Inspection on 04/07/06 for Clarondene Residential Care Home

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Clarondene Residential Care Home 18/06/09

Clarondene Residential Care Home 17/04/09

Clarondene Residential Care Home 21/04/08

Clarondene Residential Care Home 17/12/07

Clarondene Residential Care Home 04/07/07

Clarondene Residential Care Home 14/02/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Clarondene Residential Care Home View Road Lyme Regis Dorset DT7 3AA Lead Inspector Rosie Brown Key Unannounced Inspection 10:25 4th July 2006 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 DS0000065695.V302954.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. DS0000065695.V302954.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clarondene Residential Care Home Address View Road Lyme Regis Dorset DT7 3AA 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) 01297 442876 01297 442025 alia@alcurtis.fsnet.co.uk Ms Mary Alison Curtis Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places DS0000065695.V302954.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Clarondene residential care home is registered to provide care and accommodation for a maximum of 12 residents. At the current time there are seven residents living in the home including one married couple. The home has been registered to Ms Alison Curtis since January 2006 and she takes an active role in the management of the home. The home’s registered manager Mrs G Kimmons ceased working in the home during April 2006 and Ms Curtis has recently employed an acting manager. The home is situated in a quiet residential area of Lyme Regis. There is a steep walk to the town centre, which offers all the amenities of a small historic coastal town. A small parking area is available at the front of the home and a large town car park is situated nearby. The front door to the home is located at the side of the house and is accessed by a steep flight of steps. There is also a raised driveway to the home’s back entrance/kitchen door, which has an uneven surface but Ms Curtis said that improvements are planned for the near future. The home has nine single bedrooms and one double bedroom situated on the ground floor. The ground floor dining room/ lounge is comfortably furnished and accessed from the bedrooms by negotiating two steps. Another single bedroom available on the first floor is currently being used as the home’s office. Ms Curtis’s private accommodation is located on the first floor close to private rooms used by her elderly mother. The home has an assisted bathroom and a separate assisted shower room, which has recently been upgraded to a high standard. There is small, enclosed and levelled front garden with flower boarders and lawn at the side of the home near to the front entrance: this is easily accessed through patio doors from the lounge area. Garden furniture is available outside for residents to sit, relax and enjoy the warmer weather and potted plants provide an attractive display. Additionally, there is a back garden but residents rarely use this as it can only be accessed by a series of steep steps. DS0000065695.V302954.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and started at approximately 10.25am on 4th July 2006 and was concluded by approximately 7.30pm. It was the first key inspection of the home since the new owner, Ms Curtis had taken over, and 28 National Minimum Standards were assessed. Additionally, the requirements and recommendations set out during an additional inspection visit undertaken in April 2006 following concerns received by the Commission were also reviewed. The situation regarding an adult protection investigation undertaken by the local Adult Services were clarified. Ms Curtis and the acting manager were both present throughout the inspection and assisted the process. Observation skills were used when viewing the communal areas and a selection of residents’ bedrooms. Residents’ care and medication records, staff recruitment and employment records and maintenance records were examined and a selection of policies and procedures were reviewed. The inspector gained information from Ms Curtis, the deputy manager, staff on duty, one visitor and spoke with three residents. Two comment cards supplied by the Commission were received from relatives; the views expressed within them were entirely positive and have also been used to inform this inspection report. What the service does well: Clarondene is small residential home that provides personal care and support for residents in a homely environment. Friends and relatives are welcomed by the home and care staff have set up an activities programme that includes residents choice. Wholesome and healthy food is supplied to residents and alternatives are routinely provided. Care staff have started to develop a good social care programme that includes residents choices. DS0000065695.V302954.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home needs to have a statement of purpose and service users guide and this should be supplied to all prospective residents and their representatives and current residents for information purposes. Although residents had residency agreements with the previous owner they should be issued with new ones by Ms Curtis the new provider. Residents care plans and care related risk-assessments must be routinely updated when significant changes occur, eg following a fall or an admission into hospital. While care records evidenced that care professionals are consulted for guidance and assistance the home’s accident records need to include the actions taken to prevent recurrence. More recently some notifications have been sent to the Commission but Regulation 37 notifications must be sent following any untoward accidents/incidents as required. Care records should be signed to demonstrate service user involvement. It is understood that the acting manager has plans to introduce a new monitored dosage system into the home but Ms Curtis must ensure that the arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received in the care home. DS0000065695.V302954.R01.S.doc Version 5.2 Page 7 The home should have a complaints record book and a copy of the home’s complaints procedure must be supplied to all residents and their representatives. The home’s staffing arrangements would benefit from review to ensure that there are enough staff on duty at weekends to meet residents’ needs. If Ms Curtis continues to work as part of the care team and undertakes the sleep in on call duty each night then the rota should be changed to ensure that she has regular time off duty. The home should be able to evidence training undertaken by staff including the five mandatory health & safety subjects. Staff recruitment and employment procedures must be improved to ensure that residents are protected: staff should be supplied with terms and conditions of employment and job descriptions. The registered person should draw up job descriptions for herself and the acting manager to ensure there are clearly defined roles of management. A quality assurance system should be set up and used in the home: this should include obtaining the views of service users and care professionals that call into the home: staff meetings should be set up so that staff feel their views are taken seriously and contribute to the future developments in the home. The home’s fire records must be maintained and demonstrate that the regular in-house tests and checks of the fire safety system are undertaken. This should include staff training and fire drills. The home’s fire risk-assessment needs to be updated and include any changes made to the home. The Fire Safety Officer and Commission should be consulted for advice when any changes or alterations are made in the home. Generally the record keeping in the home should be more organised and improved. 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. DS0000065695.V302954.R01.S.doc Version 5.2 Page 8 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 DS0000065695.V302954.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in the outcome area is poor; this judgement has been made using available evidence including a visit to this service. Pre-admission assessment information concerning each resident is gained before new service users are admitted into the home. EVIDENCE: The home’s statement of purpose and service user guide needs to be complied and made available to residents and their relatives: the acting manager said he is drafting this information and will forward a copy to the Commission shortly. It became apparent that residents have yet to be issued a new residency agreement by Ms Curtis. The care file for one resident was examined demonstrated that a pre admission assessment form had been completed prior to admission. Information gained before admission included, personal details and personal care needs and an initial care plan was drawn up. It was not clear if a letter was sent to the resident or their representative prior to admission confirming that the home could meet the prospective resident’s needs. DS0000065695.V302954.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in the outcome area is adequate; this judgement has been made using available evidence including a visit to this service. A care plan is in place for each resident and they are being reviewed each month. Residents’ care records show that other health care professionals are contacted for advice when necessary. The recording of some aspects of medicine administration must be improved to demonstrate that residents receive their medication correctly. Residents confirmed that their privacy is respected. EVIDENCE: The care plans for two residents were examined and demonstrated that they are now being reviewed and updated each month. Daily records made by care staff show that care plans are followed and that other care professionals are contacted when necessary, either for guidance or assistance. One resident talked about receiving regular visits from a community nurse. DS0000065695.V302954.R01.S.doc Version 5.2 Page 11 The home has an accident record book and is now reporting untoward incidents and accidents that directly affect the well being of a service user. However, the actions taken to prevent recurrence must be clearly documented and incorporated into the resident’s care plan, for example following a fall or a significant change in health care needs like admission into hospital. The inspector spent sometime discussing the relevance of Regulation 37 and reporting incidents/accidents to the Commission. The acting manager reported that home’s policy concerning medication storage and administration arrangements would be updated following the implementation of a new monitored dosage system. The new system is being commenced on 17th July and staff training in relation to this system and the safe handling and administration of residents’ medicines is arranged for 13th July 2006. Although the requirements set out in the report of the additional visit in April are not fully met, Ms Curtis and the acting manager are taking steps to ensure that the new system is safe and will ensure improvements are made. On a positive note residents’ prescribed medicines are no longer stored in the home’s kitchen: Ms Curtis said that this improvement was made earlier in the year. The lockable cupboard used to store medicines has a proper Controlled Drugs (CD) cupboard for use. The cupboard was properly organised and no excess stocks were noted: some out of date eye drops needed returning to the pharmacy. Residents’ Medication Administration Record (MAR) charts were examined. In the case of one resident the tablet dose of a medicine had been changed by a GP but the chart did not reflect this and another chart had not been signed to indicate whether a medicine had been administered or refused. A drugs return book is kept and used by the home. One resident told the inspector that they spend most of their time in their room and that staff respect this choice and commented, ‘Staff are excellent and very caring, they are careful with privacy’. DS0000065695.V302954.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in the outcome area is adequate; this judgement has been made using available evidence including a visit to this service. Social activities are arranged to provide stimulation and interest for residents living in the home. Meals are nutritious, include alternatives and offer a healthy varied diet for residents. EVIDENCE: One comment card from a relative said that they are always made to feel welcome by staff and call into the home without prior arrangement. One resident confirmed that they receive regular visitors and the visitors’ book in the hallway also demonstrates that visitors regularly call into the home. Care staff arrange activities each afternoon and are beginning to develop a weekly programme of activities. A puzzle table is left out in the home’s dining room/lounge and one resident said how much they are enjoying making the current jigsaw. Another resident said they prefer to stay in their room and does not join in the activities on offer. Staff told the inspector that a library van calls at the home on a regular basis and large print books were seen in a bookcase in the lounge area. DS0000065695.V302954.R01.S.doc Version 5.2 Page 13 Ms Curtis said that she takes some residents out on shopping trips. The inspector joined residents for lunch and it was a leisurely social occasion. Staff were observed to be helpful and patient with a resident who was physically frail and encouraging with another who has a small appetite. The cook keeps a record of all the meals supplied to residents but the record should also note all alternatives that are provided. One resident said,’ I have lived in the home for seven years and since Alison (Ms Curtis) had employed the new cook the food was unspeakably better, she’s a good cook, I get more than enough to eat and always ask for a small portion’. Food stocks were plentiful and Ms Curtis has upgraded the kitchen facilities, installed a new cooker and two upright fridges: she has also implemented the requirements set out by the Environmental Health Officer who visited the home shortly after she purchased the home. DS0000065695.V302954.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in the outcome area is poor; this judgement has been made using available evidence including a visit to this service. The home has a complaints policy and procedure but this has not been supplied to residents or their representatives. One resident said they feel confident that their concerns when raised would be taken seriously. The home has guidance available on the proper response to be made following any suspicion or allegation of abuse to ensure residents are safe from harm: some but not all staff have been supplied with training in this subject. EVIDENCE: The home has a complaints procedure and this is kept in the policies and procedure file: a complaints book has yet to be set up and maintained. A copy of the home’s complaints procedure has not been issued to the residents or their representative. However one resident said they felt confident that any concerns or grumbles they had could be raised with either Ms Curtis or staff and they would be remedied. The Commission has received two complaints/concerns, one in April 2006 and the other in May: both were from members of staff. One staff member has ceased working in the home and the other remains employed: as they were working in the home at the time of the inspection some time was spent discussing the issues raised and the remedial actions taken by Ms Curtis. DS0000065695.V302954.R01.S.doc Version 5.2 Page 15 The first complaint concerned the judgemental attitude of Ms Curtis, poor medication practices, care plans not being updated and lack of staff induction training. Requirements relating to the medication arrangements and practice are referred to earlier in the report and the other matters have been rectified. The second complaint contained similar elements to the first but also raised a concern that was passed to Adult Services for investigation using the ‘No Secrets’ process. The outcome being that one resident was moved to another home at their families request: the inspector was unable to find any evidence that residents are not provided with sufficient food and staff on duty confirmed that this would not be the case. One resident said, ‘I wouldn’t hesitate to complain, if I had a problem I would go to Alison (Ms Curtis) I know she would go out of her way to put things right’. The home has a policy and procedure concerning the protection of vulnerable adults and the identification and prevention of abuse. It is recommended that the home’s copy of ‘No Secrets’ guidance is kept with these policies and that a copy of the POVA guidance be obtained and also kept for reference. Staff spoken with, were aware of abuse issues and the actions to be taken should they have any concerns. Staff training records indicated that some but not all staff have been provided with training relating to the protection of vulnerable adults and abuse. DS0000065695.V302954.R01.S.doc Version 5.2 Page 16 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 & 26 Quality in the outcome area is adequate; this judgement has been made using available evidence including a visit to this service. Residents live in a well-maintained environment: the home is attractively decorated and comfortably furnished, with a homely environment created. The home is clean, pleasant and hygienic and one resident confirmed that this is always the case. EVIDENCE: The home is furnished and decorated to a high standard with a homely atmosphere achieved and this is complimented by domestic style lighting. There is a comfortable lounge/dining room on the ground floor and the central heating radiators throughout the home are guarded for residents’ safety. The home has one assisted bathroom on the ground floor and the conventional bathroom has been upgraded and changed into an assisted shower room. The inspector noted that a high standard has been achieved but recommended that DS0000065695.V302954.R01.S.doc Version 5.2 Page 17 the Fire Safety Officer be contacted to ensure he is satisfied with the completed work. Ms Curtis was reminded that in future when changes are made to the facilities within the home the Commission should be contacted for advise, guidance and agreement. There are nine single and one double bedroom available on the ground floor. It was evident that residents are encouraged to personalise their rooms with items of furniture and pictures and possessions from their former homes. Two bedrooms have en-suite WC’s and the remaining rooms are fitted with vanity units and washbasins. The first floor is accessed by staircase and a registered single bedroom on the first floor is currently being used as an office. The Fire Safety Officer visited the home in 2005 and made two recommendations, which were addressed by the previous owner. Residents regularly use the small-levelled garden at the side of the house and garden furniture and potted plants provide an attractive place to sit outside in the sunshine. One resident whose bedroom has a view of the garden said, ‘ Alison (Ms Curtis) put a beautiful hanging basket outside by the front door so I can see it’. As stated earlier the back garden is established on a steep slope with step access only therefore residents rarely use it. DS0000065695.V302954.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in the outcome area is adequate; this judgement has been made using available evidence including a visit to this service. The home is staffed each day by management, care and domestic workers to ensure that residents’ collective needs are met. Recruitment and employment practices designed to minimise the risk of unsuitable staff being employed have not been consistently implemented and associated record keeping is poor. A staff induction and training programme including NVQ training has been set up to ensure residents receive a good standard of care. EVIDENCE: There are 10 care staff employed to work in the home and five of them hold an NVQ level 2-care qualification. Ms Curtis said that four more staff would be registered with Weymouth College to undertake NVQ training courses shortly. A copy of the staff rota was supplied and demonstrates that there are always two staff on duty by day. At night there is one wakeful staff with Ms Curtis sleeping in on call. There are often three staff rostered for work during week day mornings and two at the weekends. Ms Curtis is currently working as part of the care team at weekends and is responsible for cooking the main meal at lunchtime on these days. DS0000065695.V302954.R01.S.doc Version 5.2 Page 19 The staff rota must make clear the times of the morning and afternoon shifts and the full name and designation of each staff member. The inspector discussed the need for Ms Curtis to be additional to the staff rota so that Ms Curtis gets time off if she is to continue sleeping in on call each night: until the appointment of the acting manager she has been working long hours and covering shortfalls. Although these arrangements seem adequate given that there are only 7 residents in the home the staffing arrangements should be reviewed, eg it may be pertinent to employ a part-time cook or additional senior care staff. Ms Curtis has actively recruited and employed new staff to ensure that residents are properly cared for. The home’s recruitment paperwork was disorganised and incomplete, eg only one written reference received, but POVAFirst and CRB checks had been applied for and received prior to employment. The home must be able to demonstrate that proper recruitment and employment practices are followed to ensure residents’ safety. A staff training pack (Red Cryer) has been purchased for use and is gradually being implemented with staff: an induction-training programme has been introduced for all new staff. Records evidenced that staff have been supplied with training in: health & safety, dealing with dementia in the elderly, moving & handling, fire safety, basic first aid and food hygiene training. DS0000065695.V302954.R01.S.doc Version 5.2 Page 20 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, 35 & 38 Quality in the outcome area is poor; this judgement has been made using available evidence including a visit to this service. The home’s acting manager is experienced in management and residential care and is intending to improve recording systems in the home. A quality assurance system has yet to be implemented. Resident’s financial interests are safeguarded. Practices that promote and safeguard the health, safety and welfare of service users and staff are generally followed but these need to be evidenced by proper records. DS0000065695.V302954.R01.S.doc Version 5.2 Page 21 EVIDENCE: Ms Curtis has been managing the home since the departure of the registered manager Mrs Kimmons, although she is undertaking NVQ 4 management & care training she does not have previous experience of working in a residential care setting. She has recently employed an acting manager with a view to them becoming registered in the near future. The acing manager has an appropriate management and care qualification and previously managed another care home in the area. Management tasks and duties have yet to be formally set out in the form of job descriptions to demonstrate how responsibilities are shared. A quality assurance system has yet to be implemented and the acting manager has drawn up service user questionnaires for this purpose. Residents’ personal allowances are managed by the home and individual records are kept. Ms Curtis pays expenses for other items; she then sends an invoice requesting payment from either the resident or their representative. Staff records showed that they are supplied with an induction programme but it was not clear if this meets the updated Skills for Care specifications. Staff supervision is informal and although staff meetings have been held there are no written records to evidence this: one member of staff confirmed they had attended a staff meeting. As staff records were disorganised the home was not able to evidence that all staff have up to date mandatory health & safety training in First aid, Manual handling, Fire safety, Infection control and Basic food hygiene. The acting manager has started to update the homes policies and procedures file. The homes fire record book indicated that the fire warning system had been serviced on 4/5/06 this highlighted that one fire door was not closing properly and Ms Curtis said she has arranged for this to be remedied by an electrician on 23/6/06.Ms Curtis said that the in-house checks of the fire fighting equipment and safety system are undertaken each week but there were no records kept to support this claim. Staff fire training records indicated that nine care staff were supplied with training in the past six months but it was not clear if night staff have three monthly training. There was no evidence to determine if a fire drill had taken place since January 2006. DS0000065695.V302954.R01.S.doc Version 5.2 Page 22 Records were available to demonstrate that equipment used in the home had been serviced: electrical items had been PAT tested on 30/6/06 and a clinical waste contract was se up with the council on 29/6/06. The home’s electrical system dated June 2005 noted evidence of DIY wiring in the airing cupboard and cables in the garage/cellar that should be clipped. It also noted that a main switch at meter position should control the whole electrical installation. Ms Curtis said that she has arranged for these problems to be put right but was not aware of this at the time she purchased the home. The home’s fire risk-assessment drawn up by the previous owner must be updated and include any alterations or improvements made to the home. DS0000065695.V302954.R01.S.doc Version 5.2 Page 23 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 2 9 1 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 1 DS0000065695.V302954.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Care plans and care related riskassessments must be updated when significant changes occur, eg following a fall. Accident records must include the action taken to prevent recurrence and Regulation 37 notifications must be sent to the Commission following any untoward accidents/incidents. The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received in the care home including: a) All staff that give medication must be trained and assessed as competent to do this. b) Having a system to ensure that medication is given and recorded correctly, including the dose given when a choice is prescribed, e.g. monitoring records and the audit trail. c) Having a system for ensuring that where there is a discrepancy between the dose on the medicine label and that on the MAR chart, or as directed DS0000065695.V302954.R01.S.doc Timescale for action 31/08/06 1. OP7 15 (2) 2. OP8 13 (4) (c) & 37 31/08/06 3. OP9 13 (2) 31/08/06 Version 5.2 Page 25 4. OP16 5. OP18 6. OP29 7. OP31 8. OP38 instructions or when the GP is asked to update the prescription. d) Recording the reason for when required medicines. e) Reviewing and updating the medicines policy (see guidance provided). (Previous timescale of 30/6/06 extended) A copy of the home’s complaints procedure must be supplied to 22 all residents and their representatives. The registered person must be able to evidence that all staff are 12 (1)(a) trained in the Protection of & 18 (c) Vulnerable Adults. (Previous timescale of 1/7/06 extended) The home must be able to demonstrate that a thorough recruitment and employment procedure is followed to ensure that residents are in safe hands at all times: associated Amended paperwork and records must be Regulation individually organised and 19 properly kept. (Previous requirement of ensuring that all recruitment records are in order including two valid references is repeated and the timescale of 1/5/06 is repeated). The Registered Person and manager must have clear roles of accountability: with 12 (1)(a) appropriate job descriptions documented. (Previous timescale of 1/7/06 extended) The home must be able to demonstrate that all staff have up to date mandatory health & 18 (2) safety training in: first aid, basic food hygiene, infection control, moving & handling and fire safety. DS0000065695.V302954.R01.S.doc 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 Version 5.2 Page 26 9. OP38 23 (4)(d) 10. OP38 23 (4) 11. OP38 13 (4) (c) 23 (4) The home must be able to evidence that all staff, including the Registered Person, have recorded fire training at intervals recommended by Dorset Fire and Rescue Service eg six monthly for day staff and three monthly for night staff. The registered person must be able to demonstrate that regular in-house testing and checks of the fire safety system are undertaken with written records kept. The home’s fire risk-assessment must be updated. 31/08/06 31/08/06 31/08/06 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 OP1 OP2 OP7 Good Practice Recommendations A statement of purpose and guide should be compiled and made available to residents and the Commission. Each resident should be supplied with a terms and conditions of residency agreement. Residents and/or their representatives should be asked to sign care plans and care records to demonstrate their involvement. The home should follow guidance from the Royal Pharmaceutical Society including: a) When medicines are handwritten on the MAR chart a second competent person should check the details are accurate and countersign. b) Each medicine should be given from the labelled container in which the pharmacy dispensed it and the person responsible for administering it must sign the MAR chart. They should not be prepared in advance for someone else to give. c) Monitoring and recording the maximum and minimum temperature of the refrigerator used to store medicines daily when in use (normal range 2-8(C). DS0000065695.V302954.R01.S.doc Version 5.2 Page 27 4. OP9 5. 6. 7. 8. 9. 10. 11. 12. OP16 OP19 OP27 OP29 OP30 OP32 OP33 OP38 d) Recording the date of opening or discard date (usually 4 weeks after the date of opening) for eye drops to prevent infection. This recommendation was partly met (points c & d have been addressed) on 4/7/06, but is repeated. A complaints record and logbook should be compiled and used in the home. The Fire Safety Officer should be informed about the changes made to the ground floor shower room to ensure he is satisfied with the completed works. The staffing arrangements for the home should be reviewed to ensure that Ms Curtis has appropriate time off and that there is adequate cover at weekends. Each member of staff should be supplied with a contract of employment and job description. The registered person must be able to evidence the training that has been supplied to staff. The Registered Person should arrange meetings with staff and service users. An effective quality assurance system should be established and implemented for the home. The recommendations set out in the home’s electrical certificate should be put right as planned. DS0000065695.V302954.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000065695.V302954.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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