Inspection on 10/01/07 for Cliffe Vale

This inspection was carried out on 10th January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cliffe Vale 14/12/07

Cliffe Vale 01/02/06

Cliffe Vale 26/07/05

Cliffe Vale 26/01/05

Cliffe Vale 06/09/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Cliffe Vale 228 Bradford Road Shipley West Yorkshire BD18 3AN Lead Inspector Paula McCloy Key Unannounced Inspection 10th January 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 Cliffe Vale DS0000048525.V315911.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. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cliffe Vale Address 228 Bradford Road Shipley West Yorkshire BD18 3AN 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) 01274 583380 Cliffe Vale Registered Care Home Ltd Mrs Rita Christine Williams Care Home 27 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (23), of places Physical disability (1), Physical disability over 65 years of age (3) Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Cliffe Vale is located on a main bus route that goes from Shipley to Bradford. It is close to local shops. This detached property provides accommodation on ground, first and second floors. Access between floors is by stair lifts. There are three separate communal areas, including two lounge/dining rooms. Patio areas are available for service users outside. Parking is available. The majority of service users are elderly, a number may have physical and mental health needs. The current weekly charge at the home is £367.22. This charge does not include chiropody, hairdressing, private dental, optical or medical fees, newspapers, meals out or telephone calls. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection of the home took place on 1 February 2006. There have been no further visits to the home until this key inspection. This inspection was carried out to assess the home against a pre-determined selection of the National Minimum Standards for Older People and to check what progress had been made on meeting the requirements from the previous inspection visits. One inspector carried out the inspection over 1 day and spent approximately 7 hours in the home. The methods used in this inspection included discussions with 5 residents, 2 members of care staff, the assistant manager, observation of care practice, examination of records, and a partial tour of the home. A pre-inspection questionnaire was sent to the home prior to this visit asking for information. This questionnaire was returned. Comment cards were sent to residents and relatives; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are shared with the provider without revealing the identity of those completing them. Twenty residents and nineteen relatives wrote to the inspector with their comments. Information from these comment cards has been used in this report. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A freestanding radiator that was presenting a risk has been removed. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cliffe Vale DS0000048525.V315911.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 Cliffe Vale DS0000048525.V315911.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5 (standard 6 does not apply). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide gives all residents details of the services the home provides. Prospective residents and/or their representatives are also encouraged to visit the home so they can make an informed decision about admission to the home. All prospective residents are assessed before admission to make sure that staff can meet their needs. Residents are given a written statement of terms and conditions of residence document, which tells them in detail about the fees and any extra charges. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 10 EVIDENCE: The statement of purpose and service user guide are available from the home. These documents contain a lot of information about the home and the service that is provided. One relative said that they had been to look around the home before they decided to let their mother move in and that their mother had spent a trial day at the home. One resident said they had visited the home before they decided to move in. Twenty residents said that they had received enough information about the home before they decided to go and live there. Individual records are kept for each resident. The records for the most recently admitted resident showed that staff from the home had completed an assessment of their needs before they had been admitted. This means that staff at the home are sure they can meet residents needs before they are admitted. It would be helpful if the assessment document also contained information about the residents social interests, hobbies, religious and cultural needs together with details of family involvement and other social contacts. This will then give staff the information they need to plan for residents’ social care. Residents are issued with a contract/terms and conditions of residence document when they move into the home. All twenty residents that completed surveys said that they had received this document. The terms and conditions of residence document contains information about the fees payable, what is and is not included in the fees, the complaints procedure and periods of notice. It also states that residents will be given their room number on admission and that if a resident needs to change rooms this will not be done without discussion with the resident and their representative. The deputy manager agreed that the room number will also be included on this document in the future. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff need to make sure that the written care plans accurately reflect the care and support they are offering to residents. This will make sure that residents receive consistent care. EVIDENCE: Three care plans for residents were examined. There was no care plan in place for the most recently admitted resident, even though she has lived at the home for 3 weeks. The other two care plans contained assessment information that identified the areas each individual resident needed support with. There were no actual care plans that described in more detail how this support would be delivered. For example on one resident’s plan it was noted that they had a continence problem. There was no detailed plan about a toileting regime or if pads were required. For another resident it had been Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 12 noted that she could be verbally aggressive. There were no details recorded about the strategies staff should use with this resident. Staff are identifying residents needs and are taking appropriate action. For example they know that one resident, who is a diabetic, will often refuse meals and staff save his meal and offer it to him later but there is no formal care plan that addresses this particular need. Care plans do not contain all of the necessary assessments. Two of the care plans did not have risk assessments regarding nutrition, continence, or development of pressure sores. The third care plan did not have a nutritional assessment. One resident had a sore ankle staff took appropriate action and contacted the district nurse. She advised that a pressure relieving mattress was put on the bed. This was done the same day. The care plan doesn’t contain any information about this resident being at risk of developing pressure sores. All of the care plans contained details of residents moving and handling needs and how staff should give support. One resident said that she had been frightened when a male resident entered her bedroom at night. She had ‘buzzed’ for the night staff and the male resident left her room. Since that time staff have been locking her bedroom door and details about this have been recorded in the daily records but not on the care plan. The male resident concerned frequently leaves his bedroom at night. Staff need to complete a risk assessment in relation to this and look at the ways night staff can monitor his whereabouts so that he is not entering other residents’ bedrooms. Staff need to make sure that care plans are detailed and reflect the care and support they are offering. They also need to make sure that an initial care plan is completed for any new residents from the assessment information they have gathered before the resident is admitted to the home. Staff know residents well and are able to talk about their past life and personal preferences. This information needs to be written down and added to the care plans. This will mean that all staff will have access to valuable information about individual residents past lives and their likes and dislikes. No life histories were available on the care plans that were examined in detail, but were in place for other residents living in the home. Residents’ care and support needs are being reviewed monthly. There was some evidence that residents are involved in the review of their care. One resident had asked for her eye drops to be given at a certain time and that she wanted to get up earlier in the mornings. Staff had made sure that these requests were put into practice. Eighteen relatives said that they are kept informed about their relatives’ well being and are consulted about their care. Residents’ health care needs are being identified and met. Staff are vigilant and health care professionals are being involved as necessary. There was clear evidence of GPs, chiropodists and opticians being involved in the ongoing care of individual residents. Twenty residents confirmed that they receive the care and medical support they need. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 13 The medication records showed that residents are getting their medication at the right times and staff are signing the records consistently. All as required medication is documented together with a reducing balance so that it is very easy to established how much medication is in stock. At the moment when medication is received into the home, staff are checking the dosette boxes but not recording the date, how much medication has been received or signing the medication administration records to show this. Staff also said that when medication is either stopped or when new medication is prescribed they are removing or adding tablets to the dosette boxes. The dispensing pharmacist must do any changes to medication in the dosette boxes so that there is no margin for error. Cliffe Vale DS0000048525.V315911.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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ preferences in relation to daily routines are respected. Staff need to make sure that residents are offered both individual and group activities to keep them stimulated. Relatives and friends feel welcome to visit at any time. Meals at the home are good and food is always available. EVIDENCE: Residents are able to follow their own routines. Residents are able to get up and go to bed when they wish. From observation residents were getting up at various times during the morning and then were served breakfast. The daily records showed that at night residents that wanted to get up and have a drink or something to eat were able to do so. Staff were able to talk about Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 15 individual residents preferences and likes and dislikes. It would be helpful if this information was written down in individual residents care plans. The care staff try and organise activities in the afternoons. On this visit some residents were involved in playing dominoes and others in a sing-song. The provision of activities was one area that residents and relatives both felt could be improved upon. Currently the care plans contain very little information about the social needs of residents. Staff need to talk to residents about what they would like to do either as part of a group or individually and include this in their care plan. They also need to record what activities residents have been involved in to make sure that individual needs in this area are being met. For example one relative said that her mother would like to go out more often. Staff need to find out where she would like to go and then arrange for this to happen. Relatives said that they are made to feel welcome when they visit and that they can see their relative in private. Relatives are able to stay for a meal if they wish. Residents’ birthdays are celebrated and a birthday buffet tea is arranged. There is a choice of meal available at breakfast and teatime. At lunchtime there is a set meal but the cook will prepare something else if a resident doesn’t like what is on offer. Residents said that the food was good. At lunchtime the dining tables were nicely set and the meal was relaxed and unhurried. Cliffe Vale DS0000048525.V315911.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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system and complaints that have been made have been resolved. Staff have a good understanding of adult protection issues which protect residents from any abuse. EVIDENCE: The complaints procedure is well publicised. It is in the service user guide and on display in the home. The home keeps a complaints log. No complaints have been recorded since December 2004. The issue of recording complaints and concerns was discussed at the inspection with the assistant manager. Documenting any concerns or complaints that are made together with the action taken and outcome is helpful to make sure that any concerns and complaints are dealt with properly. There was evidence on the daily records of concerns being raised and addressed by staff. Residents and relatives said that if they had any concerns that they would feel able to raise these with the manager or one of the senior staff and that they felt confident that any problems would be sorted out. One relative said that any problems, such as items of clothing going missing, are dealt with excellently. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 17 The local adult protection procedures were available in the home. All staff spoken to had received training and were able to talk about what they would do if they felt any practices in the home were not in the best interest of the service user. Cliffe Vale DS0000048525.V315911.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): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, safe, comfortable, well maintained home. EVIDENCE: The home is located on the main Bradford Road going into Shipley. There are local shops close by. There is some car parking at the side of the building or on the road. The last inspection from environmental health took place in May 2006 when some requirements were made about hazard analysis and cleaning. The assistant manager said that the environmental health officer had visited again in June 2006 and that they were happy with the improvements that had been made. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 19 The home was clean and tidy on the day of the inspection. Nineteen residents said that the home is always fresh and clean. One relative said ‘the home is kept spotlessly clean’ and another ‘my relatives room is kept beautifully clean and smells fresh.’ There are infection control procedures in place. There have been no infection control issues at the home since the last inspection. The home was very hot on this visit and a number of residents were sleeping. The temperature of the lounges needs to be monitored and kept at around 21°C, if the rooms are too hot this may make residents sleepy. The laundry is well equipped, clean and tidy. The required ‘non return’ valves are in place on the washing machines. Cliffe Vale DS0000048525.V315911.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): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough staff on duty to meet residents needs. Staff are receiving appropriate training to meet service users needs. Any new staff are thoroughly checked to ensure that they are suitable to work with older people. EVIDENCE: The duty rotas were examined. There are 3 care assistants on duty from 8am – 10pm, one of whom is always a senior. There are also two managers who work supernumerary to the rota, Monday to Friday. At night there are two waking night care assistants on duty and the managers are ‘on call’ from their own homes. There is also cook and domestic cover everyday. The assistant manager said that two staff had recently left the home without giving any notice. Staff are doing their best to cover the shifts, whilst the home tries to recruit new staff. All of the care shifts are being covered but there are some days when there is no domestic in the home. The assistant manager was confident that the vacant posts will be filled as soon as possible. One relative commented that ‘the staff don’t leave very often so you get a continuity of excellent care.’ Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 21 Five residents and five relatives said that they didn’t think there were always enough staff on duty. One relative said ‘Sometimes as residents health deteriorates another helper would ease the burden on staff.’ The assistant manager is aware of the need to keep staffing levels under review as residents needs change. The two members of care staff spoken to felt that they were working well as a team and that they enjoyed coming to work. They also said that they thought there were enough staff on duty to meet residents needs. Agency staff are not being used by the home. There are 16 care staff working at the home. Six have completed their NVQ level 2 awards in care. This means that 37.5 of the staff team are qualified. A further 2 care staff need to be qualified if the home is to reach the standard of having 50 of its care staff qualified. Six more care staff have enrolled for NVQ training. The recruitment files for the two most recently recruited members of staff were examined. Application forms had been completed and medical questionnaires. There were two written references and one criminal records bureau check. For one member of staff a criminal records bureau check has been applied for but has not been received. This member of staff has been checked against the protection of vulnerable adults list and is working under the supervision of other staff until the full criminal records bureau check is received. New staff are given an employees handbook but neither of these new members of staff had been given any terms and conditions of employment. Staff confirmed that they are offered training. The home has an induction training checklist that is completed with new staff. Discussion took place with the assistant manager about using the ‘skills for care’ induction and foundation training with new staff. This is currently not in use. Cliffe Vale DS0000048525.V315911.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): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the residents. Practices in the home promote the health, safety and welfare of the residents. EVIDENCE: Cliffe Vale is a family owned and managed home. One of the owners is the registered manager and another member of the family is the assistant manager. At the time of this visit the registered manager was absent due to illness. The assistant manager has completed her NVQ level 4 and registered managers award. She said that discussions were taking place regarding her Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 23 applying to be the registered manager. If the decision is made for the assistant manager to take over she will have to make an application for registration to the Commission for Social Care Inspection’s central registrations team. The manager does hold money on behalf of residents. The records examined were well maintained and accurate. Residents and relatives are consulted about the running of the home via the twice yearly quality assurance questionnaires. The last survey was done in July 2006. The assistant manager said that when they get the survey information back they look at any issues that have been raised and then take any action that is necessary. Following the next survey the managers needs to publish the results so that everyone concerned is informed about the results and any action the home is taking to address any issues raised. One relative said ‘everyone seems to have the residents best interests at heart.’ The manager does hold money on behalf of residents. The records examined were well maintained and accurate. On the survey information one resident was concerned that they did not have any money. The assistant manager said that this was in the process of being sorted out with the court of protection. There is a written Health and Safety policy. Staff receive moving and handling, food hygiene, fire safety, health and safety, first aid and infection control training. The fire alarms are tested weekly and records of these tests are maintained. The stair lift and moving and handling equipment service records were all seen and were up to date. The gas safety and electrical installation certificates were seen and were up to date. During the inspection staff were seen moving two residents in wheelchairs without the footplates in place. Staff must make sure that footplates are used, unless there is a risk assessment to the contrary, to prevent injury to residents. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 25 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 15 Requirement Individual care plans must be more detailed. They must clearly set out the identified need of the resident and detailed information about the action staff need to take to make sure that need is met. Staff must make sure that residents risk assessments are up to date and that these detail the action that staff need to take to reduce any identified risk to individual residents. Staff must make sure that nutritional risk assessments and risk assessments in relation to the development of pressure sores are completed and kept under review. Staff must make sure that they document all medication that is received into the home detailing the date, amount of medication received and the person taking receipt of the medication. These details need to be recorded on the medication administration record. Any additions or removal of DS0000048525.V315911.R01.S.doc Timescale for action 31/03/07 2 OP7 13 28/02/07 3 OP8 14 28/02/07 4 OP9 13 14/02/07 5 Cliffe Vale OP9 13 14/02/07 Page 26 Version 5.2 6 OP12 16 7 8 OP28 OP33 18 24 9 OP38 13 medication to the dosette boxes must be the responsibility of the dispensing pharmacist. Staff must develop care plans that identify residents’ social needs and plan suitable activities to meet these needs. NVQ level 2 training for care staff must continue so that there are 50 of staff qualified. The results of the quality assurance surveys that staff send to residents and relatives must be published and made available. Staff must make sure that footplates are in place and used on wheelchairs when transferring residents. 31/03/07 31/07/07 31/07/07 31/01/07 No. 1 2 Refer to Standard OP29 OP30 Good Practice Recommendations All staff should be given a terms and conditions of employment document. All new staff should receive induction and foundation training that meets the Skills for Care criteria. Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cliffe Vale DS0000048525.V315911.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!