CARE HOMES FOR OLDER PEOPLE
Cressingham House 19 - 25 Cressingham Road Wallasey Wirral CH45 2NS Lead Inspector
Inger Moynihan Key Unannounced Inspection 31st May 2006 09:00 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 Cressingham House DS0000018880.V289499.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. Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Cressingham House Address 19 - 25 Cressingham Road Wallasey Wirral CH45 2NS 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) 0151 639 4626 Wallasey Free Women`s Church Council (Cressingham House) Susan Sherwen Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: Mr David Shafik from Keychange Charity is now the registered person for Cressingham House. Cressingham House had been converted from four midterraced houses. The home was set in a small courtyard garden in a quiet residential road, close to local shops and to the New Brighton promenade. Accommodation is provided on the ground and first floor. With communal areas consisting of a large and small lounge and a spacious dining room, which is located on the ground floor. There are no separate visitors room, but all rooms were single occupancy and a number are arranged as bed-sitting rooms. There are bathing facilities on both floors and a two-stage stair lift gives access to the first floor. Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Unannounced inspection took place over five hours and was conducted with Mrs Susan Sherwen, registered manager. Information about the service was obtained through a pre-inspection questionnaire and discussions with the registered manager and the staff team. Service users case files and supporting documentation was examined and a tour of the building took place. What the service does well:
Service users are only admitted into the home on the basis of a full assessment, which ensures staff can provide the appropriate package of care. Service users health, personal and social care needs are set out in an individual plan of care. Efficient systems are in place to ensure service users good health. One service user spoken to during the inspection said she felt well cared for and commented I really cant speak highly enough of the staff team. Service users feel they are treated with respect and their right to privacy is upheld. All of the service users spoken to during the inspection confirmed their needs were fully met and they praised the staff team for their kind and caring nature. One service user said the staff are fantastic, they are very kind and very understanding. A range of social activities are provided to ensure service users interest and mental stimulation. One service user commented I am aware social activities are available however I like to keep myself to myself. Service users can maintain contact with their family and friends at any time. A varied and nutritious diet is provided to ensure service users interest and good health. All of the service users spoken to commented on the high standard of food provided and said they always had enough to eat and drink and a choice was always provided. One service user commented the food is really good and I always have a choice. Service users are confident their complaints will be listened to, taken seriously and acted upon. All of the service users spoken to during the inspection said
Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 6 they were very happy with the standard of care they received and had no complaints to make. One service users stated the staff are very good, I have no complaints to make as I have everything I need. Systems are in place to ensure service users are protected from abuse. The registered manager is qualified, competent and experienced to manage the home which is run for service users best interests. All care staff are provided with regular supervision to enable them to improve and develop within their role as care providers. Discussion with staff during the inspection confirmed they enjoyed their work and they felt well supported in their role. The health, safety and welfare of the service users are promoted throughout the home. What has improved since the last inspection? What they could do better:
Service users are only admitted into the home on the basis of a full assessment, which ensures staff can provide the appropriate package of care. Issues of equality and diversity need to be explicitly addressed in the assessment process to ensure service users specific care needs are met. Service users health, personal and social care needs are set out in an individual plan of care. Issues of equality and diversity need to be explicitly addressed in the care planning process to ensure service users specific care requirements are met. Improvements need to be made to the medication administration procedures to ensure service users safety and welfare. The standard of the decor is mixed with some parts of the home being maintained to a good standard and other parts being in need of further decoration and refurbishment. The home does not therefore present as a homely and comfortable environment throughout. The home has thorough recruitment procedures to ensure suitably qualified and competent staff are employed at the home. However, the registered
Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 7 manager indicated that the staff records may need to be streamlined to ensure all of the necessary information is in place. Service users needs are met by the number and skill mix of staff although the registered manager acknowledged that an more staff are needed at certain times f the day to ensure service users care needs are fully met at all times. Staff are provided with a range of appropriate training to ensure they know how to care for the service users in accordance with good practice . However, the registered manager acknowledged that further training does need to be provided. The registered manager does not routinely handle service users money, although she does take responsibility for the finances of one service user. Some improvements need to be made to the record keeping in relation to this aspect of service provision. 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. Cressingham House DS0000018880.V289499.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 Cressingham House DS0000018880.V289499.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 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are only admitted into the home on the basis of a full assessment, which ensures staff can provide the appropriate package of care. Issues of equality and diversity need to be explicitly addressed in the assessment process to ensure service users specific care needs are met. EVIDENCE: Examination of documentation relating to the assessment process indicated that a range of appropriate issues had been assessed to ensure the staff know how to look after the service users properly. Staff spoken to confirmed they had access to this information. The assessments however did not explicitly address all issues relating to equality and diversity such as race, religion, age, gender, sexuality and disability. The registered manager stated she was not aware that any service users had specific care requirements in relation to these issues with the exception of disability, gender and age. In the light of this, the registered person is required to ensure the assessment documentation is updated to ensure service users specific care requirements in relation to all
Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 10 issues of equality and diversity are explicitly addressed in the assessment process. All of the service users spoken to during the inspection confirmed their needs were fully met and they praised the staff team for their kind and caring nature. One service user said the staff are fantastic, they are very kind and very understanding. Cressingham House DS0000018880.V289499.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, 9 and 10 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in an individual plan of care. Issues of equality and diversity need to be explicitly addressed in the care planning process to ensure service users specific care requirements are met. Efficient systems are in place to ensure service users good health. Improvements need to be made to the medication administration procedures to ensure service users good health. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: A documented plan of care has been compiled for each service user. The care plan covers a range of issues relating to service users care needs and offers
Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 12 staff guidance on how to look after the service users in accordance with these identified needs. Documentation is in place to demonstrate that service users physical and mental welfare is monitored regularly and they have access to a range of relevant health care professionals to support them with their physical and mental welfare. One of the service users confirmed she has access to her GP when she wants and sees the chiropodist regularly. One service user spoken to during the inspection said she felt well cared for and commented I really cant speak highly enough of the staff team. Efficient systems are in place for the safekeeping, handling and administration of service users’ medication and only trained staff are allowed to administer medication. A policy and procedure in relation to the administration of medication is in place and a record is kept of all medication returned to the supplying pharmacist. All of the service users spoken to during the inspection confirmed they received their medication as prescribed by their GP. The following issues arose in relation to the medication administration: • • • • the homely remedies policy needs to be more detailed and streamlined information regarding a service users eye cream had been recorded on the medication ministration record sheet, however this had not been cross-referenced to the service users case file for further information a risk assessment had not been completed for one service user who administers their own medication the medication administration record sheet had not been completed for one service user who required a skin cream. The registered manager agreed to ensure these issues were addressed by the end of the day of the inspection. Concerns have been raised at previous inspections about the way in which this aspect of care provision is managed. These concerns resulted in the CSCI pharmacist visiting the home to carry out an inspection of the medication procedures and give further advice and information. Again issues of concern are raised in relation to the way service users medication is managed. In the light of this the registered person is required to ensure all aspects of service users medication administration are accurately maintained and service users welfare is protected. While it is acknowledged that staff have completed training in relation to this aspect of care provision further training should be provided to ensure service users welfare is promoted. Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 13 Cressingham House DS0000018880.V289499.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): 12, 13 and 15 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of social activities are provided to ensure service users interest and mental stimulation. Service users can maintain contact with their family and friends at any time. A varied and nutritious diet is provided to ensure service users interest and good health. EVIDENCE: A range of social activities are provided which include an exercise class, reminiscence group, and arts and crafts etc. Staff accompany service users to the local shops and arrangements are being made for staff to take the service users on a narrow boat and to Martin Mere bird sanctuary. One member of staff is allocated specifically to provide social activities for the service users. This is in line with good practice and ensures the service users do not become bored. The service users confirmed they were aware the activities took place and confirmed they could join in if they wish. Some of the service users stated they did not wish to become involved in the activities and were happy the staff
Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 15 respected their decision. One service user commented I am aware social activities are available however I prefer to keep myself to myself. The service users spoken to during inspection confirmed the routines in the home are flexible which means they can see their family and friends when they want. Service users bedrooms are single occupancy which means they can see their visitors in private. Mealtimes are flexible and service users dietary requirements are met. A varied and balanced diet is provided to ensure service users interest and good health. Service users medical needs are catered for in the menu planning. All of the service users spoken to commented on a high standard of food provided and said they always had enough to eat and drink and a choice was always provided. One service user commented the food is really good and I always have a choice. Documentation is in place to demonstrate that staff have assessed service users dietary requirements and that their dietary intake is monitored when necessary. Cressingham House DS0000018880.V289499.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 and 18 Th The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident their complaints will be listened to, taken seriously and acted upon. Systems are in place to ensure service users are protected from abuse. EVIDENCE: The home’s complaint procedure is displayed. Service users spoken to were aware of who they should contact in the event of them wishing to make a complaint about the care provided. All of the service users spoken to during the inspection said they were very happy with the standard of care they received and had no complaints to make. One service users stated the staff are very good, I have no complaints to make as I have everything I need. All staff have completed basic training in relation to the protection of vulnerable adults from abuse and a copy of the Wirral adult protection procedure is in place to ensure staff know how to deal with an incident of abuse correctly. The service users spoken to during inspection confirmed they were very happy with the care they received and said that staff were always courteous and polite. Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 17 Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Th The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the decor is mixed with some parts of the home being maintained to a good standard and other parts being in need of further decoration and refurbishment. The home does not therefore present as a homely and comfortable environment throughout. EVIDENCE: A programme of maintenance and refurbishment is in place. Building work is currently being carried out in three of the bedrooms and it has been agreed that any additional redecoration work on this floor would be put on hold until this building work had been completed. Plans are currently being made for two new baths to be fitted and the refurbishment of the bedrooms on the first floor. Arrangements are also being made for all of the bathrooms to be refurbished as at present they are in a very basic condition and in one instance a very poor condition. Although this bathrooms is no longer used, this does reduce the amount of bathing facilities available to service users.
Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 19 In one bedroom a scrap of carpet was being used as a rug. This particular issue has been raised at a past inspection when it was highlighted to the registered manager that this was totally unacceptable. If a service user wants a rug in their bedroom then a proper rug should be purchased. The use of scraps of carpet is unacceptable and does not offer the service user respect or homely comfort. The registered person has made a clear commitment to ensure this improvement work is completed as quickly as possible. The CSCI will continue to work with the registered person to ensure this work is completed and to ensure the service users are provided with a much more pleasant environment to live. However in the interim the registered person is required to submit a copy of the refurbishment programme to the CSCI giving timescales for the completion of this work. This should include the electrical wiring, installation of new baths and the redecoration and modernisation of the bedrooms and bathrooms. All parts of the home are clean and tidy and comfortably warm and policies and procedures are in place to prevent the spread of infection. Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 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, 29 and 30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the number and skill mix of staff although the registered manager acknowledged that an increase in staff was required to ensure service users care needs are fully met. The home has thorough recruitment procedures to ensure suitably qualified and competent staff are employed at the home. However, some improvements need to be made to the record keeping to ensure all the necessary security checks are in place. Staff are provided with a range of appropriate training to ensure they know how to care for the service users in accordance with good practice. However, the registered manager acknowledged that further training does need to be provided. EVIDENCE: Information submitted to the CSCI prior to this inspection indicated that staff are evenly deployed across the week. However, the registered manager acknowledged that because service users care needs are increasing, additional staff may be required at specific times of the day. In the light of this the registered person is required to ensure sufficient staff are employed at the home at all times to ensure the safety and welfare of the service users. There
Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 21 have been few changes to the staff group which is a positive aspect of the home and ensures consistency in the care provided to the service users. Documentation was in place to indicate appropriate checks had been carried out on all staff to ensure they are suitable to work with vulnerable adults. The staff spoken to during the inspection confirmed they had completed a Criminal Records Bureau police check and that two staff references were taken up prior to their employment. The registered manager has undertaken a good deal of work to streamline all of the staffing files and certainly this information was easy to audit. However, she did say that some more work still needs to be carried out in respect of this aspect of care provision and agreed to ensure this was addressed. The information submitted prior to the inspection indicated that staff had undertaken a range of appropriate training to ensure the service users are well cared for and they are up to date on current good practice. The registered manager recognised that further training still needs to be provided and had made plans for this aspect of care provision to be developed. In the light of this the registered person is required to submit a copy of the forthcoming years training plan to the CSCI for inspection. Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 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): 31, 33, 35, 36 and 38 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified, competent and experienced to manage the home which is run for service users best interests. Systems are in place to ensure the home is run for the best interests of service users. However, some improvements do need to be made to ensure the smooth running of the home and the welfare of the service users. The registered manager does not routinely handle service users money, although she does take responsibility for the finances for one service user. Some improvements need to be made to the record keeping in relation to this aspect of service provision. All care staff are provided with regular supervision to enable them to improve and develop within their role as care providers.
Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 23 The health, safety and welfare of the service users are promoted throughout the home. EVIDENCE: There are clear lines of management and accountability within the home which is run for service users best interest. The staff spoken to during the inspection spoke well of the registered manager saying she was always available for advice and support when necessary. Although a formal quality assurance system is not in place procedures have been set up to ensure an improved standard of care is maintained. This includes the manager and senior staff speaking to service users daily and the registered manager carrying out spot checks around the building. A senior member staff carries out a monthly audit of the standard of care provided. Questionnaires are currently being drawn up and will be sent to service users and their family in order to obtain their views on the standard of care provided. The registered patients should also look to obtaining the views of relevant health care professionals on the way the service users are cared for. The registered manager takes responsibility for the finances of one service user. The records inspected were in good order, although more detailed information does need to be recorded in relation to this aspect of care provision. A system of formal supervision has recently been introduced into the home. This formal supervision gives the member of staff an opportunity to meet with their line manager and discuss any issues or concerns they may have and their development within their role. Discussion with staff during the inspection confirmed they enjoyed their work and they felt well supported in their role. The health, safety and welfare of the service users and staff are promoted throughout the home. Staff confirmed they have completed training in this aspect of care provision and have access to policies and procedures to support them within their role. Documentation examined indicated that regular safety checks are made on all equipment used in the home. Regular fire safety training is provided and the whole fire alarm system is serviced regularly. Work is currently being undertaken on the electrical wiring of the building although the points raised at the last electrical inspection that require urgent attention have been addressed. The registered manager agreed to send a copy of the electrical wiring certificate to the CSCI when the current electrical work has been completed. Staff have undertaken a range of training in relation to food hygiene, first aid, moving and handling and infection control. The manager did acknowledge that some of this training needed to be updated and confirmed that arrangements are currently being made for further training
Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 24 to be provided. In the light of this the registered person must submit a copy of the forthcoming years training programme to the CSCI for inspection. At the last inspection an issue was raised in relation to the registered manager wedging doors open. This resulted in a requirement being made for the registered person to provide proper door opening devices. These door devices have now been purchased but have not been fitted because the registered manager stated she is experiencing some difficulties in finding a company to carry out this work. In light of the fact that some service users prefer their bedroom door to be kept open because they spend a considerable amount of time in their room, the registered person must ensure this issue is addressed as quickly as possible as could lead to the service user feeling isolated. Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 3 x 2 Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 26 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 OP3 Regulation 14 Requirement The registered persons are required to ensure that issues of equality and diversity are explicitly addressed in the assessment process. The registered persons are required to ensure that issues of equality and diversity are explicitly addressed in the assessment process. The registered person is required to ensure accurate records are kept in relation to the administration of service users medication. The registered person is required to ensure the medication administration record sheets are signed to indicate any prescribed creams are administered. (previous timescale of 10/2/06 not met) The registered person is required to ensure an up to date risk assessment is in place for any service user who takes responsibility for the administration of their own medication.
DS0000018880.V289499.R01.S.doc Timescale for action 05/07/07 2 OP7 15 05/07/06 3 OP9 13 31/05/06 4 OP9 13 31/05/06 5 OP9 13 31/05/06 Cressingham House Version 5.1 Page 27 6 OP19 23 7 OP27 18 8 OP29 19 9 OP30 18 10 OP35 12 12 OP38 18 13 OP38 13 The registered person is required to ensure the standard of the decor is improved. In this instance that a copy of the programme of maintenance is submitted for inspection. The registered person is required to ensure the staffing levels provided at the home meet service users care needs. The registered person is required to ensure all records relating the employment of staff are in place and available for inspection. (previous timescale of 02/03/06 not met) The registered person is required to ensure suitably qualified and competent staff are employed in the home. In this instance that a copy of the forthcoming years training programme is submitted to demonstrate the training that will be provided in relation to care issues. The registered person is required to ensure more detailed information is recorded in relation to the management of service users finances. The registered person is required to ensure suitably qualified and competent staff are employed in the building. In this instance the registered person is required to submit a copy of the forthcoming years training programme to demonstrate the training that will be provided in relation to health and safety. The registered person is required to ensure the health, safety and welfare of the service users. In this instance that proper door opening devices are fitted (previous timescale of 16/03/06 not met).
DS0000018880.V289499.R01.S.doc 05/07/06 31/05/06 05/07/06 05/07/06 05/07/06 05/07/06 05/07/06 Cressingham House Version 5.1 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cressingham House DS0000018880.V289499.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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