. Some residents commented on how they felt the water pressure was a little too high and their dissatisfaction with the design of the sinks, which are not fitted with plugs. However the provider is in the process of reviewing this and intends to replace all sinks in the home. Most residents felt that they had the appropriate equipment available to enable them, on order to maintain there independent. One resident did state the need for a handrail in the bathroom area to assist with transferring onto the bath chair, which they felt was “wobbly” and made them a little frightened of falling. The inspector noted that in some of the bedrooms, (which were located at the rear of the building), were overlooked by houses, as there is only a wire fence. Majority of the windows in residents bedrooms are only fitted with draw curtains, therefore the public can see right into these rooms, which can effect residents privacy. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels and deployment are insufficient to meet all of the identified needs of the service users. Staff files did not reflect that recruitment procedures were being implemented in order to safeguard residents. EVIDENCE: The inspector examined the staff rotas, which over the last month highlighted high sickness levels. The staffing levels indicated that 4 care staff are on duty on majority of the shift patterns. The home currently doesn’t have the provision of relief staff to cover the sickness; therefore existing staff have worked additional hours. It was highlighted in discussions with residents that the staff are always “running around trying to meet peoples needs”, and that they “do there best but there is a lot of people here requiring support”. Some residents felt that the staff team, only had time to do the basic task orientated jobs like getting them up, dressed, and personal care. They felt they didn’t have time for any quality care like sitting with them, or going for a short walk. In discussions with the staff team is was stated that the morning shift was ”hectic” with only limited time available to spend with each resident who may at times be rushed due to the demands on staff time and the level of support required by a percentage of the people living in this home. Staff reported that they felt “very tired” at the end of their shift, and expressed how they “wished Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 18 they had time for some quality time with residents especially those who they are key worker to. Staff have little time for the completion of paperwork and expressed the fact that they “only have time to complete the basics of care duties.” Some staff reported that at times they have to do tasks in their own time just to ensure that residents can go out or to do residents shopping. Although some of these issues have been raised with higher management the responses were that the home was overstaffed not understaffed. The inspector examined four staff files. The files had not yet been standardised and two systems were in place. The files did not contain all of the required information. Records on training attended, and copies of certificates were only available in one file. Therefore it was difficult for the inspector to evidence if staff had attended all of the required mandatory training, although in discussions with staff members they did confirm positive training opportunities and attendance. The staff team expressed the initially difficulties arising from two separate teams joining as one and the closure of the homes and move to this home. Staff felt that everyone was doing their best and working very hard to get to know all the residents and working together as a team. The staff team is mainly female with one male night staff. There are a small number of male residents who would benefit from a male care assistant working in the daytime. In addition to the care roles staff also have to attend to the laundry, which takes them away from working with the residents. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents felt that the manager was competent in her role, and improvements are required to ensure all areas of health and safety are promoted and maintained. EVIDENCE: The manager of the home was appointed in March 2006, and has recently applied to be registered with CSCI. She has the required qualifications and experience to fulfil the responsibilities of her role. Residents and staff commented on how they found the manager to be approachable and felt that she was supportive. All of the management team have felt an element of frustration with the problems encountered since the home opened in relation to the environment, sickness levels and associated problems, and lack of equipment. This has prevented them from implementing all of the required Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 20 systems and facilitating supervision sessions with their allocated staff members. The managers on duty commented that due to the problems encountered this has had an impact on the completion of paperwork. The management team are trying to standardise all systems so that everyone is working to the same routines, and implementing new paperwork so that everything refers to the current situation rather than the previous homes. The inspector was informed that visits in accordance with regulation 26 were undertaken by the provider but there were no reports available at the home for the inspector to examine to confirm this. The management team are trying to ensure safe working systems are maintained and when faults are reported they refer these to the appropriate contractors. However managers stated their frustration to the length of time taken for repairs to be undertaken. The inspector was informed that staff have undertaken training on all the equipment and fire procedures within the home and stated that staff members have previously attended all mandatory training. However as previously stated the records did not reflect this. The inspector was informed that quality assurance systems had not yet been implemented but residents meetings have commenced. The inspector informed the managers on duty of her observations concerning staff members not always ensuring that footplates are fitted to wheelchairs when in use. For one resident a risk assessment stipulated that footplates must be used at all times, but the inspector observed that this was not carried out in practice. The inspector also observed that the wheelchairs were used communally and not on an individual basis. Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 21 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 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 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 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X 2 Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? N/a 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 Registered Person must ensure that all residents are given a copy of the Service user guide and have access to the Statement of purpose. The Registered Person must ensure that all residents have a care plan, which cover all of the areas in National Minimum standard 3.2 and that these plans are reviewed as recommended on a monthly basis. The Registered Person must ensure that all care plans contain a photo of the resident The Registered Person must ensure that risk assessemnts in relation to moving and handling, pressure area care, nutrirtional status and falls are completed and reviewed on all residents. The Registered Person must ensure that staff adminster and record medication in accordance with the procedures of home The Registered Person must ensure that the staff team record by using the appropriate DS0000066379.V289795.R02.S.doc Timescale for action 01/07/06 2 OP7 15 (1) (a) and (b) 01/08/06 3 4 OP7 OP8 17 (1) (a) 12 (1)(a) (b) 13 (4) (c) 01/07/06 01/06/06 5 OP9 13 (2) 01/06/06 6 OP9 13 (2) 01/06/06 Castle Court Version 5.1 Page 23 7 OP9 13 (2) 8 OP9 13 (2) 9 OP9 18 (1) (a) 10 OP27 18 (1) (a) 11 12 OP29 OP31 17 (1) (a) 26 13 OP38 13 (c) 14 OP38 16 (2) (a) (ii) code the reasosns why mediaction has not been adminstered. The Registered Person must ensure that handwritten medication instructions are countersigned by two people. The Registered Person must ensure that the temperture of the medication fridge is monitored and recorded on a daily basis. The Registered Person must ensure that all staff have recived external medication training. An assessemnt of competency should then be completed following this training. The Registered Persons must ensure staffing hours are in accordance with the dependency levels at the home and adequate staff are available during the peak times of activity. The Registered Person must ensure that staff files contain all of the required information. The Registered Person must ensure that a visit is undertaken in accordance with this regulation and a record completed, which is available at the home for inspection. The Registered Person must ensure that footrests are fitted to wheelchairs that are used for resident’s mobility, unless there is a recorded reason for this in a residents file. The Registered Person must ensure the home has appropriate facilities for communication by facsimile transmission. 01/06/06 01/06/06 01/08/06 01/07/06 01/07/06 01/06/06 01/06/06 01/06/06 Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 24 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 3 Refer to Standard OP7 OP7 OP7 Good Practice Recommendations The Registered Person should ensure that care plans include information on an individual’s social interest, hobbies, like and dislikes in respect to food and drinks. The Registered Person should ensure that all care plans are standardised within the home. The Registered Person should ensure that staff receive guidance on the completion of logs which covers; the use of non- derogatory language, recording and follow-up of significant events, the length of time in between recording events and consultation with residents about the information recorded about them. The Registered Person should ensure that residents are involved in the development of their care plan. The Registered Person should ensure that a notice of activities available is displayed within the home. The Registered Person should ensure that all residents are consulted on the variety of activities facilitated within the home. The Registered Person should ensure that all residents are consulted on the variety of the meals available and their preferred portion sizes. The Registered Person should ensure that the catering staff receive training on the equipment in the kitchen. The Registered Person should consider installing a handrail in the assisted bathroom to aid resident’s independence. The Registered Person should consult residents concerning the possible lack of privacy in their bedrooms that can be viewed by the public and agree a solution. The Registered Person should develop and implement a quality assurance tool in order to gain residents feedback. The Registered Person should ensure that all staff are supervised as recommended in the standards six times a year. 4 5 6 7 8 9 10 11 12 OP7 OP12 OP12 OP15 OP15 OP22 OP10 OP33 OP36 Castle Court DS0000066379.V289795.R02.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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