Inspection on 21/09/07 for Close (The)

This inspection was carried out on 21st September 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

Close (The) 19/10/09

Close (The) 19/06/06

Close (The) 21/02/06

Close (The) 05/09/05

Close (The) 21/02/05

Close (The) 09/09/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Close (The) 20 North Avenue Ashbourne Derbyshire DE6 1EZ Lead Inspector Tony Barker Key Unannounced Inspection 21st September 2007 09:20 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 Close (The) DS0000019961.V341938.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. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Close (The) Address 20 North Avenue Ashbourne Derbyshire DE6 1EZ 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) (01335) 345228 01335 345228 bostockk4@aol.com Parwich Hospital Trust Mrs Donna Bradley Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th June 2006 Brief Description of the Service: The Close is a large detached Grade 2 listed Victorian house within a short distance of the town centre of Ashbourne. The internal structure of the Home retains many Victorian features such as high ceilings and tiled Minton floors. The Home has nine single bedrooms and three double bedrooms. There are no en-suite facilities. There are two lounges and a dining room. Outside there is an attractive garden area, which is accessible to residents. Support services are in place with a choice of General Practitioners, district nurses, chiropodist, dentist and optician. Other health professionals are accessed as required. Regular entertainment is organised and those service users who wish to go out do so. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 7.25 hours and was a key unannounced inspection. Three residents, the Manager and two care assistants were spoken to, records were inspected and there was a tour of the premises. Three residents were case tracked so as to determine the quality of service from their perspective. Survey forms were posted to residents and relatives and staff. Nine residents, three relatives and four staff returned their completed forms. The information supplied in this way was analysed before the inspection and the outcomes included in the inspection process and reflected in this report. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection, Annual Quality Assurance Assessment, questionnaire was reviewed prior to this inspection. A copy of the last inspection report, from the Commission for Social Care Inspection (CSCI), is available in the Manager’s office and can be made available to residents and visitors. The Home’s fees are currently between £360 and £390 per week. What the service does well: What has improved since the last inspection? What they could do better: Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 6 A comprehensive written assessment of need, of a prospective resident, must be provided where there is no care management needs assessment. A care plan must be drawn up for each resident, setting out in detail the action to be taken by care staff to meet the resident’s holistic needs. The administration of controlled drugs must be recorded in a dedicated Controlled Drugs Register. All care staff working at the Home must undertake further safeguarding adults training. All staff who handle food must be provided with Basic Food Hygiene training and there must be at least one first aid trained person in the Home at all times. 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. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals’ needs had been assessed before they were admitted to the Home so that their diversity of needs were identified, planned for and met. EVIDENCE: A self-funding resident, admitted in May 2007, was case tracked and their personal file was examined. The ‘Resident Assessment Form’ on this file was dated the day of admission and provided a very brief overview of the person’s needs. It did not meet the quality of needs assessment detailed in Standard 3.3. The Manager stated that she visits all prospective residents before admission, or makes telephone enquiries if the person lives a distance away, in order to make an assessment of need and assure herself that the Home can meet these needs. She accepted that there was no record of these preadmission assessments. There was evidence, at the previous inspection, of care managers’ assessments being in place prior to prospective residents’ admission. Also, records of initial assessments of need were being reviewed and up dated. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 9 All residents who responded to the pre-inspection postal survey felt they had received enough information about the Home before they moved in. They also all felt they were receiving the care and support they need. One stated, “I have been very well looked after”. Similarly, all relatives surveyed felt the Home meets the needs of the resident. One spoke of, “the high standard of care and devoted attitudes of the staff” and another felt that the Home met the needs of their relative, “probably as near as is humanly possible...The Close is a genuine home”. The Home was not providing intermediate care. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had individual care assessments recorded which demonstrated that their health, personal and social care needs were being fully considered. They were being treated with respect and their right to privacy was upheld. EVIDENCE: The three case tracked service users’ files examined contained their personal photograph and entries were signed and dated. There were a very good range of holistic assessments but these were not actual care plans: there were few goals or actions for staff to take in order to meet individuals’ needs. This could give rise to inconsistent treatment by staff and make measurement of progress difficult. Senior care staff were completing weekly review sheets and these contained some action points such as ‘monitor and report’ and ‘continue care’ although these were not particularly person centred. Recorded care assessments addressed a very good range of person-centred matters such as preferred time of bath, bedtime drink and time of retiring as well as food and drink likes and dislikes and favourite activities, music and television programmes. There were no personal histories on file although there was Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 11 evidence of this being planned. Residents were involved in the preparation of their care assessments, as evidenced by their signatures, but they were not involved in the six-monthly in-house reviews undertaken by the Manager. She spoke of plans to hold formal annual review meetings of the care provided to self-funding residents. These would include the resident and relatives and would bring the Home’s review procedures in line with those who have a care manager from the local authority. Daily Communication Sheets were mainly health related and not holistic like the care assessment sheets. The Inspector spoke to the Manager about the benefits of linking the Daily Communication Sheets to holistic care plan goals so that staff became more proactive in their work. Records of contact with health professionals were well recorded on service users’ files and included ‘Purpose’ and ‘Observation’. Residents’ dependency levels were recorded and were being kept up to date. Risk assessments were in place for moving & handling, nutrition and tissue viability and there were general recorded risk assessments. One case tracked resident’s tissue viability risk assessment showed a risk of developing pressure sores and preventative action was recorded. However, neither daily notes nor weekly review sheets were being used to record any action taken. There were no risk assessments to address residents’ risk of falling although the Manager said these used to be used. Risk assessments and other health records were being kept up to date. Medicines, including controlled drugs, were being securely stored. Photographs of residents were in place beside Medication Administration Record (MAR) sheets. These MAR sheets were satisfactory except that there were two examples of no staff signatures against hand written entries. The administration of controlled drugs was being recorded on MAR sheets. It was explained to the Manager that, as from August 2007, the recording of controlled drugs must now be made in a dedicated Controlled Drugs Register. The Manager stated that staff had received training in the safe use of medicines although there were no records to support this. However, the two care staff spoken to did confirm they had been provided with this training. A medicines policy was in place. One resident told the Inspector how staff always knock on bedroom doors before entering. The person went on to say that staff speak respectfully to residents and they are “kind and patient”. The resident said that there was a good laundry system and the person’s clothes were seen to be well ironed. Care staff spoken to gave examples of how they ensure residents’ privacy and dignity needs are met – for example, by making sure that they are fully clothed while moving between bedroom and bathroom. Staff stay in the shower room with residents but make use of the shower curtain when they are not actively helping the resident. One resident said, in their completed postal survey, “I am completely dependent on the staff, all of whom are very helpful”. During a tour of the building one shared bedroom was seen and screening was provided around the beds to ensure that privacy could be maintained when Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 12 personal care was provided or at any other time. Private telephone lines or access to a telephone was available to all residents at the Home. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 13 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. Activities were provided at the Home that generally benefited residents. The Home encouraged family contact and provided residents with meals which were varied and which they enjoyed. EVIDENCE: A range of activities were available to residents and notices were displayed of forthcoming events. The Home provided three musical shows a year, a Christmas party, a visit to a pantomime and monthly visiting entertainment. The Manager said there were usually two outings each summer and she was planning to increase these. A number of residents spoke positively about a recent trip to Twycross Zoo. Residents who were surveyed confirmed that there were activities they could take part in but a number said they chose not to. Some staff surveyed and spoken to felt residents would benefit from more activities and outings, adding that staff were usually very busy. The Manager said she was working to achieve more outings. She said only three or four residents become involved in activities and it is hard to motivate the others. She added that a Motivator (activities co-ordinator) had been employed in the past and she would consider again. Residents spoken to were satisfied with their quality of life. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 14 A full visitors book confirmed the frequency of visitors to the Home and the Inspector noted a number on the day of this inspection. The Manager said most residents have regular visitors and one resident who was spoken to confirmed this and said their relatives could stay for as long as they liked. The Manager spoke of a biannual newsletter which aims to inform relatives about the Home’s activities and motivate them to become involved. She said there had been a cheese and wine ‘do’ early in 2007 and an open day in May 2007 that had included an exhibition of one resident’s art work. A bonfire party is planned this year, the Manager added, and she hoped that relatives and members of the local community would visit then. One resident pointed out the items of personal furniture they had brought into the Home and it was clearly the Home’s policy to allow this. The Manager stated that advocates are available to residents if they should wish for this service. She spoke of the SAGA and Care Aware organisations having been contacted in the past and said that relatives have rung the latter for advice over the telephone. The Home’s dining area was attractively laid out. Residents were observed eating lunch and those spoken to were very positive about the Home’s food. The rolling four-week menu was examined and it was found to offer residents a varied and nutritious diet. There was a displayed day’s menu by the kitchen. A visit was made to the kitchen and foodstocks were at a good level. There was evidence of fresh fruit and home baking. A record of food eaten was being made. Staff spoken to said breakfast time was flexible and residents could choose to have meals in their bedroom, adding that three do. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 15 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. Procedures for handling complaints and abuse were in place ensuring residents were protected. EVIDENCE: The Home had a well-worded complaints procedure that was displayed in the entrance hall. Two formal complaints had been received within the previous 12 months. These had been well addressed and recorded. All residents and relatives who responded to the postal survey knew who to speak to if they were not happy and all residents felt that staff listen to them and act on what they say. One relative said, in the postal survey, “Any concerns I have are usually dealt with quickly”. The majority of staff had not undertaken Safeguarding Adults training within the previous three years, although the Manager stated that further training was planned. The Home’s Safeguarding Adults procedure was examined. This did not clearly state the need to refer matters related to abuse to the local Social Services Department straight away. Also it referred to undertaking an investigation and did not make clear that this should not take place without approval from a Safeguarding Adults Strategy Meeting. This was fully discussed with the Manager. The Derbyshire Safeguarding Adults procedures and referral forms were available. The Home’s Whistle Blowing policy was satisfactory although both care staff spoken to said they had not seen it. However, they had a clear understanding of safe practice on this matter. Close (The) DS0000019961.V341938.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. 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 were living in a safe and comfortable environment, that was clean and hygienic. EVIDENCE: There was a high and tasteful standard of decoration and furnishings within the Home. Wall pictures in most areas also helped to create an attractive environment. Improvements to the Home, within the last 12 months, had included provision of a level access shower, an additional toilet, an additional corridor handrail and a ramp. The Manager spoke of plans to improve the ground floor bathing facility through the provision of a rising bath. An occupational therapist had visited the Home in 2004 to undertake a full environmental assessment. Recommendations had been made as to how the environment could be improved to meet the needs of disabled residents and all these had been met. Several bedrooms were viewed, including one shared Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 17 room, and these were nicely personalised. There was an attractive rear garden. The premises were clean and hygienic, with no unpleasant odours. The washing machine had a sluicing cycle and there was a sluicing sink. The care assistants spoken to described good infection control practices and it was noted that half of the staff group had been provided with Infection Control training. An Infection Control policy was in place although this could be more detailed. The Manager said this was in hand. Residents who responded to the postal survey confirmed that the Home was always fresh and clean. One said the Home was, “kept marvellously clean by two hardworking staff”. Close (The) DS0000019961.V341938.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home’s staff training fell short of fully safeguarding the welfare of service users. EVIDENCE: The staffing rotas were examined and these indicated that staffing levels were adequate. The residents who responded to the postal survey said that staff were available when they were needed. A staff ‘photo board’ had been provided for residents’ and visitors’ use. The completed pre-inspection, Annual Quality Assurance Assessment, questionnaire showed that 60 of care staff had achieved a National Vocational Qualification (NVQ) in Care at level 2. This met the 50 level required by the National Minimum Standards. The file of a recently appointed member of staff was examined. Matters relating to her recruitment were satisfactory, except that the Home’s job application form did not ask the applicant to provide details of... • ‘any criminal offences in respect of which (s)he has been cautioned by a constable and which, at the time the caution was given, (s)he admitted’, as required by Schedule 2 of the Regulations and • any mental health problems. Criminal Records Bureau (CRB) checks were all in place. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 19 The Manager stated that all staff had been provided with mandatory training in Fire Safety and Moving & Handling but only 50 of staff had received Basic Food Hygiene training and no staff had received First Aid training within the previous three years. There was no ’at a glance’ training matrix available for quick confirmation of this. The Manager stated that most staff had completed a training course on Dementia. The care assistants spoken to confirmed they had attended a number of training courses over the previous 12 months and were both undertaking training to ‘Skills for Care Common Induction Standards’. The Manager confirmed that all staff were currently undertaking this particular training. The Inspector noted there was a dedicated staff training room at the Home. Close (The) DS0000019961.V341938.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. 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 was well managed so that residents were protected and their best interests were promoted by the systems in place. EVIDENCE: The Manager said that she had attained a qualification in ‘Care’ and in Management to NVQ Level 4 and had 20 years experience of working with older people. Staff spoken to referred to the Home as having a “homely and friendly atmosphere” and the Inspector confirmed this during this inspection. They felt it was a “nice place to work” and the Manager “is very approachable”. Other aspects of Standard 32 were not assessed on this occasion. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 21 Records of the monthly, unannounced audit visits to the Home, undertaken on behalf of the registered provider, were examined and found to be very satisfactory. The Home’s Annual Improvement Plan for 2007/8 was examined and was found to be satisfactory. Satisfaction questionnaires had been recently sent to residents’ relatives and these had been returned with positive comments. A positive response to a satisfaction questionnaire was also seen from a care manager. Residents’ Meetings were held annually and there was a biannual newsletter. Staff said they had staff meetings every few months. The Home had a policy of not handling residents’ monies. The accounts of money loaned to residents and received back from relatives were with the accountants, the Manager stated. Cleaning materials were being safely stored in the cellar. Product Information Sheets, required by the Control Of Substances Hazardous to Health (COSHH) Regulations, were also in place in the cellar, laundry and kitchen. The completed pre-inspection, Annual Quality Assurance Assessment, questionnaire showed that equipment was being checked and maintained appropriately. Good food hygiene practices were being followed. Environmental risk assessments were in place and last reviewed in 2004. The Manager said that staff are expected to complete a Risk Management Reporting Form, together with a risk rating, when they identify a hazard in the Home. She stated that half of the staff group were provided with Health & Safety training in 2005. Fire drills were being carried out twice a year. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 22 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 2 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 23 No 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. Standard OP3 Regulation 14(1)(b) Requirement A comprehensive written assessment of need, of a prospective resident, must be provided where there is no care management needs assessment. This will ensure that care plans are clearly based on this assessment and reflect individuals’ needs. A care plan must be drawn up for each resident, setting out in detail the action to be taken by care staff to meet the resident’s holistic needs. The administration of controlled drugs must be recorded in a dedicated Controlled Drugs Register to ensure the health and safety of service users. All care staff working at the Home must undertake further safeguarding adults training in order to protect resident’s welfare. All staff who handle food must be provided with Basic Food Hygiene training to ensure the health and safety of service users is not compromised. DS0000019961.V341938.R01.S.doc Timescale for action 01/11/07 2. OP7 15(1) 01/01/08 3. OP9 13(2) 01/11/07 4. OP18 13(6) 01/01/08 5. OP30 13(3) 01/01/08 Close (The) Version 5.2 Page 24 6. OP30 13(4) There must be at least one first aid trained person in the Home at all times, to make sure that service users receive appropriate treatment in an accident. 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Refer to Standard OP7 OP7 OP7 OP8 OP8 OP9 OP12 OP18 OP26 OP29 Good Practice Recommendations Residents should be involved in the six-monthly in-house reviews undertaken by the Manager. The Manager should carry out her plans to hold formal annual review meetings of the care provided to selffunding residents. Daily Communication Sheets should be linked to holistic care plan goals so that staff became more proactive in their daily work. Daily notes or weekly review sheets should be used to record any action taken based on risk assessments. Risk assessments should be in place to address residents’ risk of falling. Handwritten entries on medicine records should be accompanied by two staff signatures and the date, to ensure a clear audit trail. The employment of a Motivator (activities co-ordinator) should be considered again Staff should be reminded about the Home’s ‘Whistle Blowing’ policy. It should be displayed prominently for staff attention. All staff should be provided with Infection Control training. The Home’s job application form should ask the applicant to provide details of • ‘any criminal offences in respect of which (s)he has been cautioned by a constable and which, at the time the caution was given, (s)he admitted’ and • any mental health problems. An ’at a glance’ staff training matrix should developed. The opinions of residents should be sought more frequently through an increased frequency of residents’ meetings and/or satisfaction surveys. DS0000019961.V341938.R01.S.doc Version 5.2 Page 25 11. 12. OP30 OP33 Close (The) 13. OP38 Environmental risk assessments should be reviewed at least annually. Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Close (The) DS0000019961.V341938.R01.S.doc Version 5.2 Page 27 - 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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