Inspection on 16/01/06 for College View Care Home

This inspection was carried out on 16th January 2006.

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

College View Care Home 13/09/07

College View Care Home 05/09/06

College View Care Home 27/09/05

College View Care Home 06/12/04

College View Care Home 23/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE College View Care Home 71 Bargate Grimsby North East Lincs DN34 5BD Lead Inspector Mrs Jane Lyons Unannounced Inspection 16th January 2006 09:30 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 College View Care Home DS0000002851.V278418.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. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service College View Care Home Address 71 Bargate Grimsby North East Lincs DN34 5BD 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) 01472 879337 Mrs Katrina Peerbux Mrs Katrina Peerbux Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: College View is a long established home situated in a pleasant central location of Grimsby, it is close to the local amenities of Scartho Village and local public transport. The building is Victorian in style maintaining much of the character and original features providing care for up to 12 service users. The home consists of two storeys serviced by stairs and a passenger lift. There are six single rooms, none of which are en-suite and three shared rooms, one of which is en-suite. All rooms apart from one are spacious. On the ground floor there is one unassisted bathroom containing a WC and on the first floor there is an assisted bathroom without a W.C. On each floor there are two W.C.’s for service users use. There are two lounges and one dining room, all of which are located on the ground floor. The home is surrounded by pleasant mature gardens including a paved area at the rear of the property. There is car parking space at the front of the property. The home is owned and managed by Mrs K Peerbux. There is a well established staff team who have considerable experience working with this service user group. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in January 2006. During the visit the inspector spoke to three staff, eight residents and one visitor to find out how the home was run and if the people who lived there were satisfied with the care and facilities provided. The inspector looked at all the communal areas, such as the lounge areas and dining room and a number of bedrooms during the visit. Paper work relating to staff recruitment, staff training, supervision, accidents, care plans and health / safety checks were looked at to make sure it was all in place and up to date. What the service does well: There was a very relaxed and homely atmosphere in the home, residents were observed to be very comfortable in their surroundings. The home was clean and tidy. Observation of staff support and interaction with the residents was seen to be very positive; staff displayed a very good knowledge of the individual residents needs, their approach was very patient, kind and supportive at all times. All service users spoken to told the inspector how kind and caring all the staff were. There is a good staff team with many having worked at the home for some time having developed good relations with the residents and their families. Staff told the inspector how they enjoyed working at the home and ensuring the residents were well looked after was their priority. Although meals and activities in the home were not looked at in detail, from observation and comments made by service users there was evidence that the home has maintained good standards in these areas. Service users told the inspector that the meals were always lovely. During the afternoon the staff provided a sing along session which most of the residents joined in with; two of the residents in particular thoroughly enjoyed themselves. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The staffing levels in the home need to be reviewed to make sure that there are enough staff on duty to provide all the care the residents need. When residents fall and sustain injuries it is important for staff to make sure that medical attention has been accessed. The management have not fully put in place a quality assurance system which would provide a better picture of all the checks and questionnaires that are carried out. The staff did not always write down how care must be given to make sure that people living in the home are kept healthy, safe and comfortable. This is important to make sure that all the staff understand the care that everyone needs and can make sure that the care they are giving is working or not. Medication recording needs to be improved to ensure all signatures are in place for medications administered by the staff, so that there is no mishandling of medication and the residents health is looked after. Recording and handling of resident’s personal money accounts needs to be improved to make sure that there are no irregularities. Staff training records must be kept up to date to make sure that all the staff have had all the training they need to ensure the safety and welfare of the residents. The tiling behind the kitchen sink needs to be repaired to ensure that the standards of hygiene can be maintained. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 7 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. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Recording of assessments prior to people moving in to the home should be clearer to demonstrate that their care needs can be met. Admission of service users with needs different to those identified on the registration category is placing service users at risk. EVIDENCE: Two service users had recently been admitted to the home for respite care; both service users had diagnosis of dementia although the home does not have this registration category. Three of the existing service users have needs associated with dementia and therefore it is vital that the home applies to the commission to vary the registration to include five beds under the category of dementia. There was evidence from staff interviews that the staff had recently accessed training in this area; and from observation of staff interaction with the service users there was evidence that the service users were well supported however two of the service users were observed to be very restless, trying to mobilise independently and both these residents had recent histories of falls where they had sustained injuries. The staff were having to monitor College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 10 these residents very closely and the inspector had concerns about the staffing levels which is covered in more detail in the staffing section of the report. Detailed assessments had been carried out on admission; staff confirmed that the registered manager had carried out pre- admission assessments although there was no clear written evidence to support these visits. Staff told the inspector that they had been informed of the new service users needs prior to admission by the registered manager however the most recent admission had been much more dependent on arrival to the home than they had expected. One of the recently admitted service users had been discharged from The Willows Respite Provision and a care plan compiled by care management was in place. The other admission (not publicly funded) had detailed transfer forms completed by the hospital staff on file; these had identified tissue viability needs on discharge from hospital; records showed that pressure relieving equipment such as an air mattress was not provided until two days following admission. The registered manager must ensure that appropriate equipment to meet the service users needs is in place on admission to the home. The registered manager must also ensure that she writes to potential service users following her assessment visits to confirm that the home can meet their needs. The home does not provide intermediate care support. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 In general there was a clear and consistent care planning system in place that provided staff with the information they needed to satisfactorily meet the service users needs. Service user’s health needs were generally monitored and reviewed appropriately however EVIDENCE: Case tracking of four service users was completed, which included examination of care records and discussions with service users and staff. Care programmes for two existing service users and two recent admissions were looked at. The format of the documentation remains the same and the care plans were generally very well developed; the documentation system was well thought out and user- friendly however a number of inconsistencies that were previously identified still remain such as not all problems having been identified on the care plans when changes in need had occurred. One of the existing service users had been admitted to hospital prior to Christmas due to a general deterioration in her health, on readmission to the home the care plan had been updated and reviewed; it clearly detailed the College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 12 current care needs. Examination of another existing service users plan evidenced that the service user had sustained a fractured hip following a fall and the care plan and moving/ handling risk assessment had been updated to reflect the service users current mobility needs. The service user had subsequently fallen again the previous week; there was evidence in the records that the service user had been taken to hospital for examination however no further injuries had been sustained. Daily records evidenced that the District Nurses were carrying out a continence assessment however there was no care plan in place to support the service user’s current continence needs. Two care plans for recent admissions to the home were case tracked; both the care plans were detailed and appeared to cover all identified needs from assessment. Risk assessments were in place for tissue viability, moving/ handling, nutrition and falls; all high-risk areas had care programmes in place. One of the service users had an identified high risk of falling out of bed; bed rails had been provided on admission and three days following admission the resident had moved herself to the end of the bed and subsequently fallen sustaining facial injuries. The risk assessment for the use of bed rails for this service user had not been reviewed; the registered provider was advised during the visit that this must take place to assess the suitability of the equipment provision. The inspector noted that the service user had sustained significant bruising to her eyes and nose; staff reported that the bruising had worsened since the accident; there was no evidence that the staff had accessed any medical review of the service users injuries since the accident four days previously and therefore the inspector advised the senior care assistant to contact the GP who instructed the home to take the service user to the accident and emergency department for assessment and examination. An accident report had been completed however there were no records of the incident in the care programme daily records for that day; staff confirmed that the next of kin had been informed of the incident. There was evidence in care records of liaison with health and social care professionals such as physiotherapist, district nurses, CPN, care manager and G.P’s. The medication policy had been reviewed in October by the registered manager; there are clear procedures in place for receipt, storage, administration and return of medication; other areas such as covert administration, administration errors and self medication are covered. The policy to support self- medication requires some review to include assessment of suitability and capability. One of the care files examined evidenced recent medication review by the G.P. As found at the previous inspection visit a number of gaps were identified in the Medication Administration Records; these included doses of Warfarin, Chlorpromazine, Ranitidine and Lorazepam medication. There were no service users currently prescribed Temazepam night sedation, however staff confirmed College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 13 that this medication would be stored in the controlled medication cupboard. The registered manager had ensured that the temperature of the medication storage area was monitored and daily records demonstrated that the temperature was in line with the manufacturers guidance. Staff confirmed that all the senior staff had accessed the accredited medication course and three care staff were now completing the course; one of whom received confirmation during the visit that she had successfully completed the course. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The home supports service users to exercise choice and control over their lives. EVIDENCE: Policies were in place which covered: promoting independence, rights, access to records, communication and risk taking. Within the staff code of conduct there is also a policy on promoting rights and interests of others. Service users at interview confirmed that the staff supported them to maintain their independence and exercise personal choices. One service user told the inspector how the registered provider had recently supported her when she wanted an early discharge from hospital and how the helpful the staff were in facilitating her trips out with friends. There was evidence during the visit from staff interviews and observation that service users were always consulted about their care provision and supported to make decisions about their activities of daily living from care support, clothing to meals and activities etc. Service users rooms were seen to be personalised to the extent chosen by the individual. Information leaflets on advocacy and financial support were available in the hall. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 15 College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home provides an atmosphere whereby people feel able to make complaints. EVIDENCE: The homes complaint procedure was clear and displayed in the staff office; a copy should be provided in the entrance area. It had appropriate timescales for resolution and included contact details of other agencies. The home had not received any complaints since the previous inspection. The service users spoken to felt able to make any complaints they may have either to the manager or staff members. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 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 and 26 Residents are provided with a safe, warm and comfortable environment that is homely and welcoming. Maintenance work should be more expediently carried out when identified to prevent undue risks to service users. EVIDENCE: The inspector did not carry out a detailed inspection of the facilities. As identified in the previous report the registered providers have recently submitted plans to support major alterations to the home to provide a first floor extension with two single en- suite rooms, alterations to shared rooms to provide single, en- suite accommodation, new bathing facilities and an extension to the lounge. Along with this work the electrical and plumbing systems will be upgraded. The service users have been made aware of these planned works and consulted where possible. Given the timescale of the proposed work it is important that the management ensure that in the meantime all necessary works still be carried out; the College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 18 repairs to the tiled area behind the kitchen sink (identified in the EHO report of April 2005) had not yet been carried out therefore an immediate requirement notice was issued. All areas seen were comfortable and clean. All residents spoken to confirmed that they liked their rooms and the staff kept them clean and tidy. Good use was seen to be made of all communal areas with residents choosing to sit in either of the sitting rooms, the entrance hall or the dining room. The staff had stored a mattress on the first floor landing which needs to be moved to an appropriate storage area. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 19 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, 29 and 30 Staff morale is good resulting in an enthusiastic workforce that works positively with service users to improve their quality of life however recent admissions have increased the dependency of the service users resulting in occasions where there are not enough staff rostered to ensure service users safety. EVIDENCE: There were ten service users residing at the home during the inspection visit. Staff at interview reported that the dependency of the service users has increased significantly in recent times with the change in need of one of the existing service users and the needs of one of the new admissions. Both service users have needs associated with dementia and both residents have a history of recent falls where they sustained significant injuries; staff are having to closely monitor these residents as they continually try to mobilise independently. From observation during the visit and staff interviews it was clear that with the current staffing arrangements the staff are experiencing difficulties in providing the close monitoring required at all times. The registered manager had been on annual leave the previous week during the time that the dependency had increased significantly. Rotas were examined which evidenced that levels of two/ three staff were rostered on the a.m. shift, two staff on the p.m. shift and one waking and sleeping staff on night duty. The care staff also have responsibilities for some catering and laundry duties; staff reported that the morning times and tea times were the busiest. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 20 The rotas confirmed that the registered manager regularly covered a number of shifts each week mainly to cover the shift deficit caused by the other registered provider moving to the sister home to cover the managers position, but also due staff sickness. An immediate requirement notice was issued for the registered manager to review the current staffing levels to ensure adequate staffing levels were provided to meet the current service users needs. The home had not recruited any new staff since the previous inspection visit, therefore the recruitment procedures of obtaining CRB checks prior to employment could not be tested however the registered provider confirmed that improved systems were in place and POVA First checks would now be accessed. Three files for existing staff members were examined and contained all relevant documentation to evidence compliance with regulations. At the previous visit it was evidenced that individual staff training records were not up to date; there had been little improvements. At the previous visit the manager showed the inspector a training matrix which identified all the training completed and planned for the year however this was not available. The staff files did contain a number of certificates but these did not reflect all the training sessions the staff themselves confirmed they had accessed over the last twelve months. All care staff spoken to confirmed that they had in fact accessed a significant amount of training over the last year which included both mandatory, general and service specific elements. Staff and records confirmed that induction training to NTO standard was in place. NVQ training continues with four staff working towards their level 3 certificates. An immediate requirement notice was issued to update all the individual staff training records and to provide an up to date training matrix which identified all training accessed over the last twelve months and future training arranged. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36 and 38 Standards in the record keeping and management systems in a number of areas have slipped which does not protect the health, safety and welfare of the people using the service. EVIDENCE: The registered manager was not on duty at the time of the inspection although the inspector was able to have discussions with the registered provider. Staff at interview reported that moral was very good; they enjoyed working at the home, there was a very good team approach and that the residents were the priority. They considered the home was well managed and the registered manager very professional with a very hands on approach. One of the service users told the inspector that “the manager was lovely and always sorted things out for her.” College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 22 Policies and procedures were in place to support the management of service users personal monies; these accounts are held in a locked safe in the manager’s office. The home manages five service users personal monies, all accounts were checked which revealed a number of discrepancies. One account was deficit of £43 and two other accounts had surplus of £1 and 79pence respectively. An immediate requirement notice was issued to the manager to carry out an audit to account for the irregularities and to review the systems to ensure the future management is safe. There was no evidence that any progress had been made towards full implementation of the quality assurance programme; documentation for audits and surveys has been sourced and now needs to be implemented. Deficiencies identified in this report and previous report such as medication administration records, supervision records, staff training records and HACCP records should be considered for inclusion in the audit programme to provide more regular monitoring by the registered manager. The staff supervision programme had not been maintained; records in the three staff examined files demonstrated that staff members had not received a supervision session since July 2005, however staff interviewed during the visit confirmed that they had accessed a session sometime before Christmas. Records evidenced that the sessions were thorough; covering all aspects of the staff member’s performance and practice. Safety checks had been carried out on installations and equipment in the home; the electrical systems have been checked, however as significant rewiring will take place as part of the works programme the electrical certificate will be issued on completion. All hot water outlets accessible to service users now have thermostatic valves fitted; records and random checks during the visit evidenced that this system was now well managed. Staff access fire drills through the training courses provided; the most recent course had been provided in October 2005. A current fire risk assessment was in place and the registered manager had implemented and maintained documentation to support weekly audits of fire safety equipment. Staff confirmed that bed rails had been provided to two service users in recent weeks; the registered manager should ensure regular checks of this equipment takes place in line with guidance from the MDA. Inspection of the fridge and freezer temperatures records in the kitchen revealed that there were still a number of gaps in the records; this had been identified in the previous report and also the EHO report of April 2005. Staff were maintaining records of cooked food daily. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 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 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 1 2 X 2 College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 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 OP33 Regulation 24 Requirement The registered person must establish and maintain an effective quality assurance system Previous timescale of 31/12/05 Unmet The registered person must ensure that care plans are updated to reflect all current care needs. Previous timescale of 31/10/05 Unmet Timescale for action 31/03/06 2. OP7 15 31/01/06 3. OP38 23(2)b and 4(a) The registered person must 31/07/06 ensure that there is a five-year electrical certificate in place. On completion of the works programme- timescale extended. The registered person must ensure that all assessment information from the preadmission visit is clearly documented. The registered person must ensure that the home writes to potential service users following assessment to confirm that the DS0000002851.V278418.R01.S.doc 4 OP3 14(1) 30/01/06 5 OP3 14(1)d 15/02/06 College View Care Home Version 5.1 Page 25 6 OP1 4 7 OP8 12(1) 8 OP8 13(4)c 9 OP38 13(4) 10 OP9 13(2) 11 OP38OP19 16(2)g,j and 13(4)c 12 OP27 18(1)a 13 OP30 18(1)(c )i home can meet their needs. The registered person must apply to the commission to vary their registration to include the category of dementia. The registered person must ensure that systems are in place whereby staff ensure appropriate medical attention is sought for service users following injuries sustained through falls. The registered person must ensure that where new service users have identified tissue viability needs prior to moving to the home that the appropriate equipment is in place on admission to meet their needs. Ensure that systems are in place to review the use of equipment such as bed rails when the service user may be put at greater risk with continued use. The registered person must ensure that staff complete the medication administration charts in accordance with NMC and CSCI guidance. The registered person must ensure that repairs to the tiling and sealed areas of the kitchen sink are carried out. Previous timescale of 30/11/05 not met. Immediate requirement notice issued. The registered person must ensure that staffing levels are reviewed to ensure appropriate levels are maintained to meet current care needs. Immediate requirement notice issued. The registered person must ensure that all individual staff training records are updated to record all training accessed over the last twelve months and to develop a current staff training DS0000002851.V278418.R01.S.doc 15/02/06 16/01/06 16/01/06 16/01/06 16/01/06 30/01/06 17/01/06 27/01/06 College View Care Home Version 5.1 Page 26 14 OP35 17(2) and 16(2)l 15 OP36 18(2) 16 OP38 16(2)j and 13(4)c programme. An immediate requirement notice was issued. The registered person must audit 23/01/06 the service users personal money accounts to account for the irregularities and develop clearer systems to ensure safe management of monies. An immediate requirement notice was issued. The registered person must 15/02/06 restart the supervision programme and ensure that care staff receive at least six formal supervision sessions per year. Programme to recommence by: The registered person must 16/01/06 ensure that all temperature records to support HACCP management are fully maintained. Previous timescale 30/11/05 not met. 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 OP16 OP38 Good Practice Recommendations The registered person should the self- medication policy includes procedures for assessment of service users suitability and capability. The registered person should display the complaints procedure in a more public place such as the entrance hall. The registered person should ensure regular checks of bed rails(when in use) are carried out in line with guidance from the MDA. College View Care Home DS0000002851.V278418.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 College View Care Home DS0000002851.V278418.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. 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