Inspection on 17/04/07 for Catterall House

This inspection was carried out on 17th April 2007.

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

The inspector 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

Catterall House 09/04/09

Catterall House 17/04/08

Catterall House 30/05/06

Catterall House 19/10/05

Catterall House 20/04/05

Catterall House 12/10/04

Catterall House 20/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Catterall House Lancaster New Road Catterall Lancashire PR3 0QA Lead Inspector Mrs Christine Marshall Unannounced Inspection 17th April 2007 1:00 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 Catterall House DS0000009690.V331995.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. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Catterall House Address Lancaster New Road Catterall Lancashire PR3 0QA 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) 01995 602220 01772 816967 rameshvarshagulati@hotmail.com Dr Varsha Gulati Mrs Maureen Margaret Stobbart Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Registered numbers to include one (1) named person under 65 years of age 30th May 2006 Date of last inspection Brief Description of the Service: Catterall House is a large, old house situated on a main road in a rural area, within walking distance of local shops, and a short drive from Garstang. It is also on a bus route. The home has been adapted to suit the needs of older people, for example, a passenger lift has been installed and ramps fitted to entrances. It is a two-storey house with single bedrooms on the ground and first floor; there is one double bedroom. There is adequate car parking space to the side of the house. Most bedrooms are now furnished to a satisfactory standard. There are basically adequate toilets and bathrooms, with the main bathroom having a bath hoist. The home provides sufficient communal space, and there is a separate smoker’s lounge on the lower floor. Carers are at the home 24 hours, every day of the year. The most recent inspection report is available from the manager. At the time of this visit, (17/4/07) the information given to the Commission showed that the fees for care at the home are from £299 to £350.50 per week, with added expenses for hairdressing, chiropody and newspapers. The registered provider is Dr Varsha Gulati and the registered manager is Mrs Maureen Stobbart. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to Catterall House took place over two afternoon periods, which were unannounced, which means that the manager, staff and residents did not know it was taking place until the inspector arrived. During the visits, time was spent sitting and talking with people who live at the home, and watching the day-to-day routines of the home, and the care staff, as they provided care and support. A tour of the home included looking at bedrooms, lounges and dining areas, toilets and bathrooms. This was to assess whether the home provided a comfortable, homely environment for the enjoyment of everyone, and to ensure the safety of the people who live there. Comment forms were sent to the home for people fill in; however only three were returned, two of which voiced some concern about the home. A pre-inspection questionnaire was completed by the registered manager, and forwarded to the commission before this visit; this offered basic information about the home and its policies, and enabled the commission to assess and plan the visit. Fourteen residents were spoken with and their comments included – “The carers are very nice.” “I have been here six years and so I must be happy.” “The food is good, and I get everything I need.” There were no visiting relatives available during the visit. Discussions took place with the registered manager, and members of the care staff. Administration records were also looked at. Everyone at the home was friendly, welcoming and co-operative throughout the visit. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The preadmission assessment forms must be reviewed to make sure that all of the aspects of daily life are included. This will make sure that each person is equally and properly assessed for their care package before they enter the home. The care plans must be reviewed regularly. People’s needs and strengths may change and this must be recorded and reviewed regularly. Medication records and handwritten instructions should have two signatures to make sure that there are no errors in the drug, the dosage and times of administering. Eye drops, creams and lotions should be stored according to the pharmacy instructions, to make sure that they are effective and remain usable. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 7 The people who live at the home must be provided with a good activities programme to interest them and enhance their quality of life. Not all of the bedrooms have been refurbished. The bathroom with the hoist was in need of clearing, cleaning and decorating. The sink in this bathroom needed to be resealed for hygienic purposes. The carpets in the lounge and conservatory were stained, worn and torn and must be replaced for the safety of the people who live there. The carpets in some corridors and two bedrooms must be replaced to make sure that nobody trips or falls. The home must be kept clean and hygienic. Staffing levels must be reviewed to make sure that sufficient carers and domestic staff are in place, to provide the care that the people who live there need. The manager should develop firm objectives about attaining the Registered Managers Award. The quality monitoring system must be reviewed so that the people living at the home can see give their views and see that improvements are made. The registered provider and the registered manager must continue to progress with the fire safety action plan so that the people who live at the home are safe and protected. Risk assessments must be done for each person who lives on the first floor of the home, with a view to fitting window restrictors for their safety. 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. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This home cannot be sure it is suitable to meet an individuals needs because it does not gather enough information about a prospective resident before they move in. Because of this, people may not be given enough information to make s proper choice about whether or not the home is suitable for them. Standard 6 The home does not provide intermediate care services. EVIDENCE: Although there are pre-admission assessments in place for the people who go to live at the home, there are differing forms used, some of which are old and not in-depth enough to give a full picture of care. Those that were sampled on this did not fully include all daily and life needs and strengths. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 10 Advice has previously been given in respect of this and again further advice was given so that these assessments can fully reflect each person’s care needs and strengths. The manager said that she would review the assessment forms again. None of the people that were spoken to were able to confirm that they had been fully assessed before they came to live at the home; however, some did say that they had been visited by the manager, before they entered the home. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual records of care are in place at this home and people are given access to health care professionals. This means that individuals have a choice of who looks after them and are involved in how their daily lives are spent. People are mostly treated with dignity and respect at this home. EVIDENCE: There is some equality of care for each person living at the home in that care plans, which are written records of the care, are given to each person who lives at the home; four of these were looked at. Three of the plans were basic but reflected the care that was being given, the fourth had not been fully completed. Two of the plans were signed by the Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 12 person or their relatives, but were in need of reviewing: The manager said that she did not always have time to attend to the care plans because she was busy working as a carer with the other staff. The daily records that were written for each person at the home were basically satisfactory and showed any particular or individual points of care that had been given; these could be improved if the actual time of writing them was recorded so that there is an accurate track of care practise. There were records of the people who live at the home having access to health care such as GP, chiropodist and District Nurses; this was also confirmed by some of the people living at the home. The medication system was basically satisfactory and the policies and procedures for this had been reviewed and basically reflected the home’s approach. Generally the manager was advised that any hand-written medication records should have the signature of the person who is writing it and also a witness signature, to make sure that the instructions are accurate and that no errors or mistakes are made. Some creams had been stored in the fridge when they should have been stored in the cupboard and advice was given to the manager about this. The people living at the home said that they were satisfied with the staff that gave them their medications. People can take responsibility for their own medications if they wish, after a risk assessment has been done to show that everything is safe. The use of blood sugar testing equipment was discussed and the manager said that she was following the proper guidelines: She also said that she would get individual test kits, to make doubly sure that no infection could be transferred from one person to another. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people whio live at the home basically benefit by being given some support, and are encouraged to keep contact with family and friends. However, more activities and interests are needed to promote the quality of their daily lives. EVIDENCE: A daily record is kept of any activities that the people might request or enjoy: However these were limited because staff were too busy with the practical care of the people who lived there. On two previous inspection visits the issue of appropriate activities has been raised. This must be addressed so that the people who live at the home can enjoy and be supported in their leisure time. The people who live at the home said that they were treated with dignity and respect and had a choice of what they did each day; some said that they went Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 14 out either by themselves or with relatives. Religious Ministers visit the home and use the small chapel that is provided for prayer and Holy Communion. Although the home has experienced some problems with the provision of cooks, on this visit the food that was served looked quite appetising and nourishing. The people who live at the home said that the food was good, plenty of it and a choice from the main menu if they wanted it. Drinks and snacks are available throughout the day and night. There is equality of choice in that diets such as diabetic and vegetarian are catered for. The home’s crockery was somewhat chipped and worn and there did not seem to be enough cutlery; there was a shortage of teaspoons and the cutlery that was there looked rather old and poor. Crockery and cutlery supplies must be replaced as soon as possible. The Environmental Health Officer’s last visit report showed that there were two minor issues, both of which had been attended to. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home are able to voice their concerns if necessary and are supported and protected by the home’s policies and procedures. EVIDENCE: There is a complaints policy and procedure in place and the people who live at the home said that they knew how to complain if they needed to. However all those people who were spoken to said that they had no complaints at all. There has been one complaint since the previous visit and this was attended to satisfactorily. All members of staff have had abuse awareness training and those staff that were spoken to said that they knew about abuse issues and what to do if they were concerned. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who live at this home are provided with a rather tired living environment. An improvement in the furnishing of the communal areas of the home and more attention to the cleanliness of the home would make it more comfortable for those who live there. EVIDENCE: The outcome judgement for these standards has been judged as poor because of the failure to fully comply with the refurbishment requirements from the previous inspection reports of January, April and July 2006. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 17 Although there is equal access to the home through a passenger lift and ramps; and there has been a refurbishment programme ongoing, with most of the bedrooms having been redecorated, the home still has areas that are of a poor standard. On this visit it was found that the lounge carpets were dirty and worn, with one area badly torn, posing a possible tripping hazard to the safety of the people who live there. The manager took action by covering the tear with non-slip tape, as a temporary measure. This must be properly attended to as a matter or priority. The carpet by the lift door on the first floor must also be repaired as a matter of priority because it was lifting and could pose a tripping hazard to people when they leave the lift. Again the manager used non-slip tape to cover the area as a temporary measure. The carpet in the conservatory was dirty and smelled offensive. The carpet in the dining room was in need of cleaning. The corridor carpets were in need of cleaning and attention in that there are patches of worn carpet and some metal threshers needed to be fixed down securely. The smoking room on the lower floor had carpets that were badly stained littered with cigarette burns. The main bathroom was cluttered, dirty and smelled offensive. The ceiling was in need of painting, as were the walls. The flooring needed to be replaced because it was patchy and worn and the bathroom sink needed re-grouting as it was dirty and coming off the wall. The bathroom by room 14 would not flush and needed repair. Bedroom 5 had a rucked carpet that could become a tripping hazard; this must be re-fitted or replaced. Bedroom 16 had stained wallpaper where there is, or has been a leak from the ceiling, and there was also a portable electric fire plugged into the wall; this appliance must be electrically tested and a risk assessment must be done to make sure that the person who is using it is safe. Bedroom 14 had a large crack in the corner wall that must be repaired. Although some of the bedrooms were clean, generally a number of areas at the home were not kept clean and hygienic and the duty rota showed that the allocation of domestic staffing hours needed to be reviewed. The home was also generally cluttered and the manager said that she did not have time to check this regularly as she was busy working as a carer with the other members of staff. Two of the comment cards that were received prior to this visit voiced concern about an outbreak of scabies. This was checked out and the home had called in the Infection Control officer and had treated those people with the infection. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 18 Not all of the first floor windows have restrictors fitted for the safety of the people who live there. This should be looked at as part of each person’s risk assessment when they are being offered the bedroom, and regularly afterwards. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at the home are basically cared for and their needs attended to; however the levels of staff at busy periods during the day and evening, might mean that the individual has to wait to be assisted. EVIDENCE: There maybe lapses of equality of care at the home due to staff not being in sufficient numbers to be able to attend to the needs of the people who live there. The staff duty rota showed that there were minimal levels of carers on duty at the home. On the day of the visit, there were sixteen people living at the home; the cook was off sick and so a carer had been allocated kitchen duties. This left two carers and the manager to look after the people there during the busy morning period. The rota also showed that there were only two carers on duty during the afternoons and evenings. This needs to be reviewed as some of the people at the home needed two carers to give them help and this would leave the other people with no staff to oversee, assist with or supervise their care. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 20 The manager was not allocated any time from care duties to attend to her management responsibilities, resulting in the home becoming disorganised rather disarrayed. All staff are equally offered training and there are over 50 of care staff with National Vocational Qualifications (NVQ), which is very good and there are mandatory training programmes in place that were mostly completed. Staff recruitment files showed that there are generally appropriate preemployment checks done for staff who want at work at the home, however some files did not have the required records; for example a photograph as proof of identity and one written reference, rather than the necessary two. All staff had Criminal records Bureau (CRB) clearance checks. Moving and Handling training files showed that there needs to be a programme developed to update all staff. Members of staff were spoken to and not all had been kept up to date with the moving and handling training. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a manager who works hard to meet the needs of the people who live there, and who tries to make sure that everyone is safe and protected by following health and safety guidelines. EVIDENCE: The registered manager has had some problems doing the Registered Managers Award (RMA) training course and as a result has enrolled on the NVQ level 4 course, as a foundation to restarting the RMA course at a future date. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 22 To make sure that she is adequately experienced, she has recently done short courses on – Management and Supervision Techniques Appraisal and Supervision Feedback Skills Managing Performances and Setting Objectives Training Techniques Care of the Aging Skin A plan for the completion of the NVQ level 4 within eight months is in place and then the RMA will be restarted. There are quality monitoring systems in place at the home, however these need to be reviewed. This was a requirement on the previous inspection report. Quality surveys must be done and the results must be made available to those that took part. None of the people who live at the home could confirm that they had been given a survey or questionnaire. Samples of the safety certificates discussions with the manager, showed that she was aware of the Health & Safety legislation and her responsibilities for the safety and security of the people who live at the home. The Fire Safety Officer was contacted and gave good verbal testimony about the progress of the fire safety requirements that were made against the home in June 2006; The action plan that was developed by the home is being followed within the timescales that were given. The Fire Safety Officer advised that he no longer has serious concerns about the home’s safety and is looking forward to his next visit, to confirm the safe outcomes of the home’s fire safety risk assessment. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X 2 X X 2 X 1 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1)(a) Requirement Pre-admission assessments should contain all aspects of care needs, strengths and social interests. Care plans must be complete and reviewed on a regular basis. Designated time must be given for social and diversional activities for the people living at the home. Suitable and sufficient crockery and cutlery must be provided for the people who live at the home. All bedrooms and communal areas must be fully redecorated and refurbished, including carpets. This is a requirement from the previous three inspection reports. Bedrooms 14 and 16 must have appropriate internal repairs and redecoration from the affects of external leaks and cracks. The main hoist-assisted bathroom must be made appropriate for use by clearing, cleaning, re-grouting, the walls painting and flooring replaced. DS0000009690.V331995.R01.S.doc Timescale for action 01/06/07 2 3 OP7 OP12 15(2)(b) 16(2)(m) 01/06/07 01/07/07 4 5 OP15 OP19 16(2)(g) 23(2)(d) 01/07/07 01/07/07 6 OP24 23(2)(b) 01/07/07 7 OP21 13(4)© 01/07/07 Catterall House Version 5.2 Page 25 8 9 OP26 OP27 23(2)(d) 18(1)(a) 10 OP29 19(1)(b) Schedule 2 13(4) 12(1)(a) 11 12 OP30 OP31 13 OP33 24(1)(a) (b) 24(2) 14 OP38 13(4)(c) 15 OP38 13(4)(a) The home must be kept clean and hygienic. Domestic staffing levels must be reviewed. Care staffing levels must be reviewed so that there are sufficient numbers of staff to deliver the care Staff recruitment files must contain the required records according to Schedule 2 of the Care Homes Regulations. All staff must undertake Moving and Handling training. Sufficient time must be allocated for the registered manager to attend to her management responsibilities. Formal quality surveys must be undertaken with the results made available to all of the stakeholders. This is a requirement from the previous three inspection reports. The portable electric fire in bedroom 16 must be safety tested and a risk assessment must be done to ensure that the person who is using it, is safe. A risk assessment must be developed for the first floor bedroom window restrictors. The registered provider and the registered manager must continue to progress with the fire safety action plan so that the people who live at the home are safe and protected. 01/06/07 01/06/07 01/06/07 01/07/07 01/06/07 01/07/07 01/06/07 01/07/07 Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 26 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 OP9 OP31 Good Practice Recommendations The actual time of writing reports should be included in the daily records. Handwritten medication records should be signed by the person writing the instructions with a witness signature to confirm accuracy. A written plan should be developed by the registered manager, for the completion of NVQ level 4 and the reenrolment of the RMA course. Catterall House DS0000009690.V331995.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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