Inspection on 18/01/06 for Charnwood

This inspection was carried out on 18th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Charnwood 23/04/07

Charnwood 10/08/06

Charnwood 16/09/05

Charnwood 07/01/05

Charnwood 03/08/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Charnwood Charnwood 7 Finchfield Road Finchfield Wolverhampton West Midlands WV3 9LS Lead Inspector Bhag Jassal Unannounced Inspection 18/01/06 08:50 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 Charnwood DS0000020883.V275884.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. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Charnwood Address Charnwood 7 Finchfield Road Finchfield Wolverhampton West Midlands WV3 9LS 01902 424579 01902 565522 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) Caram (CHWD) Ltd Mrs Krishna Devi Ram Care Home 19 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (19) of places Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All DE category service users must be accommodated on the ground floor. The agreed staffing levels are: 8am - 9pm Senior Carer 2 care staff Night staffing 2 waking care staff Care Manager hours are supernumerary Separate catering/domestic/laundry staff/activity organiser must be provided in addition to care hours. These are minimum staffing levels - and must be increased in the event of any increase in dependency of service users accommodated. CSCI will continue to monitor the staffing levels and may require levels to be increased should CSCI feel that care needs are not being met. All care staff must complete the agreed training programme before March 2006. Until such time as all staff have completed the required training, staff rotas must ensure that at least one member of staff that has completed the training is on shift at all times day and night. 16th September 2005 3. Date of last inspection Brief Description of the Service: The home is a large, detached property, which is approximately 77 years old. The home is situated in a pleasant residential area and overlooks Bantock park. There is easy access to all the local amenities. The home accommodates 19 service users in single bedrooms. Nine of the bedrooms have en-suite facilities. There are three separated sitting rooms and a dining room. There are pleasant gardens at the rear of the building. There are two bathrooms with hoists. The third bathroom/shower/WC is not suitable to be used by the current service users. The WC in this bathroom is also used by the staff. There are adequate WCs facilities in the home. There is a kitchen, laundry room and an office. At present, there is no staff accommodation and personal storage facilities for individual members of staff. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 5 Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 8.50 am and lasted 7 hours and 45 minutes. 18 places were occupied and one bed remains vacant. The inspection included discussions with the Registered Manager, service users and their relatives, and the staff. The daily routines were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside and facilities were also undertaken. What the service does well: The home is registered for 19 older people, of which five older people can have Dementia. The home makes every effort to provide individuals with a good standard of care to meet the assessed needs following a care plan. The home communicates well with the families/friends and representatives of the service users. The visitors’ book indicated a lot of activity. The service users spoken with said that they are happy and content with living in a homely and caring home. The service users were in the lounges and dining room engaging in their daily routines and activities and they further commented that they were comfortable and satisfied with the care provided. Four relatives of service users stated that they are satisfied with the standard of care offered by the home and staff are very good and committed to looking after the residents. Atmosphere within the home was observed to be relaxed, comfortable and friendly. The friendly rapport was also observed between service users and staff. Meals at Charnwood are varied, well balanced and presented to meet each individual’s choices, preferences and requirements. The home provides a good standard of accommodation, which is being maintained, safe, secure and of a good standard. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? What they could do better: The home must continue to update the service users’ needs assessments, risk assessments and care plans. The Registered Manager must ensure the quality and details of the daily care (day and night) records are improved. Those members of staff who as yet have not received training in safe working practice topics, safe handling of medication, and Dementia care must do so as a matter of priority. This training would enable staff to improve further their care practices and professionalism. The Registered Providers must implement and comply with the conditions of registration as outlined on page 5 of this report. There are a small numbers of requirements relating to the environment, which must be addressed as a matter of priority in order to have a safe and comfortable environment for service users, staff and visitors. The home must continue to progress further its quality assurance annual development plan and outcomes for service users. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 8 Overall the home has made steady progress since the last inspection dated 16 September 2005. 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. Charnwood DS0000020883.V275884.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 Charnwood DS0000020883.V275884.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): 3 and 4 The home has a comprehensive needs assessment procedure providing an effective assessment, suitable evaluation and its ability to meet the assessed needs of both privately funded and those placed by the Local Authorities, which needs updating. EVIDENCE: A sample of three service users’ care plans and files were seen at the inspection. All contained evidence that the service users receive the benefit of a comprehensive assessment prior to admission. The Registered Manager stated that she carries out assessments on both self-funded service users and those placed by the Local Authorities. The assessment details are documented on the service users’ care plans. Care plans are drawn up by the senior staff with the assistance from the service users, their relatives and where appropriate other professionals. However, it was noted that the needs assessments and the risk assessments were in need of updating. The Registered Manager stated that she would review and update the service users’ needs assessments and risk assessments by 31 January 2006. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 11 The home has a good admissions procedure, which is made available to all prospective service users and their relatives and/or representatives. The service users and/or their relatives can visit the care home prior to admission. If they indicate that the care home is able to meet the needs of the prospective service users then the home formally confirms in writing whether or not it can meet the assessed needs of the prospective service users. Once this is agreed between all the parties concerned, then the placements take place on a 28 days trial period. Charnwood DS0000020883.V275884.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, 8 and 9 The staff within the care home are aware and sensitive to the needs of each and all service users and meet their needs in a professional manner. There is clear and consistent care planning system in place, which provides the information the staff requires to meet the service users’ medical, health and care needs. EVIDENCE: It was evidenced that all service users undergo a comprehensive assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Three service users’ care plans were examined in detail and it was noted that the short-term and long-term goals and appropriate interventions required to put them into action to meet the individual service user’s needs are identified. It was evidenced that the care plans need to be updated and must continues to be reviewed on a monthly basis. The daily care (day and night) recording Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 13 formats were examined and it was noted that the quality and details of recording need further improvement. The Registered Manager stated that she will update all the service users’ care plans. The staff would need to be closely supervised and supported to make further improvements in daily care recordings. The Registered Manager stated that all the care plans would be fully updated by 31 January 2006. It was evidenced that the home ensures that the detailed nutritional screening is undertaken, including weight gain and loss records and appropriate action is taken if required. The home also maintains records of all health checks. The case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought as and when required. The Inspector spoke to twelve service users, who were able to have meaningful conversation. Generally the service users appeared to be content, comfortable and happy. It was evidenced from the staff training records updated in early January 2006 and discussion with the Registered Manager that nine carers have received their training in safe handling of medication. The Registered Manager that the remaining members of care staff are also being enrolled to undertake this mode of training shortly. However, it is the home’s policy that only senior members of staff would be responsible for handling of and administration of medication to service users. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Charnwood care home provides a good standard of care and promotes individual lifestyles for the service users in residence. Meals at Charnwood are of good homely type offering both choice and variety and catering for special needs and requirements of service users. EVIDENCE: It was seen that the home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to – social and leisure activities and cultural interests. It was also noted that the home organise entertainment delivered by external entertainers. The records of activities enjoyed by the service users are being appropriately maintained. However, the Registered Manager stated that the staff would be closely supervised and supported to ensure that they record all the activities provided and appropriately incorporated into all individual service users’ care plans. The Registered Manager stated that the social and leisure activities for the service users with Dementia care needs would be carefully planned, which would actually meet their particular needs and well being. It was evidenced that the home provided a varied, wholesome and nutritious diet. The meals provided during lunchtime on the day of inspection were well Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 15 received by the service users. It was observed that those service users, who needed assistance in feeding, members of staff were available to assist those service users. The Registered Manager stated that the menu is changed on a regular basis and in consultation with the service users. Several service users told the Inspector that the food was nice, tasty and well prepared. The kitchen is well equipped, kept clean and tidy. The catering staff are trained in food safety and hygiene matters. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Concerns and complaints are dealt with promptly and professionally. The service users’ legal rights are promoted and protected. The service users are protected from abuse by the home’s adult protection policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has good complaints procedure in place, which is referred to for information in the home’s Service Users’ Guide and in the Statement of Purpose for the home. There is a system of recording concerns and complaints. However, it was noted there had not been any complaints in the home since the last inspection and none had been directed to the Commission for Social Care Inspection (CSCI). The service users spoken to by the Inspector stated that their views and comments are always listened by the Manager and senior staff. The Registered Manager stated that as far as possible, the service users’ legal rights are promoted appropriately. Where the service users are not able to make certain decisions, then their relatives and/or representatives are requested to assist, and where possible local Advocacy Service is also requested to help. The service users are positively assisted to take part in elections and they use their voting rights. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 17 The home has a good policy and procedure in place in regard to protection of service users from all forms of abuse. The Registered Manager stated the staff have been made aware of the adult protection issues through induction training and supervision arrangements. It was evidenced from the staff training records that three members of staff have received training in abuse awareness and protection. The Registered Manager stated that the other members of staff will receive this mode of training shortly. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 21, 24, 25 and 26 The general standard of the environment is very good providing service users with a homely, comfortable and safe place to live. The good standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to all service users. The home has adequate communal space for the use of service users currently accommodated. There are two separate lounges and a dining room and a small lounge, which is used by visitors and for hairdressing and other meetings. The home is safe and suitable for its current stated purpose. The home has a rolling programme of redecoration to maintain good standards. The garden and patio areas are also well - maintained for the use of service users. However, at present there is no staff room or suitable storage facilities available in the home for staff to store their personal belongings. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 19 The Registered Manager stated that all the requirements and recommendations contained in the recent inspection reports of the Fire Safety Officer and the Environment Health Officer have been appropriately implemented. At presently, the home has two bathrooms with hoists, one on each floor. The third small bathroom/WC is located on the first floor, which is currently being used by one service user. The WC in this bathroom is also being used by the staff in the home. There is good standard of furniture and fittings provided in the service users’ bedrooms. It was noted that the bedrooms have been “personalised” by the service users. Hot water outlets in the service users’ bedrooms and communal areas are fitted with thermostatically controlled mixer valves. The hot water temperature is tested on a weekly basis and appropriate records maintained. However, the hot water temperature was tested during the inspection and it was noted tat the temperature varied from 33 Degrees C to 49 Degrees C in several bedrooms on both floors. There was no hot water supply in the small bathroom/WC on the first floor. The Registered Providers must ensure that the hot water temperature in all the hot water outlets is maintained close to 43 Degrees C at all times in the interest of safety of service users and staff. During the inspection, the home was found to be clean, tidy and free from any unpleasant odours. The home has good policies and procedures in place regarding infection control. It was evidenced from the staff training records that several members of staff have completed training in infection control. The Registered Manager stated that all members of staff have received induction training and they are made aware of the dangers of cross-infection. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The home at present is not adequately staffed at all times, which could have impact on the quality of care provided, and the ability of the home to meet the needs of the service users. The home continues to support staff to complete training. The home has good staff recruitment policies and procedures. EVIDENCE: On the basis of information provided by the Registered Manager and the available staff rotas showed that the home is not adequately staffed at all times to provide care services for the current 18 service users, including five service users with Dementia care needs. The Registered Providers’ application to vary the condition of registration was approved by the CSCI on 6 December 2005, to enable the home to admit five older people who can have Dementia care needs. As part of this approval, there are a number of conditions of registration, which are set out on page 5 of this report. The Registered Providers are required to comply with all of these conditions of registration, including the specific conditions relating to the staffing arrangements in the home. It was evidenced from the staff training records that 10 carers have completed their NVQ Level 2 qualification and three senior carers have completed their Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 21 NVQ Level 3 qualification. There are four carers currently undertaking this mode of training. The Registered Manager stated that the remaining members of staff will receive this mode of training shortly. It was evidenced that the majority of the staff have completed their safe working practice topics training and those who as yet have not received this mode of training must do so as a matter of priority. (See NMS OP38). Discussion with the Registered Manager and the examination of the most recently recruited staff files demonstrated that thorough recruitment procedures had been followed in accordance with the home’s recruitment policy. Two written references, Enhanced CRB and POVA checks are being undertaken before new members of staff are appointed. It was also evidenced from newly appointed members of staff files that the home is implementing the TOPSS Induction and Foundation training programme. It was noted that the home has provided Dementia care training to three members of staff and this mode of training is also planned for other members of staff to be held in February and March 2006. The Registered Providers should also consider providing specialist training in adult protection from abuse, management of challenging behaviours and disability awareness. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 and 38 The home has good systems of communication in place to seek views of the service users, their relatives/friends and other professionals. Money is well managed on behalf of the service users by the Manager. The staff are now receiving regular supervision. Health, safety and welfare of the service users and staff are promoted by the safe working systems put in place by the Registered Manager and the Registered provider. EVIDENCE: The home has developed an annual quality assurance development plan. The Registered Manager has prepared the draft questionnaires with the view of obtaining comments/feedback on the quality of service and facilities provided by Charnwood – care home from the service users and their relatives/friends and other stakeholders (i.e. doctors, district nurses and social workers etc.) Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 23 who visited the care home. The Registered Manager stated that the finalised sets of questionnaires would be sent out shortly to all stakeholders and the feedback received will be analysed and a report will also be prepared with an action plan as appropriate. The Registered Manager assists several service users with their monies. A sample of three service users’ money was checked and found to be satisfactory. There was evidence to show that now all members of staff are appropriately being supervised at the required intervals. Records of supervision were examined during the inspection. Accidents and fire prevention records were thoroughly examined, which were found to be appropriately maintained. All the matters pertaining to fire safety and environmental health were found to be satisfactory. However, the Registered Providers must ensure that temperature in ALL hot water outlets must be maintained at all times at the required level of close to 43 Degrees C. The legionella risk assessment must be carried out and appropriate action taken to ensure that this system is safe. Suitable window restrictors in bedrooms 7 and 8 must be fitted to ensure the safety of service users currently occupying these two bedrooms. The self–closure mechanism on bedroom doors and inter-connecting doors must be regularly to ensure that they close to their rebates. Those members of staff who as yet have not received training in safe working practice topics must do so as a matter of priority. (See NMS OP30 above). Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 2 2 X X 3 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 X 2 Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 13 & 14 Requirement The Registered Manager must ensure all the service users’ needs and risk assessments are updated by using the newly adopted formats as a matter of priority. The Registered Providers must ensure that the required hot water temperature level (i.e. close to 43 Degrees C) must be maintained in all hot water outlets at all times. The Registered Providers must ensure that all the service users’ care plans are updated, and the quality and detailed daily care (day and night) records of the care services received by the service users are appropriately recorded by the care staff as a matter of priority. The Registered Providers must ensure that there are minimum of two carers and a senior carer on duty throughout the day, and sufficient numbers of ancillary DS0000020883.V275884.R01.S.doc Timescale for action 04/02/06 2. OP25 13 19/01/06 3. OP7 13 & 15 20/01/06 4. OP27 18 18/01/06 Charnwood Version 5.1 Page 26 staff to adequately cover laundry, cleaning. cooking and activities organiser duties throughout the week for 19 service users with varying degrees of dependency levels and needs and accommodated on two floors. The Registered Manager’s hours are in addition to the above staff hours and should always be considered supernumerary to allow the Manager to manage the home effectively and efficiently. This is also a condition of registration, which is detailed on page 5 of this report. 5. OP30 12,13 & 18 The Registered Providers must ensure that those members of staff who as yet not received training in safe working practice topics must do so as a matter of priority. The staff must receive suitable training in Dementia care in line with the conditions of registration as set out on page 5 of this report. The Registered Manager must ensure that the home’s annual Quality Assurance development plan is fully implemented for the year 2006. The report on the outcome of the feedback from all the stakeholders must be made available in the home and to the CSCI. The Registered Providers must provide suitable facilities and accommodation for the purpose of changing and storage facilities for the staff employed in the home. The Registered Manager must ensure that all doors, including DS0000020883.V275884.R01.S.doc 21/04/06 6. OP33 24 02/02/06 7. OP20 23 (3)(a) 01/02/06 8. OP38 23 & 37 30/03/06 Charnwood Version 5.1 Page 27 inter-connecting doors closure devices must be checked on a regular basis to ensure that they actually close to doors rebate. The legionella risk assessment must be carried out and appropriate action taken to ensure that this system is safe. Suitable window restrictors in bedrooms 7 and 8 must be fitted to ensure the safety of service users currently occupying these two bedrooms. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations The Registered Providers should consider providing training for staff in Dementia Care, Management of Challenging Behaviours, Disability Awareness, and Adult Protection from Abuse. Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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. Extracts may not be used or reproduced without the express permission of CSCI Charnwood DS0000020883.V275884.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!