CARE HOMES FOR OLDER PEOPLE
Chy Byghan Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX Lead Inspector
Paul Freeman Unannounced Inspection 8th February 2006 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.V282077.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. Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Chy Byghan Address Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX 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.V282077.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th June 2005 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.V282077.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned unannounced inspection took place on 8 February 2006. The providers, residents, staff and visitors to the home were consulted. The environment and a number of records and documents were also considered. Other unannounced inspections had taken place on 30 November 2005 and 20 December 2005 to consider concerns that had been expressed about the management arrangements and the care and support provided. The findings of these inspections are also included in this report. The Inspector has found the requirements and recommendations set at the inspections have been acted upon. Kind thanks is given to the providers, residents, staff and visitors to the home for their cooperation and assistance at inspection. What the service does well:
Residents are able to administer their own prescribed medicines when it is safe to do so. Where the providers and staff assist residents medicines are held in secure facilities and a suitable policy and procedure is in place for staff. Medication that is no longer required is also disposed of safely. Residents were generally satisfied with the lifestyle they experience and said they felt in control of their lives and were able to exercise choice. Flexible visiting arrangements are in place and residents stated that the staff positively welcomes visitors. Residents also decide where they meet with visitors. Satisfactory arrangements are in place to deal with any complaints or concerns. Residents were confident there are no barriers to raising issues and were sure any concerns would be dealt with satisfactorily. 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. Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 6 The home is a detached property and has sea views on two aspects. The environment and facilities are well maintained and provide a comfortable setting for residents. Residents said they were satisfied with the facilities. The majority of the accommodation is provided on the ground floor and comprises of two sitting rooms, a dinning room and residents bedrooms. Three 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 ensuite 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. Following recent concerns the providers are in the process of reviewing the staffing arrangements at peak times during the weekend. At other times sufficient numbers of staff are on duty and 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. New staff at the home said they were positively welcomed and experienced an informative induction programme that had clearly outlines their roles and responsibilities. Residents said they found the staff to be respectful and they were treated in a dignified manner that promoted their independence and control. Residents also stated they were satisfied with the management arrangements and recent difficulties had been overcome. Residents were pleased about the appointment of a senior carer who had previously worked at the home. The residents commented they were confident the staff member would further develop the management arrangements. Residents are consulted about the quality of the services and facilities to make sure the home is run in their best interests. Relatives and representatives are also informally consulted. Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? What they could do better:
The providers to make sure they are able to meet the needs, preferences or choices of the person concerned assess each prospective resident. As part of the assessment the providers meet with the prospective resident and consult relatives or representatives. The views of any professionals that are involved with the person are also taken into account. The assessment information is not sufficiently detailed for the providers to be satisfied they are able to meet the needs of the person concerned. Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 8 More information also needs to be collected to make sure the providers have a clear picture of the care and support required so that a suitable care plan can be established. The records about the administration of medicines were incomplete and require improvement to make sure residents health is promoted. Some of the residents said they wanted more opportunities to participate in recreational activities. The providers stated that residents were being consultes about their preferences in order their social needs can be met and the opportunities could be expanded. The recruitment arrangements for new staff needs to be improved to make sure the providers comply with the regulations and that residents are protected. The hoist in the first floor bathroom requires attention and need to be replaced, appropriately maintained or removed. Although residents stated that repairs are always undertaken efficiently it is recommended the providers keep a log of the work that has been completed. Events in December 2005 highlighted the management arrangements in the providers absence were not robust. When difficulties did arise the providers acted promptly to make sure that residents were not placed at risk. More robust arrangements are now in the process of formulation. The arrangements to measure the quality of the services and facilities need to be developed to make sure the providers have comprehensive feedback. An annual report also need to be established that is available and accessible to residents and other interested parties. 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. Chy Byghan DS0000062587.V282077.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 Chy Byghan DS0000062587.V282077.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): 2 and 6. The assessment arrangements are not satisfactory as insufficient information is provided to obtain have a clear picture of needs, preferences and choices. This also limits the provider’s ability to be satisfied they are able to meet the needs of the prospective resident. EVIDENCE: The providers assess each prospective resident before they move to the care home. This is designed to make sure the providers are satisfied they are able to meet the needs of the prospective resident. The assessment 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 considered. Relatives or representatives are also consulted and the views of any professionals involved with the person are taken into account. It is recommended that comprehensive information is obtained where a speaclist assessment has been completed.
Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 11 This ensures the providers have a clear understanding of the residents’ needs, preferences and choices and the information then forms the basis of the care plan. It is evident the providers meet with prospective residents but the records of assessment do not provide sufficient detail in certain areas to satisfactorily provide a comprehensive picture of the persons needs, preferences and choices. The limitations of the information also restrict the provider’s ability to make sure the home is able to meet the needs of the person concerned. The providers do not offer a dedicated interim care or rehabilitation service but the providers stated that every reasonable effort is made to promote residents independence. Chy Byghan DS0000062587.V282077.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 and 9. The care planning arrangements do not provide a comprehensive picture of the residents needs to make sure residents receive the care and support required. The plans are regularly reviewed but the records of the review need to be more detailed to make sure up do date information is available. The arrangements to administer prescribed medicines require improvement to promotes residents health. EVIDENCE: Each resident has a care plan that informs the staff of the needs they have and the best way of providing the care and support they require. Where residents are unable to direct their own care more information is required in some instances to make sure the care provided is safe and occurs in the most satisfactory manner. In other care plans insufficient information is recorded about the residents needs and this was highlighted when concerns were raised with the Commission in November 2005. Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 13 Care plans need to provide sufficient detail to give staff the information, guidance and direction they require to provide appropriate levels of care and support. The care plans are regularly reviewed with the residents but the records of the review need to be more detailed. This will ensure that everyone at the care home has up to date information about the care and support required. The providers continue to develop and improve the care planning arrangements. Staff commented they found the plans to be informative and helpful in their work. Residents were generally satisfied about the care provided and manner in which the staff undertake their duties. Concerns were also expressed in November 2005 about certain aspects of the administration of medication. As a consequence the providers have reviewed to administration arrangements and taken positive steps to make sure that staff are competent and aware of their responsibilities. Consequently the shortfalls identified have been addressed. Medicines are held in secure facilities and a policy and procedure is in place to guide, direct and inform staff. The records about the administration of medication were found to be incomplete and require improvement. It is also recommended that where a General Practitioner has instructed a prescribed medicine is stopped or altered a formal record of the guidance should be made. Satisfactory arrangements are in place for control drugs and medicines that are no longer required are safely disposed. Chy Byghan DS0000062587.V282077.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, 13 and 14. Residents are satisfied with the lifestyle they experience and are able to have control over their lives. Some residents want the recreational opportunities developed in order they can experience a more varied and stimulating life. Visiting arrangements are flexible in order that residents can maintain their relationships. EVIDENCE: Many residents are satisfied with the lifestyle they experience and commented they felt in control of events. Some residents and relatives have expressed concerns following the last inspection about certain aspects of the service they receive. Where this occurs the providers have made efforts to address the issues and establish a suitable action plan to improve the care and support provided. Residents that had previously expressed concerns said that appropriate action had been taken to address the issues and they were now satisfied with the care and support provided. Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 15 There are a range of recreational and leisure opportunities provided at the home that reflect residents’ choices and preferences. Some of the residents said they were satisfied with the arrangements but others expressed an interest in broadening the opportunities available. The providers said they were currently in the process of consulting with residents individually and at residents meetings to develop the current provision. There are flexible visiting arrangements in place and residents are able to determine where they meet with their visitors. Residents aid that visitors were always welcome and well received by the staff. Chy Byghan DS0000062587.V282077.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 and 18. Satisfactory arrangements are in place to deal with any complaints or concerns raised and appropriate arrangements are in place to protect residents from abuse. EVIDENCE: The providers have not received any formal complaints following the last inspection. The Commission has received one formal complaint about care and support issues and one expression of concerns regarding the management arrangements. The management issues are addressed latter in this report. In regard to the care and support a number of specific issues were raised by a resident and their relatives that were found to be upheld. The providers have positively responded to the shortfalls and a satisfactory action plan has been undertaken to make sure the resident’s needs, preferences and choices are met. The resident said they were very satisfied with the improvements and had confidence in the care and support provided. The residents commented they were confident that the providers deal with any issues of concern appropriately and promptly.
Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 17 The policy and procedure in place to protects residents from abuse and has recently been improved to make sure it reflects the Department of Health guidance ‘No Secrets’. Any allegations or concerns are reported to the statutory authorities and investigations takes place where necessary. In the last year there have been no concerns about abuse. A satisfactory whistle blowing policy and procedure is in place for staff. This gives staff with the opportunity to raise any issues of concern with a third party and provides additional protection for residents. Chy Byghan DS0000062587.V282077.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, 22 and 26. The environment is well maintained, clean and hygienic and provides comfortable facilities for the residents. EVIDENCE: 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. Two of the bedrooms are located on the first floor with a bathroom and toilet within a close proximity. These rooms are accessed by the stairs or a stair lift. Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 19 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 ensuite facilities. The residents’ rooms are well proportioned and many of the residents have personalised their rooms. 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 speaclist assessment. The first floor bathroom does have a bath hoist that is no longer in commission and the providers are in the process of arranging for the equipment removal. The equipment will not be replaced, as the first floor is not a suitable setting for a resident that has mobility issues that would warrant the use of a bath hoist. 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.V282077.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 and 29. The staffing arrangements continue to be reviewed to make sure that sufficient numbers are on duty to meet the needs of residents and provide a safe setting. The recruitment selection and vetting arrangements are not satisfactory and need to be developed in order to protect residents. EVIDENCE: A senior care has recently been appointed who previously worked at the care home. The senior assists the providers coordinating the day to day provision of care and deputises on occasions the providers are away from the home. Residents said they were satisfied with the staffing arrangements and found the staff to be helpful, responsive and flexible to their needs and any requests they made. The residents also stated they were pleased to see the return of the senior care who they valued and trusted. A minimum of two staff is on duty during waking hours and additional staff is provided for peak hours. Recent concerns have highlighted the need for the providers to review the staffing arrangements over the weekends to make sure sufficient staff are employed. This has resulted in additional staff on duty at peak times at the weekend. Resident were very satisfied with the revised arrangements.
Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 21 Waking night staff are on duty each night and reliable on call arrangements are in place if they required any assistances. Residents said staff responded promptly to any requests for assistance at night. The providers also take an active part in the care and support provided to residents. The staff said they enjoyed working at the home and stated they were well supported. Staff commented that advice, guidance and assistance was also readily available when required. A staff member that has recently joined the team said they were positively welcomed and found the induction arrangements to be instructive and helpful. The arrangements to select, recruit and vet new staff needs to be improved to make sure that residents are protected. Certain documents required by regulation were not available and this included an up to date Criminal Records Bureau and POVA check. Chy Byghan DS0000062587.V282077.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): 31, 33, 37 and 38. The management arrangements are now satisfactory after a period of instability. Actions are being finalised to make sure robust cover arrangements are in place for any extended periods of absence by the providers. This will make sure that residents are not placed at risk. The providers continue to improve and develop the quality assurance measures to make sure the home is run in the best interest of residents. Some of the records are not satisfactory and need to be improved to make sure that residents’ needs are met. Measures are in place to provide residents with a safe and hygienic environment. The arrangements for assessing and managing risks need to be improved to safeguard residents. EVIDENCE: Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 23 Both providers play a key role in the management of the care home and in the direct provision of care and support to residents. One of the providers has become the registered manger since the last inspection following the departure of the previous post holder. The provider is currently completing the Registered Managers Award. Residents said they were satisfied with the management arrangement and stated they found the home to be well run. The recent recruitment of a senior carer that has previously worked at the home has further enhanced the residents’ confidence in the management arrangements. Concerns were expressed to the Commission about the management arrangements in December 2005. During the autumn the providers had taken three extended absences from the home and in December 2005 it was found that the interim management arrangements were not robust or reliable. At this time the providers did taken steps to make sure that residents needs and safety were not compromised. Currently the providers are in the process of developing robust arrangements for any occasions they have periods away from the home in the future. The appointment of an experienced manager that can deputise in their absence is an important part of the solution. The providers have established a range of measures to consult with residents and staff about the quality of the services and facilities provided. These include regular meetings with residents and staff and individual informal consultations with residents and their relatives or representatives. The providers stated they are in the process of developing the current arrangements and plan to produce a quality report with an action plan within the first year of their tenure. The requirements to improve the record keeping practices and risk assessment and management arrangements set at the last inspection were considered. Improvement has occurred in the records relating to residents. However there continue to be certain instances where the records are incomplete or provide sufficient information, guidance or direction to staff. An improvement was also found in other records at the home but certain records required by regulation were incomplete. There was also some improvement in the risk assessment and risk management arrangements. The assessments must provide clear guidance to staff about the steps they need to taken to minimise any potential risks. Any situations that arise that could potentially compromise a resident’s health; safety or well being must be assessed. This will make sure that all
Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 24 unreasonable risks are positively managed and provide residents with greater protection. Potential risks must also be taken account of during the assessments of prospective residents. Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 2 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X 2 2 Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP3 OP7 Regulation Requirement Timescale for action 30/03/06 30/04/06 3. OP7 4. 5. OP9 OP12 6. OP22 7. 8. OP27 OP29 14(1)(a-c) A comprehensive assessment of need must be completed for all prospective service users. 15(1) Care plans must provide sufficient information about the service users needs to inform, guide and direct staff. (Previous timescale of 20 June 2005 not met). 15(2)(b-c) A record detailing the contents and conclusions of each review must be made. (Previous timescale of 20 June 2005 not met). 13(2) Comprehensive records about the administration of medication must be maintained. 16(2)(m) A range of recreational activities must be provided that reflect service users needs, preferences and choices. 13(4)(a-c) The hoist in the first floor bathroom must be removed, replaced or appropriately maintained. 18(1)(a) Sufficient numbers of staff must be on duty at all times. 19(1)(a-c) The documents detailed in sch 2 schedule 2 must be in place as
DS0000062587.V282077.R01.S.doc 30/04/06 30/03/06 30/05/06 30/03/06 30/04/06 30/05/06 Chy Byghan Version 5.1 Page 27 9 OP31 10(1) 10. OP33 24(1-3) 11. 12. OP37 OP38 12(1)(a) 17 sch 3, 4 13 13. OP38 13 part of the robust recruitment, selection and vetting arrangements. Appropriate and robust management arrangements must be in place for all times the registered providers are absent from the care home. Effective quality assurance measures must be in place and an annual report completed and made available to service users and the Commission. Comprehensive records required by regulation must be maintained. Risk assessments must be completed on each occasion the safety or welfare of the service users could be compromised. Any action required from the risk assessment must be included in the service users care plan. 30/03/06 30/05/06 30/03/06 30/03/06 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP9 OP19 Good Practice Recommendations Wherever possible detailed assessments should be obtained from speaclist workers for all prospective residents. A formal record should be made of any changes directed by a qualified professional about prescribed medicines. An up to date repairs log should be in place. Chy Byghan DS0000062587.V282077.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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