Inspection on 20/04/07 for Culwood House

This inspection was carried out on 20th April 2007.

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

Culwood House 26/09/08

Culwood House 09/04/08

Culwood House 28/07/06

Culwood House 07/02/06

Culwood House 24/05/05

Culwood House 10/01/05

Culwood House 17/08/04

Culwood House 28/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Culwood House 130 Lye Green Road Chesham Bucks HP5 3NH Lead Inspector Sally Newman Unannounced Inspection 20th April 2007 09:55 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 DS0000022968.V330974.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. DS0000022968.V330974.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Culwood House Address 130 Lye Green Road Chesham Bucks HP5 3NH 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) 01494 771012 01494 783051 webbecj4572@aol.com www.culwoodhouse.co.uk Mrs Anita Larkin Mr Larkin Mr Chris Webb Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places DS0000022968.V330974.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accommodation with both board and care is provided at any one time shall not exceed 14 (fourteen) The Home is registered to accommodate older people 28th July 2006 Date of last inspection Brief Description of the Service: Culwood House is a privately run care home providing personal care and accommodation for 14 older people. The home is in an Edwardian building, located on the outskirts of Chesham about one mile from the town centre. There is dropping off space and parking at the front of the building. There is a mature garden with shady seating areas for residents. A part of the home is the private residence of the manager. The home is not purpose built and does not have a lift. All bedrooms are single and have en-suite facilities (WC and sink). The fees range from £595 to £650 pounds per week. Additional costs include hairdressing, chiropody, papers and personal effects. Information about the home can be obtained directly from the home. DS0000022968.V330974.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection, which was conducted over the course of three days and included a visit to the home of 5 ¾ hour duration. The visit to the home was undertaken by two inspectors and was unannounced. Ten service users and two visitors to the home were spoken to. In addition, a visiting district nurse was spoken to in private and three members of staff were interviewed. Time was spent with the manager discussing the service and feedback was provided by telephone because the manager needed to attend an appointment on the afternoon of the visit. A brief meeting was held with the registered provider. Information held by the Commission about the service was reviewed and a questionnaire sent to the service prior to the visit, was provided by the manager on the day of the visit. The questionnaire was not complete but the manager did offer to fully complete it during the course of the visit. The manager did not distribute surveys provided by the Commission on the basis that the questions relating to gender and sexual orientation had offended service users on a previous occasion. During the visit a range of records were seen and a tour of the premises was undertaken. The homes approach to equality and diversity was observed throughout the inspection process. The Commission has received no complaints about this service since the last inspection. The home has many strengths but there are also significant weaknesses. There is an over reliance on the verbal communication of important information and overall an informal approach to the service provided. Particular areas of concern focus on documentation relating to service users and specifically assessments and care planning. However, there is generally a lack of commitment to quality paperwork overall. The manager was unable to produce all of the documentary evidence requested by the inspectors. Although the manager acknowledged that these areas of weakness were unacceptable, in practice, the Commission for more than two years has required improvements in care planning. The manager and staff spoken to demonstrated knowledge of service users needs and service users themselves indicated that their needs were being met. There was little evidence that service users are put at risk by the lack of supporting paperwork. The home provides a homely and welcoming atmosphere. There is a stable staff group who are familiar to service users. The majority of service users spoken to were happy living in the home with comments received including “apart from the fact it is not home you could not get a better place”, “couldn’t get any better than this home”, “I’m happy” and “It’s a very kindly house”. DS0000022968.V330974.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Staff must respect service users right to privacy and knock before entering bedrooms. Review care-planning documentation and value them as working documents. Fully implement the proposed staff-training package. DS0000022968.V330974.R01.S.doc Version 5.2 Page 7 The manager must lead the staff team by example in respect of the completion of supporting paperwork. Implement a more formal staff supervision programme. 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. DS0000022968.V330974.R01.S.doc Version 5.2 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 DS0000022968.V330974.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There was very little documentary evidence that a thorough needs assessment is undertaken prior to a place being offered. EVIDENCE: The files for four service users who had moved to the home since the last inspection were seen. In two files only names, addresses, dates of birth and next of kin details had been recorded. The remaining two files contained only very brief information, which did not constitute thorough needs assessments. Some knowledge of these service users needs was demonstrated in discussion with the manager and two care staff. Two relatives of the two newest service users were spoken to and confirmed that they had prior knowledge of the DS0000022968.V330974.R01.S.doc Version 5.2 Page 10 home and had visited before their relatives moved into the home. They also confirmed that they had discussed the care needs of both service users with the manager. In discussion the manager confirmed that he had not yet contacted the G.P. for relevant information in respect of two of the service users despite the fact that they had moved to the home six days previously. The manager acknowledged that the lack of a formal assessment by suitably qualified persons was not acceptable and further was in contravention of regulation 14 (1). It will be a requirement that no further service users are offered a place in the home until a thorough needs assessment has been undertaken by suitably qualified persons to ensure that the home can meet their needs. This home does not provide an intermediate care service. DS0000022968.V330974.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general the health, personal and social care needs of service users are met but are not adequately reflected in care plans. There are robust arrangements for medication and service users are treated with respect and generally their right to privacy is upheld. EVIDENCE: Evidence was obtained from looking at a sample of care plans, from discussion with service users, relatives, care staff the manager and a visiting district nurse. At the inspection of 28th July 2006 it was noted that new care plan formats had been introduced but had not been fully implemented. It was evident from those care plans seen that they are not being completed fully and if reviews DS0000022968.V330974.R01.S.doc Version 5.2 Page 12 are taking place they are not being recorded. The range of documentation is cumbersome and not always relevant to a particular individual. These observations were noted at the inspection on 7th February 2006 and it was difficult to see where improvements had been made. The manager and the responsible individual have failed to recognise formal care planning as an essential tool for effective delivery of care. This lack of commitment influences the staff team and there is a general view that documenting information is undertaken to appease others outside of the home and is not a valued activity. However, in discussion with inspectors, care staff and the manager demonstrated a good knowledge of the needs of individual service users. Service users and relatives reported that their needs were being met and observations confirmed that staff and service users feel comfortable with each other. Service users were able to inform inspectors about their health care needs and confirmed that they have access to health and social care professionals when needed. Care plans seen did include a useful document, which recorded when and why health care professionals were visiting individual service users. This document was headed as ‘G.P. visits’ but included other health care professionals visits to the home. One irrelevant entry about a social activity was noted. Discussion in private took place with a visiting district nurse who confirmed she had known the home for ten years. She stated that a good relationship existed between the home and health care professionals’; she had no concerns and was confident that advice was acted upon appropriately. She visited unannounced and there were always staff on duty that were knowledgeable about service users needs. The home now uses small coded safes for the storage of medication. The pharmacy used provides medication in a monitored dosage system. The manager stated that the pharmacist does visit approximately annually to check the arrangements for medication but the last report could not be provided. In addition the pharmacist had provided training to staff but documentary evidence was not available. Some staff had attended external medication training but this had proved to be over complicated and not altogether relevant to the homes policies and practices. It was noted that at least two service users administer their own medication, which is stored in their bedrooms in unlockable facilities. It is recommended that the home provide lockable storage for those service users who self medicate. Service users spoken to felt that they are treated with dignity and respect. However, two service users stated that not all staff knock before entering bedrooms and this was observed by inspectors during the course of the visit. Staff must be mindful of the delicate balance between friendliness and over familiarity. DS0000022968.V330974.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 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 lifestyle in the home meets service users needs. Contact with family and friends is encouraged and supported and where possible service users can exercise choice and control over their lives. The mealtimes are flexible and service users enjoy the food provided. EVIDENCE: Evidence was obtained from discussion with service users, the manager, staff and visitors and from observations. Occasional activities are arranged by the home but these events are not recorded. Regular activities include the mobile library, communion on a 6 weekly basis, representative’s visit from various churches and women institute singers have performed in the home. Birthdays and special occasions are celebrated with the agreement of individuals. The manager reported that the home does have a range of board games, which are used with service users by DS0000022968.V330974.R01.S.doc Version 5.2 Page 14 staff. Discussions with service users indicated that overall they were comfortable with the lifestyle they experienced in the home and did not necessarily want lots of organised entertainment and activities. It was evident from talking to staff that the interests of service users are known but are not recorded in care plans. Visitors are welcome in the home and some service users mentioned planned visits anticipated from relatives and friends. The manager stated that most service users like to go out with their relatives when they visit. Time was spent with the housekeeper who’s responsibility it is to organise the meals. She confirmed that fresh meat is ordered from the local butcher and fresh vegetables are always available at main meals with frozen vegetables only very occasionally being used. Food is always temperature probed immediately before serving and records were in evidence. With only 14 residents it was extremely difficult to provide a regular choice for main meals but an appropriate alternative was always available if required. The housekeeper confirmed that most residents’ likes and preferences were known and during the discussion she demonstrated a sound knowledge of individuals likes and dietary needs in relation to diabetes etc. The inspector was shown documentation, which confirmed that residents were offered a range of breakfasts each morning according to individual choice. The manager confirmed that a dietician has had seen the menu but this had been an informal arrangement and no report had been provided. Overall service users spoken to were happy with the food provided with several complimentary comments being made. DS0000022968.V330974.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously. Service users are protected from abuse but staff would benefit from formal training. EVIDENCE: The home has a complaints policy which was reviewed in January 2006 and which is made available to service users. The manager confirmed that there had been no complaints or concerns made about the home since the last inspection. There was no written record of complaints available in the home and the inspectors were informed that the Registered Individual was currently holding this record. Service users spoken to indicated overall satisfaction with the service with no concerns or complaints in evidence. Since the last inspection some staff have attended protection of vulnerable adults training. The manager confirmed that a group of staff had attended arranged external training where the trainer had not turned up. A member of care staff also confirmed this during discussion with the inspector. One staff member spoken to clearly understood the range of potential abuses but could not outline the correct action to be taken. It was a requirement at the last inspection that all staff should attend protection of vulnerable adults training and whilst it is acknowledged that the home have attempted to obtain this training for all staff the requirement will be repeated. DS0000022968.V330974.R01.S.doc Version 5.2 Page 16 DS0000022968.V330974.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This home provides a safe and well-maintained environment for service users. The home is mostly clean and hygienic. EVIDENCE: A tour of the premises was undertaken, the manager and staff were spoken to and records were seen including information provided by the service on the day of the visit. Since the last inspection flooring has been replaced in the kitchen/breakfast room and four bedrooms. Also two bedrooms have been redecorated and the conservatory has been replaced. The home has now implemented a maintenance record where staff can identify broken equipment or maintenance issues. A handyman visits the home on a regular basis and undertakes repairs and general maintenance. On the day of the visit the boiler was not functioning properly. The manager confirmed that this had been the DS0000022968.V330974.R01.S.doc Version 5.2 Page 18 case for at least a week and they were awaiting a part for an engineer to fit. Outside there is a spacious garden, which several service users commented as a peaceful and enjoyable place to sit in. A gardener is used to maintain the lawns and shrub areas. The home has two assisted bathrooms, one on each floor. It was noted that the ground floor bathroom was particularly small and cramped. The manager advised that in practice most service users, whose bedrooms are on the ground floor, use the upstairs bathroom. The bathroom provision overall should be kept under review to ensure that they meet the needs of the current service users. Ground floor residents should still be able to access a bath when they are unable to manage the stairs. It was noted that some fire doors were being propped open. The manager advised that the fire officer had agreed to this practice providing that all fire doors were closed at night, however documentary evidence of this agreement could not be provided. The manager advised that the proprietor was currently costing automatic door closures as it was acknowledged that this was a safer method of holding fire doors open. In the meantime the practice of wedging doors during the day should be included in the homes fire risk assessment and regular and up to date advice should be sought from the fire officer. The manager advised that the local Environmental Health Dept had undertaken a health and safety inspection since the last inspection but the report could not be located. The manager confirmed that all issues raised by this inspection had been addressed. The pre-inspection information requested by the Commission confirmed that there is a cross infection policy, which had been implemented in 2004. Laundry facilities are sited outside the home. It was noted that no separate hand washing facilities were available in the laundry area. The staff member assisting the inspector who was responsible for the laundry confirmed that a sluice facility was available on one of the washing machines. The district nurse spoken to in private confirmed that she regularly witnessed staff wearing appropriate clothing such as gloves and aprons. It was noted that one of the carpets on the upstairs landing was heavily soiled. There was also a strong smell of urine in one of the upstairs bedrooms. The manager advised that they use an outside carpet-cleaning contractor and he would commission their services without delay. It was a requirement from the last inspection that carpets must be regularly cleaned and odours were to be eliminated. This requirement will remain with an extended timescale. In view of the ongoing problems with carpet cleaning and unpleasant odours the service should review whether the purchase of a carpet cleaner would be more appropriate to maintain the environment in a clean and hygienic condition. DS0000022968.V330974.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an adequate number of staff on duty that demonstrates knowledge of service users needs. Training is minimal but service users are in safe hands. There are recruitment procedures in place to protect service users. EVIDENCE: Service users, the manager and staff were spoken to and a range of records was seen including four staff files, staff training records and the duty rota. From the evidence obtained staffing levels were considered adequate to meet the general care needs of service users. At peak times of the day three staff are on duty, which reduces to two over the lunch time period. One of these two staff undertakes the task of cooking the main meal of the day. At night the manager sleeps in his own dedicated accommodation in the home. There is also a waking night staff that monitors service users, however, records of these checks are not maintained. Staff spoken to indicate that they felt well supported and the team worked well together. One service user indicated that the home does sometimes seem short staffed and that two staff left before Christmas and have not been replaced. The manager confirmed that one staff DS0000022968.V330974.R01.S.doc Version 5.2 Page 20 member had left and recruitment for a replacement was due to commence shortly. The staff list provided by the service indicated that in addition to the manager nine staff are employed in the home. All nine staff have been employed in the home for at least two years. Staff spoken to demonstrated a good knowledge of service users needs. It was noted at the last inspection that recruitment records and procedures had improved. It was not possible to test these improvements out as no new staff had been recruited since the last inspection. The manager advised that staff training had been problematic since the last inspection. Several staff had been released and transported to POVA training but the trainer had failed to turn up. This was confirmed in discussion with a member of staff. The service has introduced a staff-training file with individual profiles of training attended. It was noted that not all certificates were in evidence and the profiles were not always accurate. Skills for Care had visited the home and staff were in the process of completing a training needs analysis and the manager was hopeful that some appropriate training would result. The manager informed the inspector that the Registered Person had purchased a staff-training package called Mulberry House training which it was hoped would address the training deficits. This package was to be implemented at the sister home before being introduced to Culwood House. Information requested by the Commission and provided on the day of the visit indicated that in the past twelve months staff training had included pressure sore care, infection control, medication, fire safety, safer & better business, health and safety and protection of vulnerable adults. However, written evidence was not in all cases available. Induction training is not recorded but in discussion the manager undertook to obtain induction workbooks that all new staff will be expected to complete. This service does not have a formal system of staff supervision or meetings. Information is passed between staff verbally on a daily basis on a hand over type basis. DS0000022968.V330974.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): 31, 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 manager is experienced and runs the home in the best interests of service users. The financial interests of service users are safeguarded and generally the health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager has run this service since 1988. Despite registering for the Registered Managers Award in 2003 he has failed to complete the qualification. The home is run on an informal basis, which does promote a sense of DS0000022968.V330974.R01.S.doc Version 5.2 Page 22 homeliness however essential documentation is not completed to an acceptable standard and is not always readily accessible. The manager was well regarded by those staff spoken to. There was no annual development plan for the service in evidence. The manager advised that a questionnaire had been made available to service users but the results had yet to be collated. There are no formal systems for monitoring the effectiveness of the service. The home’s policy is that it does not directly handle service user’s money. Any expenditure undertaken on their behalf is invoiced directly to them. Evidence from information requested by the Commission and made available on the day of the visit indicated that there are a range of health and safety policies and procedures in place. The manager confirmed that all staff have received training in moving and handling although updates for some were due very soon. There was documentary evidence that the fire warning system is checked regularly; a competent person has checked electrical appliances and a legionella check has been undertaken on the property. In addition, an asbestos survey was undertaken in March 2007 and the report was seen. Accidents are recorded and various safety notices were in evidence throughout the home. The record for water temperature checks which are undertaken daily was seen. DS0000022968.V330974.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 X X 1 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 X X 2 DS0000022968.V330974.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 OP7 Regulation 15 Requirement All residents must have a care plan which is developed with them and which is reviewed regularly. This is an unmet requirement of previous reports and a new time scale has been set. To ensure that all prospective service users have their needs fully assessed by a suitably trained person prior to a place being offered. All staff must have Protection of Vulnerable Adults training. Carpets and flooring must be kept clean and offensive odours eliminated. To review the bathroom provision to ensure they meet the needs of service users. Timescale for action 31/05/07 2 OP3 14 (1) 30/04/07 3. 4. 5. OP18 OP26 OP19 13 (6) 16 23(2)(j) 31/05/07 30/04/07 31/05/07 DS0000022968.V330974.R01.S.doc Version 5.2 Page 25 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. 4. 5. Refer to Standard OP9 OP30 OP36 OP31 OP30 Good Practice Recommendations To provide lockable storage for service users who self medicate. Record staff induction training. Introduce a formal system of staff supervision. Manager to undertake formal professional qualification. Provide opportunities for staff to undertake NVQ training. DS0000022968.V330974.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000022968.V330974.R01.S.doc Version 5.2 Page 27 - 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!