Inspection on 23/09/08 for Chy Byghan

This inspection was carried out on 23rd September 2008.

CSCI found this care home to be providing an Adequate service.

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

Chy Byghan 23/06/09

Chy Byghan 22/04/08

Chy Byghan 07/06/07

Chy Byghan 05/06/06

Chy Byghan 08/02/06

Chy Byghan 20/06/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 23/11/2008.

CARE HOMES FOR OLDER PEOPLE Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX Lead Inspector Alan Pitts Unannounced Inspection 23rd September 2008 10:00 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 Chy Byghan DS0000062587.V372527.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. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chy Byghan Address Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX 01736 871459 01736 871423 rosemarydeane@hotmail.com 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) Mrs Jacqueline Brown Mrs Rosemary Ann Deane Mrs Rosemary Ann Deane Mrs Rachel Mary Vaughan Care Home 19 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (19) of places Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd April 2008 Brief Description of the Service: Chy Byghan is a registered care home providing accommodation and personal care for up to nineteen older people. Up to six of the residents may require care because they experience confusion. The home also provides day care for up to three older people. The home is detached and is located in the village of Sennan, approximately 11 miles from Penzance. It is situated slightly off the main road and has car parking space. The building consists of two storeys, with most of the accommodation provided on the ground floor. Several of the residents bedrooms have French doors that open directly onto an outside patio. All the bedrooms currently have single occupancy but two rooms can be shared if required. The home provides a comfortable sun lounge, a smaller second lounge and a well-decorated, spacious dining room. The registered providers live at the care home and one provider is the registered manager. Both providers play an active role in running the home on a day-to-day basis. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out on 23rd September 2008 by two inspectors. The inspectors met with the registered provider, Mrs Deane, staff, and residents, examined documentation (including surveys) and toured the premises. This home provides individualised care that the people that live there clearly appreciate. The overall rating of an adequate service largely reflects the home’s continuing inability to meet previously reported requirements and is indicative of improvements being needed in key areas of training and management. There are no concerns about the actual care provided. The issues identified in this report were discussed in detail with the registered provider, Mrs Deane, and (as stated in the previous report) it is hoped that the registered providers will now feel able to seek advice from relevant authorities (including the Commission for Social Care Inspection), where necessary, in order to meet the statutory requirements and recommendations. Mrs Deane assured the inspectors that the requirements and recommendations from this inspection would receive proper attention and action would be taken as necessary. We carried out this inspection over a period of approximately five hours. We spoke with residents, the registered manager and staff, and a visiting District Nurse. We looked round the home including the rooms of the people that live there. We inspected the homes’ documentation. Fees range from £300 to £370 per week. Fees do not include costs for chiropody, hairdressing, national newspapers (though local papers are provided. What the service does well: The Health needs of residents are well met and medical services are accessed promptly when required. Residents said they had confidence in the staff. Residents were also pleased with the way staff helped them to continue with social lives established prior to living at Chybyghan. Residents are able to participate in a range of social and recreational activities at the care home and in the local community if they wish. Some of the residents choose to arrange their own social lives. Residents are very satisfied Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 6 with menu and food provided and a have a choice of the food they eat at each mealtime. The home is a detached property and has sea views on two aspects. The environment and facilities provide a comfortable setting for residents. Residents said they were satisfied with the environment. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The 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. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide residents with the information they need. Prospective residents are assessed prior to admission. The home does not provide intermediate care. EVIDENCE: There is a Statement of Purpose and Service User Guide, but these documents are not dated, and the latter is significantly out of date. This information is not provided to residents or prospective residents. Discussion took place with the registered manager as to how this could be improved. The care documentation for the most recent admission to the home showed that a care needs assessment had been carried out prior to admission. Discussion took place with the registered manager as to how this could be improved. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate care. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in place in order that residents receive appropriate care and support, but these are not comprehensive. Good arrangements are in place to meet health needs and medicines are safely administered. EVIDENCE: Each resident has a care plan to inform the staff of the needs they have and the best way of providing the care and support they require. The care plans summarise the residents’ needs each day and night. The care plans seen were not comprehensive however, one did not mention a significant health care need identified in other documentation. More information would better direct staff as to how to meet residents’ care needs (e.g. “needs assistance with washing and dressing” could be improved by stating what assistance is needed). The risk-assessments contain information that should be in the care plan, and do not identify and address identified risks. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 11 There is evidence the plans are regularly reviewed, but this process does not involve the resident, and the reviews seen did not identify changes in care identified during the inspection. The registered provider said that the care documentation is still under review. Residents said that they were very happy with the care and support provided. It is clear that staff support residents positively and promote independence as far as possible. The records indicate that District Nurses and General Practitioners regularly visit different residents. Residents are able to administer their own prescribed medication where they wish and providing it is safe to do so. The medicines are kept in secure facilities. The staff also complete appropriate records of the medicines they have administered. Any medicines that are no longer required are disposed of safely and the providers have established a positive relationship with a local pharmacist. Discussion took place with the registered provider about ensuring that staff had received training in medication administration. Residents spoken with were complimentary of the staff and care provided. Comments received from staff and residents included: • “The care that is given is excellent” • “…being here is most comfortable and I cannot fault the care given to me” Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to participate in a range of social and recreational opportunities at the care home and in the local community. This helps to promote a varied and stimulating lifestyle for residents. A varied and nutritious menu is in place that reflects the residents’ needs, preferences and choices. EVIDENCE: Residents confirmed that staff are helpful and assist them in maintaining their social life, sometimes established before admission to the home, and that there are a range of recreational and leisure opportunities provided at the home and in the community. The opportunities reflect residents’ choices and preferences. Some of the residents elect to arrange their own social and leisure time. The daily records made by staff do not do justice to the efforts made by them or the comments of the residents in this respect. There is a portable telephone available to residents and two have their own telephone. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 13 The visitors’ book near the entrance shows frequent and regular visitors to the home, and Mrs Deane confirmed that there is open visiting. Residents said that visitors were always welcomed and well received by the staff. Residents look after their own finances or have a relative doing so for them. The registered providers are not appointees for anyone at the home. The registered providers do hold some money securely on site for residents, but Mrs Deane confirmed this is transferred to individual accounts if it accumulates. There are appropriate individual records and receipts kept. The residents stated they are satisfied with the food and menu, and confirmed they are provided with a choice at each mealtime. The providers regularly consult with residents about the menus and choices available. The inspectors do have some concerns about the kitchen, but this is covered under the environment section of this report. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents said they would feel able to make any concerns known. Residents are protected by staff who have received relevant training in safeguarding. EVIDENCE: The home’s complaints procedure is displayed discreetly in every resident’s room. The Commission for Social Care Inspection has received one complaint since the last inspection, which was largely not upheld (one unproven aspect relates to the attitude of Mrs Deane and this has relevance in the staffing section of this report). At the previous inspection Mrs Deane said she would be installing a comments/complaints box near the entrance and she would then record and complaints received and any subsequent action taken. This has not happened, and Mrs Deane agreed to introduce a complaints book to record any complaints received. Most of the staff have now received safeguarding training recently, though the certificates were not yet available. Discussion took place with Mrs Deane in respect of a safeguarding procedure to give staff clear direction as to what to do in the event of an allegation of abuse, and also to continue with the safeguarding training for all the staff. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is clean and hygienic and provides comfortable facilities for the residents, with the exception of the kitchen where attention is needed. There are signs of wear and tear that require monitoring to make sure that standards are maintained. EVIDENCE: The environment is clean, pleasant and hygienic. Residents said they were very satisfied with the facilities, which they described as comfortable and homely. The home does not employ a maintenance person. At the last inspection the registered provider, Mrs Deane, said she would do a complete audit of the premises in order to produce and action plan of maintenance and repair work including priorities and timescales. Mrs Dean said she would forward a copy to Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 16 the Commission for Social Care Inspection. This has not happened, and the requirement remains The property is detached and has sea views on two aspects. The majority of the accommodation is located on the ground floor and this includes the two sitting rooms and the dinning room. It was noted at the last inspection that some of the flooring in the communal corridors is covered with duck tape where carpets join and this is still the case. This could present a potential tripping hazard. Two of the bedrooms are located on the first floor with a bathroom and toilet within a close proximity. The stairs or a stair-lift access these rooms. A bathroom is also located on the first floor. Bathroom and toilets are also situated throughout the ground floor and within a reasonable distance from residents’ bedrooms and the communal areas. Some of the bedrooms are also provided with en-suite facilities. The residents’ bedrooms are well proportioned and many of the residents have personalised their rooms. A laundry is also provided on site that is suitably equipped. The laundry has been recently redecorated, and was seen to be clean and orderly. The laundry has domestic-style drying and washing machines. A range of disability equipment is provided at the home to assist residents to maintain their independence and also to promote their safety. In addition individual residents are provided with disability equipment where this is required and following an appropriate specialist assessment. The kitchen is being used as a thoroughfare by staff. The cooker is badly situated and is not fully functional. Cupboards are in need of replacement or repair. A cleaning schedule is not in use. Some of the equipment, such as freezers, are also in need of replacement. The registered provider showed the inspectors to a vacant bedroom to be used as an office during the inspection. Discussion took place with Mrs Deane about the merits of having dedicated office space. Mrs Deane said that she would allocate a vacant bedroom to be an office so that managerial duties could be more easily carried out, and meetings could be held in comfortable privacy without imposing on residents’ accommodation. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers are sufficient to meet the needs of the residents, but the numbers do not currently allow for sufficient managerial time. Residents’ needs are met and they are protected by the home’s recruitment practices, though these must be followed consistently. Training and training records need improvement. EVIDENCE: Shifts are arranged: 8am-2.30pm 2.30pm-9pm 9pm-8am There are usually three care staff on duty in the morning, two in the afternoon, and one at night (supported by the registered providers who live in the adjoining building and are available as needed). At the time of the inspection there were 3 staff and 15 residents. Staff carry out multiple roles (caring/cleaning/laundry). Additional staff can be provided at peak hours where required to make sure that residents have the level of care and support they require at all times. Residents said they were very satisfied with the care and support they receive. Sufficient managerial hours are not shown on the duty rota. The registered manager is too often working as one of the care staff. This report and previous Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 18 ones identify requirements and recommendations, some of which have carried over from more than one previous inspection, that require the registered manager’s attention. This view is supported by comments received from staff “I feel we could do with a couple more part-time staff, which would release the manager from shifts”. Mrs Deane provides on-call cover at night, 7 nights a week. Though residents’ accommodation is generally clean, there is insufficient staff to carry out the cleaning and maintenance needed (specifically in the kitchen). NVQ certificates are displayed in the entrance. There are 7 care staff (not including the registered providers) of which 6 have achieved NVQ Level 2 or above, or equivalent. Staff training records are scattered and certificates of achievement not always kept. At the previous inspection the registered provider, Mrs Deane, said she would spend time on this to collate individual staff’s certificates and identify their training needs. One possibility discussed was using a ‘at a glance’ training matrix. This has not been provided. At the last inspection the registered provider, Mrs Deane, agreed to review the staff application form to allow more information to be asked for and provided (such as responsibilities in previous posts), and also to ensure that dates are provided by applicants, and referees details also include position/role/rank. Employment files seen were generally satisfactory, though only one reference was evident on one file. There is no evidence of new staff undertaking a National Training Organisation compliant induction programme, which was again discussed with Mrs Deane. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Comments from the people that live at Chybyghan show that the home is run in the best interests of the residents, but there is insufficient evidence to be confident in the management of the home. Improvements are required regarding the management systems, the management of risks, quality assurance, and the meeting of outstanding requirements. This will further safeguard residents. EVIDENCE: Both providers are involved in the day-to-day running of the care home and both provide direct care. One of the Providers, Mrs Deane, is also the registered manager and has successfully completed the Registered Managers Award. The number of requirements, including those carried over from previous inspections, causes concern for the registered providers’ ability to Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 20 effectively manage the home. This was discussed with Mrs Deane, who said that she would commit to achieving the requirements and recommendations in this report. Mrs Deane also said that she knew that they should seek advice if in doubt about how to best proceed. It is clear that residents are regularly consulted about the quality of the service and facilities provided. From the consultations that take place the indications are that residents are satisfied. However at this time the providers have not established any systematic arrangements to obtain, record or formally analyse feedback, though Mrs Deane said that they had started to formulate some questions for a planned questionnaire. This was identified as a requirement at the last inspection. The providers will assist residents to manage their personal allowances if this is required and suitable records are maintained. The records detail the transactions that have taken place and a running balance is maintained. The registered provider, Mrs Deane, has bought some bound notebooks and said she would be replacing the current loose-leaf records with these. Money and valuables are stored securely. Staff comments at the time of the inspection and staff files confirm that they are not being supervised. There is sufficient and appropriate insurance cover for the service. Fire equipment and appliances at the home are monitored and maintained and staff are regularly trained. There is a comprehensive fire risk-assessment in place. An outstanding requirement from the previous inspection and the one before that is for the registered providers to ensure the safety of the residents and others in respect of scalding with hot water. Mrs Deane said that thermostats had been fitted, but was unsure where. The water was tested by hand and found to be safe. Mrs Deane agreed to confirm in writing what work had been carried out and where the thermostat(s) had been fitted. Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 3 Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 22 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 4, 5 Requirement The registered provider must review and amend the Statement of Purpose and Service User Guide to ensure it provides up-to-date information for the people that live at Chybyghan, and prospective residents. The registered provider must make the information available to residents and prospective residents. The registered provider must review the care plans to ensure they accurately reflect the care needs of the residents, and clearly instruct staff on the interventions needed to meet those needs. The registered provider must involve the resident, wherever possible, in the development and review of their care plan. The registered providers must develop a safeguarding procedure providing clear instruction as to the action to take in the event of an incident DS0000062587.V372527.R01.S.doc Timescale for action 01/01/09 2. OP7 15 01/01/09 3. OP18 13 01/11/08 Chy Byghan Version 5.2 Page 23 4. OP27 18 of abuse and the relevant contact details (e.g. Department for Adult Social Care). The registered providers must ensure that the registered manager’s managerial hours are shown on the duty rosta (as distinct from care hours). The registered provider must arrange for sufficient staff to provide an on-call system that does not rely on one person. The registered provider must arrange for sufficient staff in order to provide necessary cleaning and maintenance tasks. The registered provider must arrange for appropriate training for staff, monitoring their training needs and keeping a record of training undertaken. The registered providers must ensure that all new staff undertake an National Training Organisation compliant induction programme (www.skillsforcare.org). Effective quality assurance measures must be in place and an annual report completed and made available to service users and the Commission. 01/12/08 5. OP30 18 01/01/09 6. OP33 24(1-3) 01/03/09 7. 8. OP36 OP38 OP19 (Previous timescales of 30 May 2006, 30 October 2006, 30 October 2007 not met). 18 All staff must receive supervision from management at least 6 times per year. 13(4)(a)(c (Previous timescales of 30 October 2006, 30 October 2007, ), 23(2)(a)(c and 30 July 2008 not met). ) The registered providers must carry out and record a thorough DS0000062587.V372527.R01.S.doc 30/10/08 01/01/09 Chy Byghan Version 5.2 Page 24 risk-assessment of the premises (to include hot water), identifying risks and potential risks with an action plan and timescales for necessary action to be taken. The registered provider must include the kitchen in this audit. 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 OP3 Good Practice Recommendations The registered provider should review the pre-admission assessment form to include information about the persons’ history, important contacts, and preferences. The assessment should be dated, signed, and indicate where the assessment took place. The registered provider should ensure that all staff with responsibility for medicines receive relevant training. The registered provider should ensure that the daily entries better reflect the lifestyle of the residents and the efforts made by staff (as evidenced by the comments from residents). The registered provider should record any complaints made, including any action taken as a result. The registered providers should consider expanding the laundry into the adjacent unused kitchenette to provide separate dirty and clean areas. When practical, the registered providers should replace the current laundry equipment with industrial machines that offer a sluice cycle and 90( wash. Not inspected at this time 2. 3. OP9 OP12 4. 5. OP16 OP26 Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. Extracts may not be used or reproduced without the express permission of CSCI Chy Byghan DS0000062587.V372527.R01.S.doc Version 5.2 Page 26 - 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!