Inspection on 27/11/07 for Cloyda

This inspection was carried out on 27th November 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 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 10/05/07

Cloyda 01/08/06

Cloyda 13/04/06

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 Alison Ford Key Unannounced Inspection 27th November 2007 10:25 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.V355422.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. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 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 cloyda@hotmail.com Mr Vallabhbhai Morarbhai Patel Mrs Dahiben Vallabhbhai Patel Post Vacant 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.V355422.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2007 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 on the ground and first floor, 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. The latter can also be obtained from The Commission for Social Care Inspection via the internet. Fees at the time of writing range between £398 and £520 and would be discussed prior to admission. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection visit to the home, the second this year, was undertaken as a part of the inspection process for the year 2007/2008. At this visit, all of those standards, considered by The Commission for Social Care Inspection, to be key to the inspection process were assessed. When writing this report consideration has also been given to other information received about the service including notification of incidents, pre-inspection comment cards, complaints and concerns. The inspector was accompanied to the visit by a representative from Age Concern, who was acting in the role of an “expert by experience” and her comments have been incorporated into the report. In this instance the “expert” was a healthcare professional, with many years experience, whose mother had lived in a care home. This had given her an insight into the needs of older people who need nursing care. She was able to spend time talking with residents about their views of the home, speak with members of staff and also to look at the environment in which residents were living to see if it was suitable for their needs. Previous inspection reports highlighted the numerous concerns that have been raised about this home in the past. This resulted in local authorities making a decision not to place their clients in the home and in some instances to move them. The management team of the home have worked alongside the local authority and The Commission to improve the situation and this embargo on placements has now been lifted. An independent consultant was also engaged to help improve the standards within the home. Although there is still a great deal of work that needs to be done, this report is reflective of their commitment to improving the lives of those people who use this service. What the service does well: Many of the people who use this service, are not able to contribute to the inspection process however, those who are, say that staff are kind and helpful and that the home is a nice place to live in. They all appeared happy and content, and seemed to be having their personal care needs met. Staff members, were very caring and kind and they were available for residents. Some were seen spending time talking with them and others were dancing. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 6 Residents made comments that “ its nice here” “ everyone is lovely “ I have a nice room “ and “there is nice food to eat here” The “ expert by experience” also said that she thought that the staff were kind and sensitive to the needs of the residents. Assessments of potential residents healthcare needs are undertaken prior to admission to ensure that they can be met in the home and individual care plans are in place to identify the help and support that they need and how care staff will help them. These are reviewed on a regular basis to ensure that any changes are identified. Residents say that they enjoy the meals that are served in the home and fresh fruit and drinks are also available for them on the table all of the time. The “expert by experience” was able to be present at lunchtime and she said that the meal was nicely presented and there had been a choice available. Residents could also have an omelette or sandwich if they preferred and she considered that mealtimes were a pleasurable experience in the home. There is low staff turnover in the home, providing continuity of care for those who live there and robust recruitment procedures are in place to ensure that they are protected from those who have been judged as being unsuitable to work with vulnerable people. Visitors to the home are encouraged and a limited amount of structured activities are facilitated. What has improved since the last inspection? Although a considerable amount of work remains to be done, the substantial decrease in the number of requirements issued at this latest inspection is reflective of the hard work being undertaken by all of the people currently involved in running this service. Since the last inspection Ms Louise Sutton has been appointed as a manager although an application is still waited for her registration. She has a commitment to raising the profile of the home and ensuring good outcomes for the people who live there. She is ably supported by a deputy manager, who has been in post for several years, and together they have been able to provide structure and leadership to the staff team. Training has been improved with all staff being supported to attend training to help them to meet the needs of the residents that they are caring for and, although there is still scope for improvement, there has been an increase in the amount of activities that are being arranged in the home. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 7 Care plans now accurately reflect the support that resident’s need so that all staff are aware how they prefer to be cared for. They are reviewed regularly so that they remain up to date and any changing healthcare needs are identified. They are beginning to provide a comprehensive profile of residents lives in the home and how they spend their days. Work is being undertaken to improve the environment for residents although it is slow and there is still someway to go. Priority is being given to ensuring that resident’s health and safety are protected and requirements that were made relating to fire safety are currently being completed. Three bedrooms have been decorated and refurbished; three more are currently being finished and when these are occupied work will start on others. It has included the purchase of new furniture and bed linen and the completed rooms are attractively presented. What they could do better: As has been noted there has been a great deal of work undertaken in order to improve the outcomes for the people who use this service and issues affecting their health and safety have been prioritised. However, there are other issues that still need to be addressed. There is a Statement of Purpose available for the home, which is the document that sets out the aims and objectives of the home, the services and facilities that it offers to residents and how it is intended that their needs will be met. In order to reflect the current situation in the home and give potential residents all of the information that they need when they are choosing a home this now needs to be updated. There is also a Service User Guide, which should be a residents “guide book” to the home however the current format is not completely suitable for the people who use the service and work needs to be done to address this. Each resident has an individual care plan, which details how he or she should be supported in line with their preferences. These still need to contain information about the actions to be taken in the event of them becoming unwell or in their death. In this way all staff will be aware of the actions to be taken and unwanted hospital admissions may be avoided. Medication procedures within the home are generally in order however a new “homely remedies” policy needs to be introduced. The doctors who visit the home have all given permission for a range of simple” over the counter” remedies to be given to residents, on a limited basis without the need for a prescription. There now needs to be a policy written to give guidance to staff about exactly how these should be administered. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 8 The range of activities that are offered to residents has been increased however, given the limited abilities of this particular client group, it is considered that they would benefit from input from people who are specially trained in this area to provide both enjoyment and added stimulation. Redecoration and refurbishment of the home is underway and it is recognised that this will all take some time. However, it must be noted that currently the home still does not provide the best possible environment for people who are confused to live in. Décor, furnishing and signage will all need to be improved in order to fulfil the homes objectives to provide good quality care for people who have dementia. 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. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 9 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.V355422.R01.S.doc Version 5.2 Page 10 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): Standards 1,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use this service have their care needs assessed before moving in to the home to make sure that they can be met however, limited information is available to help them to make a choice as to whether they will be happy living there. This home does not offer intermediate care; this standard does not apply. EVIDENCE: The Statement of Purpose for the home was seen however; this was written some time ago and still needs to be updated to reflect the current situation within the home. A copy of the Service User Guide was seen. In order to provide a useful reference for any residents in the home it must now be produced in a format that is suitable for the people for whom it is intended. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 11 The information that had been gathered relating to a resident who was about to come and live in the home was seen. There was evidence both of an assessment from the Care Manager and one that had been undertaken by the manager of the home and her deputy. This showed that their healthcare needs had been carefully considered and this assessment would then form the basis of an individual care plan. The majority of the people who are admitted into the home would be too frail to visit first and see what it is like therefore, it was previously recommended that a brochure or information pack should be developed. They would then be able to look at it when the pre-admission assessment is undertaken. Work to complete this is in progress. This home does not offer intermediate care so this standard does not apply. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9,10,11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service believe that their healthcare needs are being met and they seem to be well cared for. They are treated with sensitivity dignity and respect. Medication policies and procedures are in place, however they could be improved in order to ensure protection of residents. EVIDENCE: The care plans of three residents currently living in the home were seen. There is an improvement in these since the last key inspection and generally, there was good information available about the needs of the residents and the outcomes that were hoping to be achieved. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 13 There was limited evidence to show that residents or their representatives had contributed to the care planning process. However, it is acknowledged that the majority of residents are very frail and confused and do not have the ability to participate. Also, many of them do not have relatives that are interested in becoming involved Some work still needs to be done to identify resident’s wishes in the event of them becoming unwell or their death. This will minimise the risk of unwanted hospital admissions and ensure that all staff are aware of resident’s preferences. Care plans show that other members of the multidisciplinary healthcare team are involved in the care of residents as necessary. There are no trained nurses working in this home and community nurses visit on a regular basis to undertake any nursing tasks that are required. Nurses from the palliative care team to are currently supporting staff to look after a resident who is terminally ill and has expressed a wish to stay and be cared for in the home where she knows everyone. Medication records were in order and at this visit all medication was locked away. However it is a time consuming task to administer medication, as staff have to keep returning to the cupboard. It recommended that to minimise the risk of staff “short cutting “ the process a medicine trolley should be obtained. There is a list of medication that can be given in line with a homely remedies procedure. Although the staff member spoken with was aware of the protocol to be followed a written policy must be put in place to minimise the risk of any errors occurring. Staff were observed treating residents very gently and with kindness and respect. Residents commented that “they are nice girls, they always come and help us” and “they are always lovely and kind”. The “ expert by experience” also commented on the kindness and sensitivity of the staff towards residents who were at times quite demanding. It was noted that the home currently does not employ any male carers. In order to offer residents a choice it is recommended that consideration should be given in the future to addressing this shortfall. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards12, 13,14,15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service seem to find that life in the home meets their needs although it is considered that they might benefit from a range of activities provided by a specialist person. The food that is served in the home is wholesome and well presented and suits resident’s preferences. EVIDENCE: People who live in this home are encouraged to exercise an element of choice in their daily lives. They get up and go to bed when the want to, they have a choice of meals every day and two of them are able to handle some of their own money. Staff in the home organise various things for them to do and it is acknowledged that these have increased since that last inspection. The notice board is updated daily with the days events and photographs show some of the organised activities that have taken place. The manager is obviously working hard to try and broaden the options available however; it is considered that some of the activities could be improved and the employment of someone with Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 15 specialist skills in providing activities suitable for this client group would be of benefit. Spiritual needs are now being addressed and there are monthly services held in the home. Visitors would always be made welcome. There is a large garden to the rear of the property and there are plans to increase the paved areas in order to allow more residents the opportunity to enjoy it. The residents that were spoken with confirmed that they enjoyed the meals that were served in the home and the “ expert by experience” was able to be present while lunch was being served. She considered that the meal was nicely presented and it was an enjoyable experience for residents. Choices are always available and drinks and fruit are on the table for residents to have at any time. The daily menu was displayed on the wall although one resident said that she would have liked a menu on the table. This had apparently been tried before but was not successful. . Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service have an appropriate system in place for the effective handling of complaints. Training, policies and procedures are in place to ensure their protection. EVIDENCE: Information is made available in the Service User Guide about how a complaint, concern or suggestion should be made, and how this will be handled. This information also includes details about how a concern may be raised with the Commission for Social Care Inspection. In common with other documentation intended for the people who use this service it would benefit from being produced in a format that was more suitable for their capabilities. No complaints have been received about the home since the last inspection. The home has a copy of the Royal Borough of Kingston Council’s adult protection procedures. Staff members have all undergone training in the Protection of Vulnerable Adults since the last inspection. Recruitment procedures are in place to ensure that there is no one working in them home Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 17 that has been judged as being unsuitable to be working with vulnerable people. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people who use this service are living in an environment, which does not always meet their individual needs or help to ensure their safety. EVIDENCE: A high number of requirements were made at previous inspections of the home regarding poor maintenance of the building, poor hygiene standards and the failure to provide a homely and comfortable atmosphere. It is acknowledged that work is currently in progress to meet all of these requirements and many of the concerns have already been addressed. However there remains a great deal still to be done to make this home a safe and suitable environment for residents with dementia to live in. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 19 Some redecoration has been undertaken, three bedrooms have been redecorated and refurbished and as these are occupied more will be done. New beds have been purchased throughout the home. There is currently work going on to meet the requirements made by The Fire Safety Officer, door alarms and keypads have not yet been fitted although it is noted that the timescale for implementation has not yet been reached. Communal areas and bathrooms still remain in need of redecoration and refurbishment to make them pleasant for residents. Consideration must also be given to colour coordination and increased signage in order to help orientate them in the home. Several residents bedrooms are quite sparse and do not contain any of their personal possessions. The management team are still trying to encourage resident’s families to help make the rooms more homely and reflective of their personalities. Despite all of the redecoration going on the home was quite clean and generally free from malodour. Hand washing facilities have been improved for staff, they all have access to anti-bacterial hand cleanser to minimise the risk of cross contamination and the majority of them have undertaken training in control of infection issues. . Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service can be confident that there are sufficient numbers of staff on duty and that they are all undertaking further training in order to meet their specific healthcare needs. EVIDENCE: On the day of the inspection there were sufficient numbers of staff on duty to care for residents and they seemed to have time to spend with them. Due to reduced occupancy in the home no new staff have employed for some time and staff turnover was very low prior to that. Recruitment procedures had been satisfactory so staff files were not looked at during this visit. There is an increased commitment now to staff training and it was pleasing to note how much has taken place. The majority of care staff have gained an NVQ level 2 and some are undertaking level 3. A training needs analysis is available and shows that all mandatory training has been completed as required and several other topics have been covered as well. Both the new manager and her deputy have gained NVQ level 4. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 21 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): Standards31, 33,35,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people who use this service live in a home, which is being run by someone competent to do so, and in their best interests. Some arrangements for maintaining their health and safety still need to be improved. EVIDENCE: Ms Louise Sutton is now managing the home although an application is still awaited for her registration. She has many years experience of working with elderly people an obvious commitment to improving the status of the home and the lives of those people Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 22 who are using the service. She is ably supported by a deputy manager who has worked at the home for many years and staff turnover is low. This provides a stable environment for residents allowing them to feel comfortable and safe and provides direction and leadership for staff. The management team are trying to explore ways to gain the views of residents and their relatives about the service they provide and a survey will be going out to them in the near future. Relatives are invited into the home for social events and this gives them the opportunity to meet with staff as well. Some money is held on behalf of residents. The system has now been improved so that it was possible to check that records well kept and are accurate. Records that show the health and safety of residents and staff is protected were seen and were generally in order although a Fire Risk Assessment still needs to be undertaken in line with regulatory guidance. Previous requirements made by the Fire Safety Officer still remain unmet although the timescale has not been met and there is work in progress on all of these. It was noted that the policies and procedures in use in the home have not been updates for several years and this must now be addressed. They will all need to be reviewed to make sure that they are in line with current best practice and then disseminated to staff so that they are made aware of their content. Health and Safety practices in the kitchen area have improved significantly and all of requirements made by the Environmental Health Officer have been met. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 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 3 X 3 X 3 X X 2 Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The Statement of Purpose must be updated to reflect the current situation in the home and explain how the needs of those who live there will be met. Timescale for action 30/03/08 2. OP1 5 Previous Timescale 30/08/07 not met The Service User Guide must be 30/03/08 produced in a format that is suitable for the people who will read it and made available to every resident; so that it provides a guide to the home and the services that will be provided. Care plans must identify resident’s wishes and preferences in the event of them becoming unwell or their death so that all staff are aware of them and unwanted hospital admissions can be avoided. A protocol concerned with the administration of medicines under the homely remedies policy must be introduced so DS0000013381.V355422.R01.S.doc 3 OP7 15(1) 30/03/08 4 OP9 13(2) 30/03/08 Cloyda Version 5.2 Page 25 5. OP19 23(2)(a) that all staff who administer medication are aware of the procedures to be followed and residents are protected. The home must provide a suitable environment, which meets the needs of the people who live there. Previous timescale 30/08/07 not met All of the fire doors leading out of the home must be alarmed so that staff are alerted if residents open them Previous timescale 30/08/07 not met. Timescale of 10/12 07 set in conjunction with Fire Safety Officer. An application must be made to the Commission for Social Care Inspection for a suitable person to be appointed to the post of Registered Manager. Previous Timescale 15/04/07 30/08/07 not achieved. 30/03/08 6. OP19 23(2)(a) 10/12/07 7. OP31 8 (1) (a) 30/03/08 8. OP38 23(4)(c) A fire risk assessment must be produced to show that all hazards have been identified and wherever possible minimised. Previous timescale 30/08/07 not met. Timescale of 10/12 07 set in conjunction with Fire Safety Officer. Designated fire doors must have a suitable closing mechanism to allow them to be operated easily in the event of a fire without needing a key. Previous timescale 30/08/07 not met. Timescale of 10/12 07 set in conjunction 10/12/07 9. OP38 23(4)(b) 10/12/07 Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 26 10. OP38 18(4) with Fire Safety Officer All of the policies held in the 30/03/08 home must be updated to ensure that they are appropriate and in accordance with best practice guidelines. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP8 OP12 Good Practice Recommendations It is recommended that a medicine trolley should be obtained to help make medication administration simpler and reduce the possibility of errors occurring. It is recommended that consideration should be given to the employment of male care staff in the future in order to offer more choice to residents. It is recommended that specialist input should be gained from a person who is trained in organising activities for elderly people with dementia. Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Cloyda DS0000013381.V355422.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!