Inspection on 13/04/06 for Cloyda

This inspection was carried out on 13th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Cloyda 27/11/07

Cloyda 10/05/07

Cloyda 01/08/06

Cloyda 15/09/05

Cloyda 26/04/05

Cloyda 01/11/04

Cloyda 12/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Cloyda 227 Malden Road New Malden Surrey KT3 6AG Lead Inspector `Diane Thackrah Key Unannounced Inspection 13th April 2006 10:45 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 Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cloyda Address 227 Malden Road New Malden Surrey KT3 6AG 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) 020 8949 1839 020 8949 1839 Mr Vallabhbhai Morarbhai Patel Mrs Dahiben Vallabhbhai Patel Mrs Avril Smith Care Home 35 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (25) of places Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: Cloyda is a residential care home registered with the Commission for Social Care Inspection to provide care for up to thirty five people over the age of sixty five, ten of which may have a diagnosis of dementia. The home is a large detached property, located on a main road close to the centre of New Malden. There is easy access to the A3 and to public transport. Accommodation is provided over three floors, all of which can be accessed by passenger lift. There is a large garden to the rear of the property. Copies of the home’s Statement of Purpose and Service User Guide can be obtained from the Registered Providers on request, as can a copy of the Commission for Social Care Inspection’s most recent inspection report. Fees at the time of writing range between £406 - £510 and there are no additional charges. , Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 13th April 2006 between 10.45 and 16.20. A partial tour of the premises took place and care records were examined. The Registered Provider, Registered Manager, Deputy Manager and two staff members were spoken with. Three service users also gave their views on the home. Some service users living in the home do not have the mental capacity to share their views regarding their care. Observations of care practices and interactions with staff members occurred in order to make judgements about the care that these service users received. One visitor was spoken with. What the service does well: What has improved since the last inspection? Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 6 Of the 22 Requirements made at the last inspection of the home, 12 have been met. All service users now have an up to date moving and handling risk assessment and there have been improvements in the way that medication is handled. At the last inspection, one service user did not have suitable storage space for their clothing; this issue has now been rectified. There have been improvements in reporting incidents and accidents that occur in the home, the relevant authorities are now notified of incidents to ensure that the wellbeing of service users is protected. Some environmental improvements have occurred including the replacing of carpets and the redecoration of a small lounge. Improvements to health and safety arrangements have occurred including the testing of all electrical appliances in the home and the testing of the fire system. Risk assessments have been compiled in relation to the use of hazardous substances and to fire safety. 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. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 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 Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 6. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for planning care are good for ensuring that the health, personal and social care needs of people living in the home are met. EVIDENCE: National Minimum Standard 3 was assessed as being met at the last inspection of the home and as there have been no changes regarding needs assessments in the home, it remains that it is considered met. A recommendation was made at the last inspection of the home regarding the need to monitor the effectiveness of communication between service users and staff members. No concerns have been raised regarding this issue since the last inspection of the home, and no problems were highlighted during this inspection. The home does not provide intermediate care. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 9 Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 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 this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for planning care are good for ensuring that the health, personal and social care needs of people living in the home are met. The home, in general provides care that ensures that the care and health needs of service user are met. There continues to be a need to ensure that all interactions between service users and health and care professionals are documented. Failures to ensure this may result in some service user’s needs not being met. There have been improvements in the handling of medication in the home. Practices now promote the wellbeing of service users. There have been improvements in care practice, which now ensure that service users are treated with respect and have their dignity upheld. EVIDENCE: Not all service users’s had a risk assessment in relation to moving and handling at the last inspection of the home. The Registered Manager said that all service users now do have such an assessment and three care plans Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 11 examined supported this. Care plans examined contained additional risk assessments and had been signed by a representative of the service user. There were records detailing that the Registered Manager reviews care plans at least monthly. There was also documentation detailing that one service user had had a yearly review conducted by their placing authority. There were records detailing that each service user has their weight monitored monthly. A community nurse was visiting one service user in the home at the time of this inspection and there were records detailing that community nurses see other service users. The relative of one service user said that the home had been good at ensuring that their relative received health care treatment for their eyesight and that they had been consulted with about how health care would be provided. There was very limited information in one service user’s daily notes, for one month there were only three entries. There were letters detailing that this service user had two hospital appointments during this month, but there were no records detailing the outcome of these appointments. The Registered Manager said that these appointments had been cancelled following consultation with the service user’s family members however, this information was not recorded. A concern was raised at the last inspection of the home about the quality of record keeping in relation to health care. There must be clear records detailing all consultation with family members and health and social care professionals regarding each service user in the home. A repeat Requirement is made regarding this. There have been improvements in the way that medication is handled in the home. Three Requirements were made at the last inspection regarding poor practice in medication handling and these have now all been met. All medication seen was stored securely and within it’s ‘sell by’ date and the allergy section had been completed on Medication Administration Records. Ten members of staff have attended training in ‘Care and Control of Medication’ Certificates of attendance of this training were available in the home. The Registered Manager said that there had been an inspection of medication systems in the home by the local Primary Care Trust in December 2005. A report provided by the Registered Manager in relation to this inspection detailed that; in general, there were good policies and procedures for handling medication in the home. One care practice issue highlighted at the last inspection put into question the home’s ability to promote the dignity of service users. Action has been taken to address this area of concern and Standard 10 is now considered met. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 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. National Minimum Standards 12, 13 and 14 were assessed as being met at the last two inspections of the home and as there have been no changes regarding these Standards in the home, it remains that they are considered met. In general, service users receive a varied, wholesome and nutritional diet that meets their preferences, however, there are some practices in relation to food hygiene, choice of meal and settings for meals that do not promote the well being of service users. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users were observed to be enjoying the lunch of chicken casserole and fresh vegetables that was served at the time of this inspection. Service user’s spoken with said that the meal was “Very nice”, and “Lovely” There is a large dining room that has recently been refurbished where most service users eat their meals. Other service users sit in a smaller lounge. At the last inspection of the home a recommendation was made that there is provision of tablecloths, condiments, table decorations or other homely touches in this smaller dining area in order to provide a more congenial setting. It was disappointing to note that no action has been taken to address this Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 13 recommendation, and service users continue to eat in an environment without these homely touches. It is strongly recommended that action be taken to address this issue. The Registered Manager said that there is always a choice of meals for service users, however, the menu board in the dining room did not display a choice. There should be a menu, offering a choice of meals in written or other format to suit the capacities of all service users, which is given, read or explained to service users. There were poor hygiene standards in the kitchen. This is considered in more detail under Standard 26 of this report. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 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 and 18. National Minimum Standard 16 was assessed as being met at the last inspection of the home and as there have been no changes regarding complaints in the home, it remains that it is considered met. There have been improvements in the procedures for reporting incidents that occur in the home, this ensures that the well being of service users is promoted and protected. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The Registered Manager has demonstrated an awareness of her responsibility for reporting incidents and accidents that occur in the home, to the relevant authorities. Correct procedures have been followed since concerns were raised regarding this issue at the last inspection of the home. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 15 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, 20, 21, 24, 25 and 26. Some improvements to the environment have been made. However, there remain a number of serious matters of concern which put people at risk of harm and do not provide safe, homely and comfortable surroundings in which to live. There are poor hygiene standards throughout the home that place service users health, safety and wellbeing at risk. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Carpeting and flooring has been replaced in some areas of the home in line with Requirements made at the last inspection. A small lounge in the home has been repainted. However, the home was found to be in a poor state of Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 16 repair in some areas, unhygienic in some areas and in breach of some fire regulations. Requirements made during the last inspection that remain unmet include: * The driveway is uneven and potholed. * The garden is unsafe with items of machinery, glass and piping. * Water temperatures are not close to 43 degrees from all hot water outlets. Additional areas of concern in relation to maintenance include: * * * * * * Worn wallpaper in the main lounge. Worn paintwork and crumbling walls in the bedroom 2. A broken window in the ground floor toilet. Bedroom 5 has worn paintwork and a cabinet above the sink that is broken. There is no hot water in bedroom 15. There is no window restrictor in bedroom 20. Concerns in relation to fire safety identified during this inspection, of which immediate Requirements were made include: * * * * The communal lounge doors being propped open with chairs or wedges. The doorway in bedroom 2 being propped open with a wedge. The fire exit in the dining room being too stiff to open. Rubbish bags and cleaning equipment being stored in the fire exit to the side of the home. * The front door being locked without a key being close buy. Risk assessments have been carried out on all chemical and hazardous substance used in the home in line with a Requirement made at the last inspection. Poor hygiene standards were found throughout the home. Requirements are made in relation to the following areas: * There is a dirty door handle, radiator cover and net curtain in bedroom 5. * The first floor landing has a very strong smell of stale urine. * The kitchen has unclean floors and unclean food storage areas. * There were cups taken from dishwasher that were unclean * There were unclean fridges. * There were unclean surfaces and walls in the kitchen. * There was a hand washbasin in the kitchen that was unclean with mould growing around the taps. There were no paper towels available at this sink. These were not made available during this inspection despite this being requested. * There was an unclean oven. A piece of cardboard was found in the oven. * There were cobwebs around doorways and on ceilings throughout the home. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 17 * The wallpaper in the small lounge was stained and dirty. The home is registered to provide accommodation for up the 35 service users. There are only 24 comfortable chairs available between four separate seating areas. The Registered Provider said not all service users like to sit in the communal lounges. However, it was noted throughout this inspection that a number of service users were sat in communal areas without a comfortable seat. Some remained in wheelchairs and others sat on hard dining room chairs. This is not appropriate. There must be at least one comfortable armchair per service user, available in the communal areas. Service users must be provided with a comfortable and homely environment in which to live. It is of additional concern that one communal lounge is used by some staff members to undertake NVQ Level 2 in Care training one day each week. Training must not take place in areas that are designed to provide comfort, relaxation and a homely environment to service users. No progress has been made for ensuring that risk assessments are in place were service users do not have a bedroom door key. The matters described above are of serious concern and put into question the fitness of the Registered Providers and Registered Manager. Action must be taken to address the Requirements and repeat Requirements to avoid possible enforcement action. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 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 and 30. National Minimum Standards 27, 28, 29 and 30 were assessed as being met at the last two inspections of the home and as there have been no changes regarding these Standards in the home, it remains that they are considered met. Some improvements to the environment have been made. However, there remain a number of serious matters of concern which put people at risk of harm and do not provide safe, homely and comfortable surroundings in which to live. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 19 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 and 38. There is a qualified Registered Manager who has long-term experience of running a care home. However, there are a number of concerns regarding practices in the home that put into question the Registered Manager and Registered Providers fitness to ensure that the aims and objectives of the home are met. There remain a number of concerns regarding health and safety in the home, which potentially place the wellbeing of service users at risk. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The Registered Manager has managed this home for a number of years. She has demonstrated an ability to meet the assessed needs of some service users Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 20 and has taken action to address some Requirements made at previous inspections. Some staff members spoken with said that they received good guidance and support from the Registered Manager. A visitor said that the Registered Manager consulted with them on a regular basis regarding the care of their relative. However, a large number of Requirements have been made during this inspection and there remain a number of unmet Requirements from previous inspections. These serious concerns in relation to care practices and health and safety issues raise concerns about the Registered Manager’s and Registered Providers fitness for running this home. A Requirement was made at the last inspection of the home regarding the need for the Registered Provider to carry out monthly quality assurance checks in the home and supply the Commission for Social Care Inspection with a report following each check. Regulation 26 quality assurance checks were carried out in November and December 2005, no records were available detailing any further checks. A repeat Requirement is made regarding this issue. The Registered Manager said that she has been given responsibility for carrying out the Regulation 26 inspections. This arrangement is not in appropriate. A Registered Provider who is not in day-to-day charge of the home must carry out regulation 26 inspections. There has also been no progress in ensuring that the results of quality assurance surveys are published and made available to service users and their representatives. A repeat Requirement is made regarding this issue. Additionally, no annual development plan has been produced for the home, despite Requirements being made regarding this issue at the previous two inspections. There were records detailing that all portable appliances in the home have been safety tested since the last inspection. Records available also detailed that safety checks have occurred on the home’s emergency lighting and fire detection systems and that fire drills have occurred. A detailed risk assessment has been carried out in relation to fire safety in the building. There is an old call bell system in the home. This system must be safety tested by a person trained to do so. Records of this safety testing must be available for inspection. A large number of Requirements have been made following this inspection in relation to concerns regarding the arrangements for health and safety in the home. These requirements must be addressed within agreed timescales in order to ensure that the wellbeing of service users in promoted and protected. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 21 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 1 3 X X 2 2 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X X X 1 Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 22 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. 1. Standard OP8 Regulation 12 (1)(a) 15 (1) Requirement The Registered Provider must ensure that a written record is maintained of all communication between health and social care professionals, and family members were this relates to a service user. Timescale for action 01/05/06 2. OP19 23 (2)(g)(h) 3. OP19 12 (1)(a) 23 (4)(b) Repeat Requirement, timescale of 01/10/05 unmet. The Registered Provider must 01/06/06 ensure that there is at least one comfortable armchair provided in the communal lounges for each service user. The Registered Providers must 20/04/06 ensure that: 1. All fire exits and escape routes in the home are accessible. Repeat Requirement, timescale of 01/10/05 unmet. 2. The communal lounge doors are not propped open with chairs or wedges. Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 23 4. OP19 12 (1)(a) 23 (1) 23 (2)(d) 3. The doorway in bedroom 2 is not propped open with a wedge. 4. The fire exit in the dining room is accessible at all times. 5. Suitable arrangements are made for ensuring that the front entrance can be used as a fire escape. Immediate Requirement issued. 6. Cardboard is removed from inside the oven. The Registered Providers must 01/06/06 ensure that corrective action is taken in relation to the following: 1. Worn wallpaper in the main lounge. 2. Worn paintwork and crumbling walls in the bedroom 2. 3. A broken window in the ground floor toilet. 4. Bedroom 5 has worn paintwork and a cabinet above the sink that is broken. 5. There is no window restrictor in bedroom 20. The Registered Providers must ensure that the driveway is not uneven and have potholes. Repeat Requirement, timescale of 01/12/05 unmet. The Registered Providers must ensure that all areas of the garden are made safe and kept in good order. All items of machinery, glass and piping must be moved from the garden. Repeat Requirement, timescale of 01/10/05 unmet. 5. OP19 23 (2)(b)(o) 01/06/06 6. OP20 23 (2)(b)(o) 01/05/06 Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 24 7. OP20 23 (2)(a)(h) 8. OP25 13 (4)(a)(c) The Registered Providers must 01/06/06 ensure that the communal lounges are not used to carry out staff training when occupied by service users. The Registered Providers must 01/05/06 ensure that: 1. Water that is at a tempreture close to 43 degrees is available from in bedroom 15. 2. Water temperatures are monitored on a regular basis and records of this monitoring are maintained and made available for inspection. Repeat Requirement, timescale of 16/07/05, 01/12/05 and 01/10/05 unmet. 9. OP26 13 (4)(a) 23 (2)(d) 23 (5) The Registered Providers must ensure that: 1. The dirty door handle, radiator cover and net curtain in bedroom 5 are cleaned. 2. There is not a strong smell of stale urine first floor landing. 3. The kitchen floors and food storage areas are cleaned. 4. The dishwasher in the kitchen is repaired, or replaced. (Cutlery and crockery must be cleaned thoroughly before being used by service users) 5. Fridges are kept clean and hygienic at all times. 6. Kitchen walls and surfaces are kept clean at all times. 7. The mould is removed from the hand washbasin 01/05/06 Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 25 in the kitchen. 8. Paper towels are available by the kitchen hand washbasin. 9. The oven in the kitchen is clean and hygienic at all times. 10. Cobwebs are removed from ceilings and around doorways. 11. Stains and dirt are removed from the wallpaper in the small lounge. 10. OP33 24 (1)(a)(b) The Registered Providers must publish the results of satisfaction surveys and make these available to service users and their family members. Repeat Requirement, timescale of 01/12/05 unmet. 11. OP33 26 The Registered Providers must: 1. Ensure that a written report is compiled, at least monthly. This report must focus on the maintenance of the premises, health and safety issues, any incidents, accidents and complaints, consultation with service users and visitors about care provided and record keeping. 2. Ensure that these reports are not complied by the Registered Manager. 3. Supply copies of these reports to the Commission for Social Care Inspection. Repeat Requirement, timescale 01/08/05 & Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 26 01/07/06 01/06/06 01/11/05 unmet. 12. OP33 24 (1)(a)(b) The Registered Providers must produce an annual development plan and make this available for inspection. Repeat Requirement, timescales 01/08/05 & 01/11/05 unmet. The Registered Provider must ensure that the call bell system is safety tested by a person trained to do so. Records of this safety testing must be available for inspection. 01/07/06 13. OP33 23 (2)(c) 01/08/06 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. Refer to Standard OP7 OP15 Good Practice Recommendations The Registered Providers should ensure that care notes are written more regularly. The Registered Providers should ensure that service users eat in a homely environment and that tablecloths, condiments, table decorations etc are provided at meal times. The Registered Provider should ensure that there is a menu, offering a choice of meals in written or other format to suit the capacities of all service users, which is given, read or explained to service users. The Registered Providers should ensure that risk assessments are in place were service users do not have a bedroom door key. 3. OP15 4. OP24 Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Cloyda DS0000013381.V287813.R01.S.doc Version 5.1 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!