Inspection on 15/09/05 for Cloyda

This inspection was carried out on 15th September 2005.

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

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

Other inspections for this house

Cloyda 27/11/07

Cloyda 10/05/07

Cloyda 01/08/06

Cloyda 13/04/06

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 Unannounced Inspection 15th September 2005 11:45 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.V251324.R01.S.doc Version 5.0 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.V251324.R01.S.doc Version 5.0 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.V251324.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th April 2005. Brief Description of the Service: Cloyda is a residendial 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 whom 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. Accomodation 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. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 15 September 2005 between 11.45 and 17.20. A partial tour of the premises took place and care records were examined. The Registered Provider, Registered Manager, and two staff members were spoken with. Four service users also gave their views on the home. An additional visit to the home occurred on 4 October 2005 between 10.30 and 11.40. Medication handling was examined. What the service does well: What has improved since the last inspection? There have been some improvements to the environment since the last inspection including some areas of the garden being made safe and improvements to some lighting and flooring. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 6 Efforts have been made to gain feedback about the service via a service user satisfaction survey and organising a relatives meeting. Individual staff training profiles are now in place and these detail that staff training has been ongoing. 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.V251324.R01.S.doc Version 5.0 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.V251324.R01.S.doc Version 5.0 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. The arrangements for planning care are good, ensuring that the health, personal and social care needs of people living in the home are met. However, some staff members do not speak fluent English. This has potential for some service users not being understood, and therefore not having their needs fully met. EVIDENCE: Senior management in the home are responsible for carrying out an assessment of needs as part of the admissions process for all service users. Service users needs are assessed in their own homes, in hospital, or when spending time in the home. A needs assessments carried out for the most recent service user to be admitted to the home covered health and personal care and social needs. This service user had been admitted to the home through Care Management Procedures and a Care Management assessment had been obtained. The home aims to address the needs of service users through staff training. Almost half of the care staff team have achieved a qualification at NVQ Level 2 Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 9 in Care. This qualification involves staff members developing skills including effective communication, report writing, providing personal care sensitively and the awareness of abuse. The needs and preferences of service users from specific minority ethnic communities and religious groups are catered for. One service user is regularly provided with cultural meals, and all those wishing to practice their individual faiths are supported to do so. Care records examined indicate that the home liaises with both health and social care professionals in addressing the needs of service users. It was apparent from discussions with two staff members, and from feedback received prior to this inspection, that some staff members are not fluent speakers of English. It is therefore unclear whether communication between staff members and service users is always effective. This has the potential for service users not having their needs fully met. It is acknowledged that the majority of staff members present during this inspection spoke English well. Also, the Registered Manager said that four staff members are currently undertaking English language courses. However, a recommendation is made that this situation is closely monitored by the Registered Providers. Measures should be taken were problems are identified. The home does not offer intermediate care. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 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. The home, in general provides care that ensures that the care and health needs of service user are met. There is a need however, to ensure that care plans fully detail the needs of service users, and identified risks, and 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. In general, there is safe handling of medication in the home. Some practices in handling medication however, do not fully ensure the safety of service users. The home has a philosophy of care that is based on treating service users with respect and preserving their dignity. However, this has not been followed in one instance. EVIDENCE: Each service user has a written care plan that has been generated from an initial needs assessment. Care plans examined provided information about how the home plans to meet individual needs. One service user’s care plan Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 11 detailed how their cultural needs, in relation to food and worship would be met. The home has made efforts to involve service users and their family members in the drawing up and reviewing of care plans, in line with a Requirement made at the last inspection of the home. The Registered Manager said that staff members spend time with service users, discussing any changes made to care plans. Two of the four care plans seen, had been signed by a family member. It is recommended that further efforts be made for giving service users, or their family members opportunities to sign care plans, and agree to changes to care plans. There were risk assessments in place regarding moving and handling, however, there has been a failure to record and monitor other areas of identified risk. One service user has no possessions in their bedroom, including clothing. The Registered Manager was able to provide an explanation for this; however, there were no details about this in the service user’s care plan. Nor was this service user’s care plan signed. A risk assessment must be in place detailing the reason for this infringement on the service user. The service user’s representative, if possible, must sign this, or a record must be maintained as to why this has not been signed. Additionally, records detailed that another service user has a recent history of leaving the home unaccompanied, when it is unsafe for them to do so. There was no written risk assessment in place regarding this service user. A Requirement is made regarding the need to record all identified risk to service users. All service users are registered with a GP on admission to the home. Records examined detailed that local health and social care professionals are involved in the provision of care to service users. However, it was evident that records have not been maintained of involvement between one service user and the Community Psychiatric Nurse and Care Manager. In order to ensure that health is promoted and maintained, there must be accurate record keeping detailing any contact between service users and health and social care professionals. A Commission for Social Care Inspection pharmacy inspector examined medication systems in the home in May 2005. Five Requirements were made following this inspection. Improvements have been made in medication handling. Medication Administration Records examined were accurate and correspond with the labelling on medication. Also, systems are in place for disposing of medication that is no longer in use. However, some issues remain unaddressed. There was cream for one service user that was out of date. Medication Administration Records for September 2005 did not detail whether the service user suffered from an allergy. It is acknowledged that Medication Administration Records for July and August 2005, and some care plans did contain this information. Some items of medication were stored in an unlocked draw, in an unlocked office. Requirements are made regarding these issues. The recommendation that controlled drugs be stored in a cupboard that complies with Misuse of Drugs (Safe Custody) Regulations, is reiterated. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 12 Throughout this inspection staff members were observed to consult with service users appropriately and engage in respectful interactions. There are locks on bathroom doors. Care records detailed that the views of some service users or their representative had been sought, and followed. There is training in issues of dignity and respect for all staff members. However, one service user’s clothing is kept in a draw away from their bedroom. Whilst the reason for this is appropriate, it is unclear why items that require to be hung up, are not. A Requirement is made that a wardrobe, or clothes rail is provided for each service user. Were there are reasons that the wardrobe cannot be utilised in the bedroom, alternative space must be found. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 15. There are opportunities for service users to maintain contact with friends and family and for decision making. This allows them to maintain some control over their lives. Wholesome and enjoyable meals are provided. Service users are consulted about meals and therefore differing expectations and lifestyles are well catered for. EVIDENCE: There is a flexible visitors policy in the home and service users are able to see visitors in their bedrooms, or in the communal areas. There were no visitors present during this inspection, however, daily observation records indicated that a number of service users receive visitors on a regular basis. Some service users choose to see religious representatives in the home. The autonomy and choice of service users was respected throughout this inspection. The home does not handle finances for service users but can provide safe storage for small sums of money. Some service users have brought items of furniture, ornaments and pictures with them to personalise their bedroom. The Registered Manager said that access to personal records could be facilitated for service users. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 14 A hot meal of chicken casserole, potatoes and fresh vegetables was served for lunch during this inspection. This meal appeared nutritious and was well presented. One service user said, “meals are always good here” another service user said that the meal was “nice and hot” There was also records of feedback received from a relative of a service users which detailed, “Meals always look very good” There was a clean, well organised kitchen and supplies of fresh fruit and vegetables. Meals served are typically British dishes, and this largely reflects the preferences of current service users. Arrangements have been made with the family of one service user for them to provide their relative with cultural food on a regular basis. Hot and cold drinks are provided routinely throughout the day, or on request. Service users were provided with appropriate assistance throughout lunchtime, including those who needed help with eating. There is a large, and in general, pleasant dining area were the majority of service users take their meals. Some service users eat in a smaller dining area/lounge. A recommendation is 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. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. There is an accessible complaints procedure, which ensures that service users and their relatives know that their concerns will be listed to and acted upon. There are shortfalls in the procedures for responding to service users who go missing from the home. Service users are therefore not fully protected. EVIDENCE: The home has a detailed complaints procedure and service users are their family members are made aware of this. The Registered Provider said that no complaints have been made since the home was last inspected. There are policies and procedures in place for dealing with suspected or alleged abuse and the home has a copy of the Royal Borough of Kingston Upon Thames adult abuse procedures. There is policy in place regarding aggression against staff and, missing persons policies and procedures. Documentation was available detailing that there have been a number of recent incidents involving one service user going missing from the home. Whilst care records detail that the house and grounds were searched, and that that the police, and family member of the missing service user were informed without delay, there was a failure by the home to keep the service user’s Care Manager and Commission for Social Care Inspection informed. There was also a failure to fully document each instance of the service user going missing. Correct procedures were followed by the home on one occasion of the service user going missing. A Requirement is made that all relevant parties must be Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 16 informed, without delay, following a serious incident involving a service user. Accurate and up to date records must be maintained of any incident. Criminal Records Bureau and Protection of vulnerable adults checks have now been carried out for all staff members working in the home and the Registered Providers are aware that these checks must be in place prior to any new staff member commencing work in the home. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 17 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, 21, 24, 25 and 26. Some improvements to décor have been made. There are a number of serious matters outstanding which put people at risk of serious harm and do not provide safe and comfortable surroundings in which to live. EVIDENCE: Since the last inspection there have been some environmental improvements in the home. The garden pond, which was unsafe, has been removed and the vegetable garden has been made safe. The lighting in a toilet and the flooring in another toilet have been improved, in line with a Requirement. Chairs in the main communal lounge have been rearranged, creating a more homely environment. There remain however, a large number of areas that require immediate attention, including: * Carpeting in the ground floor hallway and bedrooms 4 &15, and flooring in the dining room and ground floor toilet that is badly fitted and a trip hazard. * The carpet in bedroom 18 is dirty and has an unpleasant odour. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 18 * The carpet in Bedroom 20 is badly stained. * The driveway is uneven and potholed. * Some furniture and paintwork throughout the home is chipped. A number of these issues were raised at the last inspection on the home and it is of concern that no action has been taken to address them. There is a large garden to the rear of the home. Generally this is well maintained and provides a pleasant seating area, however, part of the garden contains old sinks, toilets and piping. Additionally, there were paint pots, weed killer and other chemical substances stored on a table in the garden. This is unsightly and potentially dangerous. The home was inspected by the local environmental health officer in February 2004 and found to comply with their requirements. The Registered Manager said that the local fire officer has also inspected the home recently and found it to meet fire regulations. However, at the time of this inspection, one fire exit was locked and the key kept in a different area of the home and another fire exit was via a patio door that was very stiff and difficult to open. There are sufficient toilets throughout the home and these are in close proximity to bedrooms and communal space. One toilet has poorly fitted flooring and a Requirement has been made regarding this issue. All bathrooms and toilets were clean at the time of this inspection; however, the linoleum flooring in two toilets had recently been washed and had been left very wet and slippery, and accessible to service users. This practice is potentially dangerous and must not occur. Bedrooms viewed all contained a sink, covered radiator with accessible controls, window restrictor and call bell. Lighting, ventilation and heating were appropriate. All sinks are fitted with thermostatic valves and generally, water temperatures in bedrooms were found to be close to 43 degrees. However, in one bedroom the temperature exceeded this, and in another the temperature was only 26 degrees. A Requirement was made at the last inspection of the home that water temperatures must be monitored on a regular basis to ensure the safety of service users. This has not occurred and the Requirement is repeated. Two service users did however, state that that they were happy with the water temperatures in their bedrooms. Service users are not provided with a bedroom door key. The Registered Manager said that keys could be provided on request. Details about service user’s views on having a bedroom door key should be recorded in care plans. Bedrooms, in general, are adequately decorated and furnished. Repeat Requirements have been made regarding the poor state of the flooring in some bedrooms. Most areas of the home were clean and hygienic. Laundry facilities are adequate, and sited away from the kitchen and hand-washing facilities are available. Requirements have been made regarding stained carpets and an Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 19 unpleasant odour in one bedroom. A Requirement has also been made regarding cleaning staff leaving toilets unsafe for use. A further, repeat Requirement is made regarding the need for risk assessments to be carried out on any chemical or hazardous substance which is used in the home, and action to be taken to reduce identified risk. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. There have been improvements in procedures for staff recruitment, which now offer protection to people living in the home. Staff members are employed in sufficient numbers and receive training, which, in general provides them with the skills necessary for meeting the needs of service users. However, some staff members do not speak fluent English. This has potential for some service users not being understood, and therefore not having their needs fully met. EVIDENCE: Staffing levels, evidenced in staff rotas, and in numbers on shift at the time of this inspection were found to be appropriate and safe, in accordance with the care and social needs of the service users. There is a skills mix of staff including senior workers, care staff, cleaners and a cook. All service users spoken with spoke positively about staff members. One service user said that staff members are “very kind” and there was feedback from one family member detailing that they were very satisfied with the level of care afforded to their relative, by staff members. All staff members originate from Sri Lanka, and some do not speak fluent English. A recommendation has been made regarding this issue. The Registered Provider said that discussions about the cultural needs of service users are discussed with new employees as part of the interview process. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 21 The Registered Provider said that no new staff members have been employed since the last inspection of the home. Criminal Records Bureau and Protection of vulnerable adults checks have now been obtained for all existing staff members. There are plans to implement a new staff induction programme. This will be examined in more detail once implemented. Individual staff training records indicate that training has been ongoing. The cleaner has undertaken training in positive communication, safe food handling, fire safety and basic first and has completed NVQ Level 1 in Cleaning. The deputy manager is currently undertaking NVQ Level 4 in Care. The home is on target to having 50 of the care staff team being qualified at NVQ Level 2 in Care by the end of 2005. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 28 There have been some improvements to the quality assurance system however current systems do not allow for the quality of the service to be assessed effectively. Some practices do not promote and safeguard the health, safety and welfare of people using the service. EVIDENCE: Since the last inspection, a ‘Residents and Relatives Satisfaction Survey’ has been undertaken. The Registered Manager stated that a small number of responses were received from this. The results of satisfaction surveys must be published and made available to service users and their family members. Efforts have been made to organise a service user and relatives meeting in order to gain feedback about the home. This is seen as good practice. There is no business plan and there continues to be a failure by the Registered Providers to carry out Regulation 26 visits to the home. A repeat Requirement is made that, a written report is compiled, at least monthly. This report must focus on the maintenance of the premises, health and safety issues, any Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 23 incidents, accidents and complaints, consultation with service users and visitors about care provided and record keeping. Copies of these reports must be made available to Commission for Social Care Inspection. The home does not handle finances for service users but can provide safe storage for small sums of money. There is training for staff members to ensure safe working practices in moving and handling, fire safety, first aid, infection control and food hygiene. Refresher training in safe working practices must occur, as two toilets were left unsafe for use after being cleaned. An accident and incident book detailed that only two accidents have occurred in since the last inspection. There are facilities for the safe storage of hazardous substances; however, there were paint pots, weed killer and other chemical substances stored on a table in the garden. Risk assessments must be carried out on any chemical or hazardous substance that is used in the home and action taken to reduce identified risk. A contract is in place for the collection of clinical waste. Records detail that testing for legionella occurs but there continues to be no system in place for monitoring water temperatures. All hot water outlets have a thermostatic safety valve, however, monitoring must occur to ensure the safety and well being of service users. There has been a failure to carry out safety tests on portable appliances, despite this being made a Requirement at the last inspection. Windows have restrictors, and there are covers on radiators. Fire fighting equipment is available throughout the home and records detail that the fire alarm is tested on a weekly basis. There were no records detailing that fire drills occur, or that emergency lighting is tested. A risk assessment in relation to fire, or any other hazards in the home was not available. These must be produced in order that identified risks can be reduced. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 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 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X 2 X X 3 2 2 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 X X 2 X 3 X X 1 Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 25 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 OP7OP7 Regulation 12 (1)(a) 15 (1) 12 (1)(a) 15 (1) Requirement The Registered Providers must ensure that there is a care plan in place for each service user that details all identified risks. The Registered Provider must ensure that a written record is maintained of all communication between health and social care professionals were this relates to a service user. The Registered Providers must ensure that medication that is out of date in not administered to service users. The Registered Providers must ensure that all medication kept in the home is stored securely. OP7The Registered Providers must ensure that the allergy section on Medication Administration Records is completed for all service users. (Repeat Requirement. Timescale of 01.06.05 not met) The Registered Providers must ensure that a wardrobe, or clothes rail is provided for each service user. Were there are DS0000013381.V251324.R01.S.doc Timescale for action 01/10/05 2 OP8 01/10/05 3 OP9 13 (2) 01/10/05 4 5 OP9 OP9 13 (2) 13 (2) 01/10/05 01/10/05 6 OP10 12 (1)(a) & (4)(a) 01/11/05 Cloyda Version 5.0 Page 26 7 OP18 37 (1)(ag) 17 (1)(a) 8 9 OP19 OP19 12 (1)(a) 23 (4)(b) 13 (4)(a) 23 (1)(a) 10 OP19 12 (1)(a) 16 (2)(k) 11 12 OP19 OP19 23 (2)(b)(o) 12 (1)(a) 23 (2)(b) 23 (2)(b)(o) 13 (4) 18 (1)(c)(i) 13 OP19 14 OP21 reasons that the wardrobe cannot be utilised in the bedroom, alternative space must be found. The Registered Provider must ensure that all relevant parties are informed, without delay, following a serious incident involving a service user. Accurate and up to date records must be maintained of any incident. The Registered Providers must ensure that all fire exits in the home are accessible. The Registered Providers must ensure that carpeting in the ground floor hallway and bedrooms 4 and 15, and flooring in the dining room and ground floor toilet that is badly fitted and a trip hazard is made good. (Repeat Requirement. Timescale of 16.07.05 not met) The Registered Providers must ensure that the carpets in bedrooms 18 and 20 are replaced. (Repeat Requirement. Timescale of 16.07.05 not met) The Registered Providers must ensure that the driveway is not uneven and have potholes. The Registered Providers must repair, replace or make good chipped paintwork and furniture throughout the home. The Registered Providers must ensure that all areas of the garden are made safe and kept in good order. The Registered Providers must ensure that: 1. Wet flooring is not accessible to service users. 2. Refresher training in safe DS0000013381.V251324.R01.S.doc 01/10/05 01/10/05 01/11/05 01/10/05 01/12/05 01/12/05 01/10/05 01/10/05 Cloyda Version 5.0 Page 27 15 OP25 13 (4)(a)(c) 16 OP26 13 (4)(b) 17 OP33 24 (1)(a)(b) 18 OP33 26 working practices occurs for staff members responsible for cleaning the home. The Registered Providers must ensure that: 1. Water which is at a tempreture close to 43 degrees is available from outlets in bedrooms. 2. Water tempreatures 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 not met) The Registered Providers must ensure that risk assessments are carried out on any chemical or hazardous substance which is used in the home and action taken to reduce identified risk. (Repeat Requirement. Timescale of 01.08.05 not met) The Registered Providers must publish the results of satisfaction surveys and make these available to service users and their family members. 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 visitor about care provided and record keeping. 2. Supply copies of these reports to the Commission for Social Care Inspection. (Repeat Requirement. Timescale of 01.08.05 not 01/10/05 01/10/05 01/12/05 01/11/05 Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 28 19 OP33 24 (1)(a)(b) 20 OP38 12 (1)(a) 23 (1)(a) 21 OP38 23 (4)(a)(e) 22 OP38 13 (4)(a)(b)( c) met) The Registered Providers must produce an annual development plan and make this available for inspection. (Repeat Requirement. Timescale of 01.08.05 not met) The Registered Providers must ensure that portable appliance testing occurs and that records of this are available for inspection. (Repeat Requirement. Timescale of 01.08.05 not met) The Registered Providers must ensure that: 1. Fire drills occur on a regular basis. 2. Emergency lighting is tested on a regular basis. The Registered Providers must ensure that risk assessments are carried out in relation to fire and any hazards in the premises. 01/11/05 01/11/05 01/10/05 01/11/05 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 Refer to Standard OP4 Good Practice Recommendations The Registered Providers should ensure that there are systems in place for monitoring the effectiveness of communication between service users and staff members who do not speak fluent English. Measure should be taken were problems are identified. The Registered Providers should make further opportunities for service users and their family members to sign care plans. DS0000013381.V251324.R01.S.doc Version 5.0 Page 29 2 OP7 Cloyda 3 4 OP9 OP15 5 6 OP24 OP33 The Registered Providers should ensure that controlled drugs are stored in a cupboard that complies with the Misuse of Drugs (Safe Custody) Regulations 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 Providers should ensure that risk assessments are in place were service users do not have a bedroom door key. The Registered Providers should seek the views about the service from health and social care professionals, religious representatives; hairdressers and any other interested parties by provided them with satisfaction surveys. Cloyda DS0000013381.V251324.R01.S.doc Version 5.0 Page 30 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.V251324.R01.S.doc Version 5.0 Page 31 - 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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