CARE HOMES FOR OLDER PEOPLE
Chy Byghan Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX Lead Inspector
Paul Freeman Unannounced Inspection 7th June 2007 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.V340415.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.V340415.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Chy Byghan Address Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX 01736 871459 01736 871423 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 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.V340415.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th September 2006 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.V340415.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned unannounced key inspection took place on 7 June 2007 and 11 June 2007. The inspection considered the key elements of the services and facilities provided which included care planning, health and safety, staffing arrangements and meals. The environment and a number of records and documents were also considered. The residents, staff and the person in charge of the home were also consulted. The Providers had also sent written information to the Commission about the services and facilities provided. What the service does well:
The providers assess each prospective resident to make sure they are able to meet the needs, preferences or choices of the person concerned. As part of the assessment the providers meet with the prospective resident and consult relatives or representatives. The views of any professionals involved with the person are also taken into account. The Health needs of residents are well met and medical services are accessed promptly when required. Residents said they had confidence in the staff who they found to be diligent in making sure there were no outstanding health issues. Residents were also very positive about the care and support provided and the dignified manner they are treated by staff. 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 said they experienced a varied and stimulating lifestyle and were able to have direct control over their lives. Residents are very satisfied with menu and food provided and a have a choice of the food they eat at each mealtime. A suitable adult protection policy and procedure is in place to protect residents from abuse and any allegations or concerns are reported to the statutory authorities for investigation. Residents stated they were able to raise any issues, concerns or complaints with the managers or senior staff. 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 enviroment.
Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 6 The majority of the accommodation is provided on the ground floor and comprises of two sitting rooms, a dinning room and residents bedrooms. Two bedrooms are also located on the first floor and are accessed by stairs or a stair lift. Bathrooms and toilets are distributed throughout the home and within a reasonable distance from communal areas and residents bedrooms. Some of the resident’s bedrooms also have en-suite facilities and many rooms have been personalised by the occupants. The house keeping staff maintains a good standard of cleanliness and hygiene and residents stated the home is always clean. Sufficient numbers of suitably trained and qualified staff are on duty each day and night. The residents are satisfied with the care and support they receive and it is clear that positive and trusting relationships have been established. Residents said they were very satisfied with the manner in which staff undertook their duties. Waking night staff is on duty each night and reliable arrangements are in place for additional staff to be called upon in an emergency. Staff at the home said it was an enjoyable place to work and they were well supported by colleagues and the managers at the home. The staff said there was a good team spirit and the staff worked well together. The home is well managed and suitable arrangements are in place for senior staff to assist the providers in the running the home. A range of measures is also in place to promote safe working practices in respect of the services and facilities provided. What has improved since the last inspection?
The care planning arrangements continue to improve and develop and residents are regularly consulted about their care plans to make sure all their needs are met in a satisfactory manner. In consultation with residents the providers have also continued to broaden and develop the recreational and social opportunities available. The recruitment selection and vetting arrangements have improved and this makes sure that residents are safeguarded. Better arrangements are also in place where the providers assist residents to manage their personal allowances and suitable records are maintained. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 7 The providers have continued to improve the risk assessment and risk management arrangements and therefore better guidance and direction are in place for staff. The measures also further safeguard and protect residents. What they could do better:
The care plan format needs to be improved so that the information is easily accessible to staff and residents. The providers must also make sure that all the staff are clear about the different records and documents that form the care plan. This will make sure that residents are provided with the care and support they require. The kitchen is maintained to the required standard but the records regarding the upkeep require improvement. The complaints policy and procedure is currently in the process of review. This is to make sure that robust arrangements are in place. The water temperature from certain hot taps around the care home appeared to exceed the minimum temperature required. This matter is re-notified from the last two inspections and requires urgent attention to make sure that residents’ safety is not compromised. The decoration requires improvements in certain areas and the communal corridor flooring is showing signs of wear and tear. The induction arrangements for new staff would benefit from review and improvements. This will make sure that newly appointed staff have a comprehensive introduction about the care and support needs and the preferences and choices of residents. The providers need to establish good and reliable arrangements to make sure they formally consult the residents and other interested parties about the services and facilities provided. The conclusions of an annual quality assurance review should also be shared with the residents and other stakeholders. The fire safety arrangements continue to need improvement to make sure they comply with the Fire Regulations. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 8 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.V340415.R01.S.doc Version 5.2 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 Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 3 and 6. Quality in this outcome area is good. Each prospective resident is assessed to make sure the providers are able to meet their needs and provide the care and support required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers assess each prospective resident before they move to the care home. This is to make sure the services and facilities are suitable to meet the needs of the prospective resident. The assessments also provide the information for the residents care plan. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 11 The current assessments summarise the needs, preferences and choices of the prospective resident. Where necessary the most suitable means of providing the care and support required by the person are also recorded. Relatives or representatives are also consulted and the views of any professionals involved with the person are taken into account. The providers said that where a professional was involved with a prospective resident written information was requested. This was not always provided. It is recommended the providers formally record when requests of this nature are made. Residents that had recently moved to the care home confirmed they had been consulted prior to the move and had being given the opportunity to visit the care home. The residents also said they had received a positive welcomed from the staff and residents when they moved to the home. The providers do not offer a dedicated interim care or rehabilitation service but every reasonable effort is made to promote each residents independence. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 7, 8, 9 and 10. Quality in this outcome area is good. Satisfactory care plans are in place in order that residents receive the care and support they require. Good arrangements are in place to meet health needs and medicines are safely administered. This judgement has been made using available evidence including a visit to this service. 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 and there is clear evidence the plans are regularly reviewed to make sure they meet each residents needs at all times.
Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 13 The providers have continued to improve the information provided to staff in order that good advice, guidance and direction are in place. There continue to be a few occasions when more detailed information and directions are required for staff. This will make sure that more complex or demanding needs are met in a more consistent manner. It was however evident from speaking with the staff there were different interpretations of which documents were part of the care plan. Therefore the care planning arrangements would benefit from a review. The staff also requires clear guidance about the key documents they need to regularly consider. Residents said that they were satisfied with the care and support provided and were able to direct their own care. It is clear that staff support residents positively and promote independence as far as possible. Residents were very satisfied with the manner in which their health needs are met. The records indicate that District Nurses and General Practitioners regularly visit different residents. The records at the home also indicate that health services are promptly accessed when required. In addition residents said they had confidence their health needs were met sensitively and efficiently. Residents are able to administer their own prescribed medication where they wish and providing it is safe to do so. Where staff assist residents the medicines are kept in secure facilities and the staff have all been suitably trained. 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 Pharmacist. Residents are all very satisfied with the manner in which they are treated and were very complimentary about the staff and the care and attention they receive. Residents said that staff always treated them in a respectful and dignified manner. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 12, 13, 14 and 15. Quality in this outcome area is good. Residents are able to participate in a wide 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 nutrition menu is also in place that reflects the residents’ needs, preferences and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents said they are satisfied with the lifestyle they experience and commented they felt in control of events. There are a range of recreational and leisure opportunities provided at the home and in the community. The opportunities reflect residents’ choices and preferences. The providers also continue to consult with residents about their
Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 15 individual choices and preferences. This has resulted in additional opportunities being introduced. The residents that participate in activities were positive about the arrangements in place. Some of the residents elect to arrange their own social and leisure time. There are flexible visiting arrangements in place and residents are able to determine where they meet with their visitors. Residents said that visitors were always welcomed and well received by the staff. A varied menu is provided and two cooks are employed. Care staff also assist in the preparation of some meals and the staff concerned have been appropriately trained. Both cooks are experienced and have also been appropriately trained. The equipment in the kitchen is regularly serviced and maintained and appropriate health and safety measures are in place. However the records regarding the health and safety arrangements require improvement. The Providers have taken steps to make sure good records are in place. 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. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 16 and 18. Quality in this outcome area is adequate. Satisfactory arrangements are in place to protect residents from abuse. The arrangements regarding complaint are currently under review. This is to make sure that reliable and robust procedures are in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers or the Commission have received one compliant sine the last inspection (18 September 2006). The matter continues to be under investigation. The providers have established a policy and procedure to deal with complaints and residents said there were no barriers to raising any issues or concerns. As part of the current investigations the providers are reviewing the policy and procedure to make sure good arrangements are in place that meet the regulatory requirements. The arrangements to protect residents from abuse reflects the Department of Health guidance ‘No Secrets’ and a suitable policy and procedure is in place to
Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 17 guide and direct the staff. Any allegations or concerns are reported to the statutory authorities and investigations takes place where necessary. A satisfactory whistle blowing policy and procedure is in place for staff. This gives staff the opportunity to raise any issues of concern with a third party and provides additional protection for residents. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 19 and 26. Quality in this outcome area is adequate. The environment is well maintained, clean and hygienic and provides comfortable facilities for the residents. There are certain signs of wear and tear that require attention to make sure that standards are maintained. The hot water continues to appear to exceed the minimum standard required and could compromise the residents’ safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 19 The environment is well maintained, clean, pleasant and hygienic. Residents said they were very satisfied with the facilities, which they described as comfortable and homely. 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 the flooring in the communal corridors was showing signs of wear and require attention. 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 accesses these rooms. A bathroom is also located on the first floor. It was noted the bathroom flooring requires improvement. The hot water temperature in this bathroom appears to exceed the required temperature. 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 hot water temperature in some of these facilities also appeared to be excessive. This requires urgent attention to make sure that residents’ safety is not potentially compromised. 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. However plans need to be established to redecorate the laundry to make sure the required standard of decor is maintained. 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. Residents said the providers promptly responded to any repairs that were required but currently they do not keep a record of the action that has been taken. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 27 to 30). Quality in this outcome area is good. Sufficient numbers of suitably trained and qualified staff are on duty each day and night to meet the needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers have reviewed the staffing arrangements since the last inspection and additional staff have been provided at peak hours where required. This has made sure that residents have the level of care and support they required each day and night. A minimum of two staff is on duty for waking hours and one staff member is awake each night. Additional staff or the providers also sleep at the home each night and can be called upon in an emergency. Domestic and catering staff are also on duty each day. Residents said they were very satisfied with the care and support they receive and commented that staff responded quickly and efficiently to any requests they made.
Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 21 A range of staff training is provided and this includes the NVQ qualification and training around the key tasks staff are required to undertake. The staff said there was a good team spirit and mutual support. The recruitment selection and vetting arrangements were also satisfactory and recently appointed staff said they had been well supported. Newly appointed staff are provided with an induction programme but the providers need to make sure this is comprehensive and reflects the standards set by Skills for Care. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 31, 33, 35 and 38. Quality in this outcome area is adequate. The management arrangements at the care home are generally good and the service is run in the best interests of the residents. Improvements are required regarding the management of risks, fire precautions and quality assurance. This will further safeguard residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management arrangements at the home are seen by the residents and staff as reliable and positive. The providers have also improved the
Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 23 arrangements for any periods they are absent from the care home and senior staff are left in charge. The indications are that the difficulties encountered in the past have been overcome and reliable arrangements that safeguard residents are now in place. Both providers are actively involved in the day-to-day running of the care home and both provide direct care. One of the Providers, Rosemary Deane acts as the registered manager and has recently successfully completed the Registered Managers Award. The providers acknowledge they require assistance to establish reliable and verifiable quality assurance measures. 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 record or formally analyse the findings. 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. Appropriate policies and procedures have been established to promote safe working practises at the home that are also designed to protect residents. The equipment and services at the home are regularly maintained and where necessary equipment is replaced. The Fire Officer inspected the facilities on 20 March 2007 and identified arrears of non-compliance that included the fire risk assessment and fire detection arrangements. The providers have taken steps to improve the arrangements and have employed a specialist company. This is to make sure robust and reliable arrangements are in place. As part of this process it is recommended the policy and procedure is reviewed. It is positive that the fire equipment and appliances at the home are monitored and maintained and the staff are also regularly trained. There are continued improvements in other areas of risk assessment and risk management arrangements. The information and guidance provided to staff is clearer and the evidence indicates that all risk management plans are regularly reviewed. However there were certain occasions where risks had been identified but the actions taken by the staff or action required to be taken to safeguard the residents were incomplete. This could result in the resident’s health; safety or well-being becoming compromised. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 24 Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation Requirement Timescale for action 30/10/07 13(4)(a-c) The providers must offer training 15(1) and/or guidance to all staff in the use of the care planning documents that form the care plan. 13(4) (a) (c) 23(2)(b) (d) 12(1)(a) 13(4)(a) (c) The providers must repair or replace all worn and damaged communal floor coverings. 2. OP19 30/03/08 3. 4. OP19 OP25 The laundry room must be 30/12/07 reasonably decorated. The water temperature from taps 30/07/07 must not exceed 43 degrees. (Previous timescale of 30 October 2006 not met). The provider must monitor the temperature of the hot water in all the areas that are accessible to service users. Measures to safeguard service users must be taken where the water temperature exceed the recommended temperature. 4. OP33 24(1-3) Effective quality assurance measures must be in place and
DS0000062587.V340415.R01.S.doc 30/10/07 Chy Byghan Version 5.2 Page 27 an annual report completed and made available to service users and the Commission. (Previous timescale of 30 May 2006 and 30 October 2006 not met). 5. OP38 13(4)(a-c) Any action required to safeguard 15(1) residents from risk must be taken, recorded and included in the residents care plan. 23(4)(a) A detailed fire risk assessment must be in place. (Previous timescale of 30 October 2006 not met). 30/07/07 6. OP38 30/09/07 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 4. 5. Refer to Standard OP7 OP15 OP16 OP19 OP30 Good Practice Recommendations The care plan format should be improved. This will promote user friendliness. The kitchen records regarding health and safety practices should be improved. The complaints policy and procedure should be reviewed. An annual redecoration and replace plan should be in place. The induction programme for staff should be developed and the providers need to make sure the programme reflects the standard set by Skills for Care. Chy Byghan DS0000062587.V340415.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Devon Area Office Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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
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