CARE HOMES FOR OLDER PEOPLE
Chargrove Lawn Shurdington Road Cheltenham Glos GL51 5XA Lead Inspector
Mrs Ruth Wilcox Announced Inspection 30th January 2006 09:00 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 Chargrove Lawn DS0000016401.V276115.R01.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. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Chargrove Lawn Address Shurdington Road Cheltenham Glos GL51 5XA 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) 01242 862686 01242 862686 CTCH Ltd To be appointed Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th October 2005 Brief Description of the Service: Chargrove Lawn is a care home registered to provide personal care for 26 older people over the age of 65 years. In cases where nursing care is needed, it is accessed from community sources. The home is part of the CTCH Ltd group of homes and is set in a semi-rural location on the outskirts of Cheltenham. The home has been adapted from a large domestic residence and has two purpose built extensions. Single rooms are provided throughout. All rooms have en-suite toilets but eleven also have en-suite bathrooms. The home is arranged on two floors with a shaft lift providing access to the first floor. There is a large amount of communal space for residents use including three lounges, one of which includes the dining area, and there is a garden room adjacent to the hairdressing salon. One of the smaller lounges provides an area where smoking is permitted. There are gardens to the side and rear of the property with patio area and garden furniture. A ramp allows easy access for people who use wheelchairs. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector carried out this announced inspection over six and a half hours, on one day in January 2006. The temporary acting manager was present throughout the inspection, with the CTCH Ltd Group Care Manager attending for a short time; both provided information and assistance where requested, remaining completely open and cooperative with the inspection process. The availability of information about the home to assist prospective residents and their families in making their choice about it was looked at. Care records and the systems for the management of medications were inspected. The care of three residents was closely looked at in particular, and there was direct contact with nine residents, two visitors and seven staff. Their views regarding the standards of services and care at the home were sought wherever practicable. The opportunities for residents to engage in social activities were looked at, and the quality and choice of food was inspected. The management arrangements for the home were looked at, as were the procedures for dealing with complaints, and the policies and procedures for protecting the rights of vulnerable residents. The provision of staff and the way in which they are recruited and trained was inspected. A tour of the premises took place, with particular attention to the standard of maintenance, health and safety and cleanliness. Since the last inspection in August 2005, a complaint investigation was carried out by the CSCI in October 2005, which looked into the following concern raised by a complainant: • Staff had been disrespectful and rude to residents – UPHELD (Although this did not seem to be commonplace in the home, there was evidence to confirm that it had happened, involving isolated staff members). • Staff shout at residents on occasions - UNRESOLVED Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection?
Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 7 The complete care planning documentation has been replaced with a new system, and this has led to a much improved standard of planning and recording of each resident’s care. Also, there is a big improvement in the management of medications, with security and recording being improved generally. Residents spoke much more positively about the staff group on this occasion. There has been additional training and guidance to improve certain staff practices, some of which had previously been disrespectful to residents. An additional tier of management has been introduced to ensure greater continuity in the home, with the appointment of an assistant manager; this role has yet to be fully developed however. A number of maintenance issues highlighted at the last inspection have now been satisfactorily addressed. The staff office has been relocated to make way for a ‘quiet room’ for resident’s and visitor’s use if they wish. There are improved infection control practices employed in the laundry room, with any foul laundry items appropriately segregated. What they could do better:
Although it is reported that there have been significant improvements in the standard of care planning, staff must pay particular attention to conducting and recording falls risk assessments and pressure area care plans in all cases where these issues apply. Likewise, despite improvements in the management of medications, there are two particular issues that still require attention in order to ensure safe and consistent practice. Two extractor fans in bathrooms were not working and require repair, and the laundry room flooring requires replacement in order to ensure appropriate standards of hygiene in this area. Although staff are provided with a sanitising hand gel for use in the laundry room, it is recommended that a sink be provided in here. Recruitment of staff is carried out in a methodical and thorough way in the vast majority of cases, however isolated instances of gaps in safe recruitment practice were identified during this inspection. This is with regard to incomplete employment histories in some cases, and failure to obtain the reason why they left previous employment in cases where they had worked with vulnerable adults. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 8 Staff training records have not been adequately maintained recently, and this will now be remedied, with records checked and updated; this must include the frequency and content of fire safety training also. Supervision arrangements for new staff are not sufficiently clear on this occasion, and it is important that full and appropriate levels are ensured for all new staff, with proper records maintained. Despite appropriate health and safety arrangements in certain regards, the home must now make arrangements to ensure that the variable height bath, which is a load bearing piece of equipment, is properly serviced and checked for safe use. Staff must also ensure that all chemicals and detergents in use around the home are clearly identified with a product label to ensure safe and proper usage. 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. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The pre-admission information ensures that residents have access to a good deal of information when making their choice about the home, though potentially not all that is required in every case. EVIDENCE: The home has produced a full Statement of Purpose, a copy of which has been supplied to the CSCI, and is available in the home to anyone choosing to read it. Prospective residents are supplied with a copy of the home’s Service User Guide, which contains much of the required information, plus a good amount of very useful supplementary information about the home. Although a copy of the inspection report is available in the home for anyone to read, the guide does not make mention of this, and a copy of the most recent report is not included either. The guide seen at inspection did not contain the most up to date details about the CSCI, referring to it by its previous and outdated name of the NCSC. Chargrove Lawn does not provide intermediate care.
Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 11 Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10 The new and improved care planning system adequately provides staff with the information they need to satisfactorily meet residents’ health and personal needs. Also, the improved systems for the management of medications ensure that residents’ medication needs are more safely met; attention to very isolated gaps in both systems will ensure greater consistency and safety for those residents concerned. Increased emphasis on certain staff attitudes has ensured that care and support is more consistently offered in such a way as to promote the residents’ privacy and dignity. EVIDENCE: Staff have been working very hard to introduce a new care planning format, and have made very good progress. Each resident has an individual plan of care, which is based on an assessment of all their needs, including a range of risk assessments; three were selected as part of the case tracking exercise. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 13 Recording was personal and individualised, and in the main contained a lot of very good detail regarding the preferences, care and health needs of each individual. Each plan had evidently been formulated in consultation with the resident concerned, and was regularly reviewed. In one case, the resident had recently fallen, sustaining an injury; the plan of care was not fully reflective of this, with no recorded falls risk assessment. In the same case, the resident had been assessed as being at risk of developing pressure sores. There was no recorded plan of care to address this either, although it should be known that the pressure areas were intact at this time. Since the CSCI Pharmacist’s inspection, the home has made significant improvements to their management of residents’ medications. Storage has been improved, ensuring greater security, and there is much better stock control. More up to date information, guidance and reference material is available for staff, and prescriptions are now received into the home for checking before going to the pharmacy. Printed medication charts are currently being thoroughly recorded by the staff, and the temporary acting manager has introduced a regular medication audit to ensure good practices are promoted and can be maintained. There continues to be one particular arrangement where a resident prefers to take a specific medication in a yoghurt; there is no care plan or clear agreement for this arrangement in this person’s care notes. In at least one case, the resident’s known drug allergy had not been recorded on the medication chart. Resident’s care plans were reflective of individual’s privacy, dignity and independence. Staff were observed to be fully respectful, kind and supportive to the residents during their contact with them. Since the incident reported in the summary of this report regarding a complaint about the attitude of some staff, there has been an increased focus in this area, to ensure that all staff remain fully mindful and respectful of residents at all times. Residents themselves were very positive regarding the attitude of staff on this occasion, confirming they were kind and caring, with some saying they were ‘wonderful’. The visiting hairdresser said that she had only ever witnessed staff being ‘sweet and kind’ with the residents. Also, a visiting district nurse confirmed that the staff were ‘brilliant’ with her patient, and that they looked after her very well. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 14 Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 15 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 & 15 The home offers an entertainments programme, in order to provide residents with regular and varied opportunities for social activity, and encourages and supports residents to pursue personal interests. Dietary needs of residents are well catered for, with a good selection of food available that meets their tastes and choices. EVIDENCE: A monthly diary of events is produced, with the latest one for February being made available to residents to coincide with this inspection; this diary includes observation of any festival or calendar dates, including resident’s birthdays. Residents’ social interests and preferences are recorded in their plan of care. As well as planned activities to suit a variety of interests, some residents go out regularly, and the home endeavours to maintain links within the community. Residents were spending their time in accordance with their wishes, with some just watching television, reading or listening to the radio. One person was particularly active, and was involved in some academic work, and was attending lectures of interest to her in the community. The hairdresser’s visit is routinely a very sociable occasion, with residents gathering to chat and have coffee. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 16 Menus show a range of varied and nutritious meals available for residents, and from conversation with the residents themselves and the Cook it was evident that they are also offered a good degree of choice. The Cook demonstrated awareness of individual requirements and preferences, and kept the appropriate records in the kitchen. The lunchtime meal looked wholesome and appetising. Staff served the meal in the spacious and pleasant dining room, and were attentive and helpful where required. Residents spoke very positively about the quality and quantity of food provided for them, saying that it was ‘very good’. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 17 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 & 18 The home has a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. Arrangements for protecting residents from forms of abuse are generally good, with the home taking seriously any issues of concern that have arisen. EVIDENCE: A copy of the complaints procedure was clearly displayed for anyone wishing to read or use it. The temporary acting manager has introduced a ‘Complaints/Concerns’ Form, for use when an issue is raised. A clearly recorded action plan had been drawn up to address the concerns indicated on one such form. There was no record in the home of the complaint recorded in the summary of this report, which was investigated by the CSCI. The temporary acting manager resolved to re-establish a complaints folder immediately after this inspection, so that all such records could be maintained appropriately in the home. Residents confirmed that staff were attentive to them, and that they had confidence in the staff to do what they could to help them if they had any concerns. The home has written policies and procedures for the prevention of abuse and the protection of vulnerable residents.
Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 18 Staff receive training on abuse issues during their induction, and there are mandatory training units in the NVQ training programme. Staff spoken to were conversant in the Whistle Blowing procedure. Further to the complaint investigation detailed in the summary of this report, the home took the appropriate actions in response to the findings, ultimately instigating disciplinary procedures where applicable, for the prevention of abusive staff practices and the protection of residents. Additional ‘Recognition and Prevention of Abuse’ training was provided for staff. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 19 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, 25 & 26 Chargrove Lawn provides a generally satisfactorily maintained home for the residents, and provides clean and comfortable accommodation. Investment and increased health and safety measures have improved safety for residents, though there is an issue in the laundry that poses a risk to them ultimately if not addressed. EVIDENCE: A number of maintenance issues have been addressed since the last inspection. The home is generally adequately maintained and decorated, and provides a comfortable and homely environment. There is a peripatetic maintenance person within CTCH Ltd, and records of all maintenance requested or undertaken are kept. On this occasion, the extractor fans were not working in the ground floor shower room and the identified assisted bathroom on the first floor. The office has been relocated to make way for a small quiet room, which can be used by residents and their families if they wish.
Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 20 Work has finally been completed to provide low surface temperature safety features to every radiator, and maintenance records show that random checks are carried out on hot water temperatures at outlets accessible to residents, in the interests of their health and safety. The home is adequately cleaned, and staff demonstrated awareness of infection control procedures; gloves and aprons are provided throughout the home, as is liquid soap and paper towels. The washing machine in the small laundry room provides a disinfection cycle for foul laundry, and red dissolvable bags have been provided for use with any such items to avoid direct handling. There is no sink in the laundry, although sanitising hand gel is provided, and there are hand-washing facilities in the adjacent staff room. The cupboards in the laundry room have now been boxed in, making the room look much tidier. The flooring in the laundry room has become worn and split in two areas, one of which is next to the washing machine. The flooring is lifting and ‘bubbling’ here, and has allowed moisture to get underneath, posing a cross infection risk. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 21 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, 28, 29 & 30 Staffing provision is adequate to meet the needs of the residents currently living in the home. Training records, if properly maintained, would show that staff have good training opportunities, with care staff encouraged to undertake a care qualification, in order that they can fully understand their roles. Robust recruitment procedures would ensure that suitable staff are employed for the protection of residents, however any failure to observe these consistently poses some risks. EVIDENCE: Staff rotas are maintained. There are routinely three care staff on duty throughout the day and evening, with just one carer overnight and a sleep-in carer in case required during the night; rotas did not reflect this night time arrangement however. Evidence was seen of a recent incident when a night carer, in need of guidance and support, did not refer to the sleep-in carer for it, with no explanation as to why available at the time of this inspection. The temporary acting manager, when at Chargrove Lawn, works in a supernumerary capacity, as is the usual adopted management practice here. The interim management arrangements and the strategy to address the manager recruitment in this home are to be confirmed in writing to the CSCI. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 22 An additional management tier has been introduced, with the appointment of an assistant manager; this person is currently receiving additional support and time to develop this role. The home is making very good progress with the NVQ training programme. There are eight care staff who have achieved NVQ level 2 awards as a minimum, with two of these being at level 3. There are a further two staff commencing NVQ training, one at level 2 and one at level 3. When speaking with staff, there is evidently a sustained interest amongst them regarding progression with the NVQ programme and their continued professional development. A selection of staff files was chosen for inspection, on the basis of recent recruitment. Each record contained application forms. A full and complete employment history had not been obtained in every case. Although the home has sometimes sought verification of why a worker ceased to work in their last place of employment, where it involved care of vulnerable adults, this had not been consistent in each case in which it applied. Records of interviews were seen. Full and complete evidence of the required pre-employment checks was seen. Formal induction training records were contained in newer staff records. The in-house induction training programme, more specific to Chargrove Lawn could not be evidenced directly, though the assistant manager confirmed that this had taken place for the two staff identified. There was also no record of who three of the new workers’ named supervisor may have been for the duration of their induction. Training records have not been adequately maintained in recent months, although staff have received a range of mandatory training appropriate to their work and roles in recent months. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 23 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, 35 & 38 There are management issues that require some resolution at Chargrove Lawn, however systems are in place to promote the interests of the residents in most regards, with isolated health and safety risks requiring attention. EVIDENCE: The registered manager has left the home since the last inspection, and currently there is no registered manager at Chargrove Lawn. CTCH Ltd is ensuring some management consistency however, with the Group Care Manager providing additional support and leadership to the home at this time. There is also a part time placement of a temporary acting manager from another home within the company, at which she is the registered manager. This person is to be commended for her hard work and commitment to this home and its residents, whilst addressing any shortfalls and issues as
Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 24 efficiently and robustly as possible, and providing strong leadership to the staff group. Recent advertising to recruit a new manager has not proven successful to date. The home is also taking this opportunity to review its management structure, and has appointed an assistant manager position. Some residents have placed personal money and valuables with the home for safekeeping. Clear and transparent records for each person, which include transaction details, running totals, and receipts, are kept. A random check on one arrangement proved to be accurate. Residents or their representative can sign to acknowledge transactions, but where this is not possible in the majority of cases, two staff members sign the record to witness on behalf of the resident. The home has written health and safety policies, procedures and risk assessments, and ensures the provision of manual handling equipment and associated health and safety training for staff; the frequency and content of fire safety training was not entirely clear from the records. A fire safety risk assessment for the building was reported to have been carried out, with due regard to revised fire safety regulations, however this was not seen on this occasion. Appropriately qualified engineers, with the exception of the load bearing variable height bath, carry out servicing and maintenance checks of certain equipment and installations. An unlabelled bottle of a detergent chemical had been left in a corridor, and was promptly removed; this was an isolated case, with all chemicals generally stored safely and securely when not in use. Staff have received the Appointed Person’s First Aid training, and are qualified to provide emergency first aid. The kitchen was inspected by the Environmental Health Department last year, during which some areas for improvement were identified. These included some cleanliness and hygiene issues, which are now being better addressed. The dishwasher is still not functioning however, and remains in its state of disrepair in the kitchen; staff continue to wash up by hand. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 25 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 2 Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5(1) (d, f) Requirement The Registered Person must include a copy of the most recent inspection report and the current contact details for the CSCI in the Service User Guide. Staff must ensure that all elements of care planning are fully detailed, in order to clearly demonstrate how residents needs are to be met; this is with particular reference to pressure area care. (Previous timescale of 30/09/05 not met in full) Staff must ensure that falls risk assessments are recorded where appropriate, and that they contain clear guidance as to how identified risks must be reduced. Staff must ensure that the arrangements around the consent and administration of medications in food for the identified resident are fully documented in the relevant plan of care. Staff must ensure that any resident allergies are clearly recorded on their individual
DS0000016401.V276115.R01.S.doc Timescale for action 31/03/06 2. OP7 15(1) 28/02/06 3 OP7 13(4.c) 28/02/06 4 OP9 13(2) 31/03/06 5 OP9 13(2) 28/02/06 Chargrove Lawn Version 5.1 Page 27 6 OP19 23(2.b) 7 OP26 13(3) 8 OP27 18(1.a) 9 10 OP27 OP29 17(2) Sch 4(7) 19)(b.i) medication charts. The Registered Person must ensure that the extractor fans in the ground floor shower room and first floor bathroom are repaired to working order. The Registered Person must replace the flooring in the laundry room, to prevent any infection control risks. The Registered Person must provide the CSCI with a written explanation of the arrangements for providing adequate night staff cover. The staff rotas must reflect the provision of staff cover on the night shift. When recruiting new workers, the home must ensure that: • • A full employment history is obtained Written verification of the reason why the person ceased to work in their last position (if it involved contact with vulnerable adults or children) is obtained 31/03/06 30/04/06 31/03/06 28/02/06 28/02/06 11 OP30 18(2) The Registered Person must ensure that: • An appropriately qualified and experienced member of staff is appointed to supervise a new worker for the duration of their induction training As far as is practicable the ‘staff member’ is on duty as the same time as the new worker The new worker does not escort any resident away 28/02/06 • • Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 28 12 13 OP30 OP38 17(2) Sch 4 (6). 23(4.d, e) 14 OP38 23(2.c) 15 OP38 13(4.c) from the care home premises unless accompanied by the ‘staff member’. The Registered Person must maintain a record of all training undertaken by staff. The Registered Person must ensure that all staff receive timely fire safety training, with appropriate records kept to demonstrate frequency and content of training delivered. The Registered Person must ensure appropriate arrangements for the servicing and safety checks of all load bearing equipment provided by the home; this is with particular reference to the variable height assisted bath. The home must ensure that the appropriate product labels are attached to all bottles of chemicals and detergents in use in the home. 31/03/06 31/03/06 30/04/06 30/04/06 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 OP26 OP30 OP38 Good Practice Recommendations A wash hand basin should be provided within the laundry room. The home should identify the named supervisor for new workers on their induction programme, and/or the staff rota for the duration of their induction. It is strongly recommended that the Registered Person ensure six monthly inspection examinations be carried out on all equipment used to lift residents, by an appropriately competent person. The Registered Person should replace the dishwasher in
DS0000016401.V276115.R01.S.doc Version 5.1 Page 29 4 OP38 Chargrove Lawn the kitchen. Chargrove Lawn DS0000016401.V276115.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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