Inspection on 24/05/05 for Culwood House

This inspection was carried out on 24th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 20/04/07

Culwood House 28/07/06

Culwood House 07/02/06

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 Mike Murphy Announced 24th May 2005 9:30am 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 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. Culwood House Version 1.10 Page 3 SERVICE INFORMATION Name of service Culwood House Address 130 Lye Green Road, Chesham, Bucks, HP5 3NH Telephone number Fax number Email 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 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 Culwood House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2005 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 located on the outskirts of Chesham about one mile from the town centre. The home was formerly a large family residence. There is dropping off space and limited parking at the front of the building. The rear garden is level and accessible, with mature shrubs and flowerbeds providing a pleasant environment and privacy for service users. The garden is well maintained. 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). Culwood House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted over two visits in May 2005 by one inspector. Between the two visits the inspector and the Regulation manager arranged to meet with the proprietor (the registered manager was on holiday at the time) to discuss the apparent lack of progress on outstanding requirements and failing to fully comply with enforcement notices within the required timescale. It is noted that the home made significant progress in reviewing its medicines policy and in reorganising the files of services users and staff after this meeting and before the inspection was resumed towards the end of May. What the service does well: What has improved since the last inspection? What they could do better: Fully address the requirements and recommendations of inspections. Offer a range of social activities tailored to meet the needs of residents – individually and collectively. Establish a programme of redecoration. Establish a programme of individual supervision for staff. Culwood House Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Culwood House Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Culwood House Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The statement of terms and conditions fails to provide all of the information required by this standard. This can disadvantage both prospective service users enquiring of such information and current service users who have a right to receive it. EVIDENCE: The home has revised its statement of terms and conditions. The document is written in a straightforward style. It outlines the overall care and services provided, the frequency and preferred method of payment of fees, services for which additional payment is required, the terms and conditions of occupancy, and termination of the contract. It does not give details of the room to be occupied. Reference to the ‘National Care Standards Commission’ (the former regulatory body) requires updating. There are two appendices to the main document: a ‘Resident’s Room Statement’ and a checklist on who is responsible for the resident’s finances. The room statement outlines some health & safety precautions, a disclaimer on valuables and money and advice on clothing. It does not include space for the room number. It requires the signature of the resident or of his or her representative. The finance statement says that ‘The Commission for Social Care Inspection are now asking that we keep on file- information concerning who is responsible for each Resident’s Culwood House Version 1.10 Page 9 finances, and in what capacity’. It has not been possible to confirm any new general requirement on homes other than a recent policy relating to monies held on service users’ behalf by corporate appointees. This would not apply to Culwood House in view of its current policy. Culwood House Version 1.10 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9 and 10 The service user care plans reviewed on the first day of this inspection fell well short of current standards. This can impede effective assessment, care delivery and care evaluation and fail to provide adequate records of care given. The home’s current medication policy and practice fails to support safe practice which can increase the potential for errors in the control and administration of medicines. Comments received from both residents and relatives were positive indicating that residents feelings are treated with respect. EVIDENCE: Three care plans were examined on the first day of the inspection (May 4). Care plans are in two parts: the first, an individual folder intended for biographical information, assessment of needs and a plan of care; the second, a daily log filed in a separate folder. The format of care plans in the home has been under review over the past year and on the evidence of this inspection that review has still not been completed. The format of care plans lacks coherence and the quality of recording information is poor. The order of pages was different in each of the plans examined, information recorded in the Culwood House Version 1.10 Page 11 assessment was not followed through on the care plan, some pages did not have the residents name, entries were unsigned and undated, the repeated use of a symbol (the letter ‘t’ within a circle) on one care plan could not be explained by staff, some pages had no entries at all. The presence of some pages is questionable – a ‘medication sheet’ when there are separate records elsewhere for medication (the MARS sheet) and an ‘outpatient referral’ sheet. Some sheets were either inappropriately titled or inappropriately used (a page entitled ‘special precautions’ used for recording medical notes). Daily records were extremely brief and limited to recording physical problems and treatments. There were no records of psychosocial aspects of residents lives in the home. A page headed ‘Night Report’ solely contained daytime entries. There was no evidence of monthly reviews and no evidence of the involvement of the service user. Care Plans were reviewed again on the second day of the inspection (May 24) after the meeting with the regulatory manager and proprietor. A marked improvement in organisation and content was noted. The home had made considerable progress between the two visits. Residents expressed satisfaction with the care provided in the home. They described a caring and homely environment, attentive staff, the involvement of their GP if needed and said that if they had any concerns then they would raise them with the manager. A relative expressed her appreciation of the persistence of staff in seeking a second opinion on a skin lesion on her mother’s hand which turned out to be malignant and which was treated by specialists. Other relatives stated that they were satisfied with the ‘overall care provided’ by the home. The home’s arrangements for the storage and administration of medicines was inspected by a CSCI pharmacist in August 2004. Failure to conform to the recommendations of that inspection led to an enforcement notice being issued in January 2005. The deadline for compliance with this notice had passed by the time of this inspection on 4 May 2005. The inspector found partial compliance. The home had adopted as a draft document the policy of another home in the business. This brief single page document failed to meet the recommendations of the inspecting pharmacist as set out in her report of August 2004. The policy did not include reference to the need to record medicines received or removed from the home, there was no reference to homely remedies, there was no procedure for self-administration of medicines, no reference to the control of medicines during a period of respite care, no reference to the actions to be taken when an error in administration occurs – other than in the event of an overdose, and no reference to the home’s procedures for medicines requiring cool storage. The policy requires substantial revision. However, some aspects of practice in the home had improved. New secure medicine safes had been purchased and were located in the larder (a Culwood House Version 1.10 Page 12 significantly cooler location than the kitchen). NOMAD cassettes and some medicines in bottles were stored in the safes. Records were retained of medicines received and returned to the pharmacist. The inspector was informed that medicines were not now left unattended MARS charts examined were generally in order – only one omission was noted. The inspector recommended reviewing the wording of guidance on one prescription (regarding the interaction between a benzodiazepine and alcohol) where the home’s practice (the medication was not given if alcohol had been consumed) was at variance with the wording of the prescription (‘avoid alcohol’). There was no written policy or procedure governing homely remedies or selfadministration of medicines. With regard to the latter, rooms do not have a lockable space for the storage of medicines - however, the draft policy does state that ‘Residents have the right to self-administer if they wish and a lockable cupboard will be provided for those wishing to.’ Recording of Temazepam as a controlled drug (a good practice) was not being carried out. A suitable training course for staff has not been identified. The inspector was informed that the home has not had an inspection by its pharmacist since summer 2004 - this was attributed to pressures on the pharmacy arising from the closure of a local GP practice. Progress continued between the two visits and by the second visit on May 24 a further revision of policy (dated 18.05.05) had been carried out and the Temazepam prescription amended by the GP in line with practice. The revised policy is a significant improvement on the previous edition but requires further development in order to fully meet the recommendations made by the inspecting pharmacist in August 2004. Staff require accredited training. The policy permits the sharing of medicines in an emergency or if authorised by a doctor. The section on controlled drugs includes a reference to interactions with alcohol – this would also apply to other medicines and is not specific to controlled drugs. The home has sought advice on ‘homely remedies’ and the new policy lists 13 medicines. In the opinion of the inspector this is too many, particularly since the list includes medicines that could mask signs and symptoms (such as Immodium), interact with other medicines (such as Piriton) or for which fewer options would be advisable (the list includes three analgesics). The inspector undertook to obtain the opinion of a CSCI pharmacist on this. Arrangements for the privacy and dignity of residents appear satisfactory. Personal care is given in bedrooms or bathrooms. There is a telephone point in all rooms and a house phone in the hallway. A portable handset is available for use if required. Culwood House Version 1.10 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 13 and 15 Residents interests are not recorded and the home does not provide a varied range of social activities on a regular basis. This may lead to social activities being centred on occasional or special events than on the interests of the resident group living there at any time. Visitors are welcome to drop by at any time which maintains relationships with family and friends. EVIDENCE: Individual routines are varied but most residents tend to spend the day in the lounge or conservatory reading, resting or watching television. The home has a pleasant garden which is used on warm days. The care plan format does not facilitate recording of social interests and activities – the revised format should address this deficit. Residents are not generally keen on group activities but constraints on staffing mean that where a resident requires ‘one to one’ support then individual outings only occur when family or friends visit and are able to provide such support. The home organises small group outings on occasions – most recently to a pantomime – but take up of places can be low. The registered manager occasionally takes a small group of residents to the local park or swimming pool. Care plans have few references to social activities: daily records none at all. Culwood House Version 1.10 Page 14 Residents may have visitors at any reasonable time and there are a number of places around the home (including bedrooms) where residents can meet their visitors in private. Members of the local Women’s Institute have visited the home and organised events. A new ‘people carrier’ has been purchased and that trips to Waddesdon Manor gardens were planned. Two weeks (handwritten) menus were provided for the inspection (for weeks 25 April 2005 and 2 May 2005). The menus are reported to take account more of dietary preferences than resident choice. Meals are freshly prepared by staff. Lunch, served at 1.00 pm, is the main meal of the day and is a two course meal (on this occasion roast beef and vegetables followed by mandarin cheesecake). Breakfast is served in residents own bedrooms around 9.00 am and supper is served either in the dining room or in the resident’s bedroom around 5.30 pm. Residents reported satisfaction with meals in the home. A relative expressed appreciation that the food was freshly cooked on the premises. Drinks are served at intervals throughout the day and as required. As a matter of policy the home does not manage money on behalf of residents. Residents may bring some personal possessions with them in agreement with the registered manager. Culwood House Version 1.10 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 The complaints procedure does not facilitate receipt of complaints by residents dissatisfied with the service, in particular those with impaired abilities. This means that dissatisfaction is not effectively addressed and the home does not have a record of complaints received over time. The home’s own policy and procedure on adult protection fails to take account of relevant legislation and guidance and to outline a clear procedure to staff. A consequence of this is that staff do not have access to detailed guidance on the subject of abuse or contact details for external organisations to whom such concerns may be reported. An omission to obtain a pre-employment ‘POVA first’ check was noted on examination of staff records. Failure to obtain such a check exposes residents to risk through the appointment of staff considered unsuitable to work with vulnerable adults. EVIDENCE: The home’s complaints procedure is outlined in its statement of purpose. It was recommended at the last announced inspection in August 2004 that this be revised in order to conform to current good practice. This has not been done and the procedure remains inappropriate for the resident group. The procedure differentiates between a ‘problem’ and a ‘complaint’ and states that ‘…if a problem turns into a complaint then (the complainant is required to) complete a complaints form’. No complaints have been recorded since the last announced inspection. Culwood House Version 1.10 Page 16 Residents are registered to vote. This inspection took place the day before the 2005 general election and it was noted that many residents had opted for a postal vote and was informed that those wishing to vote in person would be offered a lift to the polling station. The home has acquired a video training package on the protection of vulnerable adults and has a copy of the 2001 Buckinghamshire inter-agency guidelines. It was a requirement of the 2004 announced inspection that the home’s policy on abuse be reviewed and updated by January 2005. This has not been carried out and the present policy fails to conform to current requirements – for example there is no mention in the policy of the Public Interest Disclosure Act 1998 (on ‘whistleblowing’) or of the Department of Health guidance ‘No Secrets’. It was noted that the home had omitted to carry out a POVA first check prior to a recent appointment. The home has a policy on dealing with aggression. The home does not manage money on behalf of residents. As a matter of policy the home does not manage money on behalf of residents. Residents may bring personal possessions with them in agreement with the registered manager. Culwood House Version 1.10 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 standard(s) 19,26, The home is a detached house with pleasant gardens which are greatly appreciated by residents. The interior is pleasant, if rather cluttered in places, and residents expressed positive views describing it as homely. Some areas of the interior have not been adequately maintained in recent years and the home failed to meet some aspects of current health and safety requirements. This exposes residents to risk. EVIDENCE: The home is a detached house in a residential area. There is a parking and drop off area at the front. The rear garden is accessible to service users and is pleasant and well maintained. Service users make use of the garden on warm days. The home has failed to fully comply within the agreed timescale to a notice from the fire service on fire precautions – the Commission followed this up with an enforcement notice. The home was generally clean and tidy and residents expressed satisfaction with the environment. The emergency lighting had been renewed, radiator covers had been fitted, and the electrical wiring had recently been renewed. Culwood House Version 1.10 Page 18 However, a carpet in one bathroom was due for replacement, water temperature regulation valves had not been fitted in residents bedrooms (the temperature of the hot water in room 3 on the second day of the inspection was tested at 570 Celsius), areas of the home were due for refurbishment and the first floor office did not fully comply with the content of the enforcement notice (a smoke detector had not been installed). The shed in which garden chemicals were stored was open. The home does not have a control of infection policy. Some sinks for washing hands did not have liquid soap dispensers. Culwood House Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28, 29 and 30 The staffing arrangements for the home have been established historically and all care staff have mixed job descriptions incorporating care, domestic and cooking duties. This can lead to staff being fully involved in tasks, particularly in the morning, and having little free time to spend in social activities with residents. Staff training is inconsistent although this is now being addressed. This means for example that at times there are not staff on duty who have up to date training in first aid. EVIDENCE: Between 08.00 and 14.00 hours three to four care staff are on duty. Between 14.00 and 19.00 hours two care staff are on duty. Between 19.00 and 21.30 hours two care staff are on duty. Between 21.30 and 08.00 one waking care worker is on duty. The registered manager lives on the premises. The deputy manager supplements staffing as required. All staff have mixed job descriptions incorporating care, domestic and cooking duties. One member of staff has a lead responsibility for cooking and kitchen duties. Two staff are close to completing the NVQ2 qualification in care. The home is unlikely to achieve the 50 requirement (staff trained to NVQ2) by the end of 2005 unless staff already qualified are appointed. Culwood House Version 1.10 Page 20 Recruitment procedures have not been updated in line with changing legislation and on the day of the inspection omissions with regard to POVA first checks and references were noted. It was noted that CRB certificates have now been obtained for existing staff. The content of files examined did not conform to Schedule 2 (of Regulations 7, 9, 19). A copy of a contract was not signed and dated by the employer. Staff are given a copy of the GSCC codes of practice. In-house training, using an external training organisation, has been provided in moving and handling and food hygiene. Training on abuse has centred on a video training package. It was reported that instruction in fire procedures was undertaken but not recorded. There has been no training in control of infection or on first aid. The home has failed to conform to a requirement on first aid training since February 2004. There is an induction checklist but the home’s induction programme does not conform to standard 30.2. Staff files were poorly organised on the first day of the inspection. Significant improvements in the organisation and content of files had been made by the second day. Culwood House Version 1.10 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 The standard of record keeping observed on the first day of the inspection was poor but had significantly improved on the second day. Good record keeping is essential to the provision of safe and effective care and the improvements observed in the records of residents and staff on the second day of the inspection will support this. Some health and safety matters are still outstanding and failure to rectify these will compromise the safety of residents and staff. Practice in the kitchen has improved in line with the recommendations of environmental health officers and hazards previously identified have now been reduced or eliminated. This reduces the risk of adverse consequences for residents. The décor in some areas of the interior requires attention. Repair and redecoration will prevent further deterioration and improve the quality of the environment for residents. Culwood House Version 1.10 Page 22 EVIDENCE: A number of records were inspected during the course of the inspection and the overall quality remains uneven to poor and unchanged since the last announced inspection. Policy documents have not been reviewed in line with external changes and many are now out of date. Significant improvements in some records (resident care plans and staff files) took place between the two visits. The home has been rewired since the last inspection. Some improvements to fire safety have been carried out in line with the recommendations of an inspection by the fire service in October 2004 and following the issue of an enforcement notice by CSCI in January 2005 but one requirement remains outstanding. Standards in kitchen hygiene have improved and the report of a recent inspection by the environmental health department is awaited. Staff have received in-house training on basic food hygiene to an accredited standard (certificates in basic food hygiene issued by The Royal Society for the Promotion of Health). Thermostatic valves have not yet been fitted to hot water outlets in service users bedrooms but have been installed in bathrooms. The water temperature in one bedroom was tested to be 570 Celsius – unacceptably high. The home requires an ongoing programme of redecoration. A shed in the garden containing garden chemicals was unlocked at the time of the inspection. Metal cutlery was placed beside a toaster which had not been unplugged on the first floor landing – a potentially lethal oversight in the opinion of the inspector. Significant progress had been made on some these matters on the second day of the inspection. Staff files had been reviewed and refiled. The toaster on the first floor had been stowed away and no longer posed a danger. The shed was padlocked and COSHH information on the garden chemicals stored there was being obtained. Culwood House Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 3 1 x x x x x x 1 1 Culwood House Version 1.10 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 25.8 Regulation 13(4)(c) Requirement The proprietor is required to fit thermostatic valves to water outlets in service users bedrooms. The proprietor is required to submit a plan of fitting thermostatic valves to reach the Aylesbury office of the NCSC within 28 days with commencement of fitting by 8th December 2003.(PREVIOUS TIMESCALE OF 8 DECEMBER 2003 NOT MET) The manager is required to ensure that the home has a qualified first aider on duty at all times. (PREVIOUS TIMESCALE OF 1 FEBRUARY 2004 NOT MET) The registered manager is required to establish a programme of staff training in the hones system of assessing care needs and of planning, recording and reviewing care.(PREVIOUS TIMESCALE OF 31 JANUARY 2005 NOT MET) The registered manager is required to review and update the homes policy and procedures on abuse. (PREVIOUS TIMESCALE OF 31 JANUARY 2005 NOT MET) Version 1.10 Timescale for action 30 SEP 2005 2. 38.2 13(4) 30 SEP 2005 3. 7 15 30 SEP 2005 4. 18 13(6) 31 OCT 2005 Culwood House Page 25 5. 30 18(1) 6. 33 24 7. 38 12 & 13 The registered manager is required to develop a training programme for 2005. (PREVIOUS TIMESCALE OF JANUARY 31 2005 NOT MET) The registered manager is required to develop or adopt a method of quality assurance for the home. (PREVIOUS TIMESCALE OF JANUARY 2005 NOT MET0 The registered manager is required to ensure that the home conforms to relevant health & safety legislation. (PREVIOUS TIMESCALE OF NOVEMBER 2004 NOT MET) 31 AUGUST 2005 31 October 2005 30 SEP 2005 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. Refer to Standard 7 9 16 36 Good Practice Recommendations Care plans to be reviewed and kept up to date with current needs recorded It is recommended that a senior member of care staff attend a training course (such as the Aylesbury College Certificate in the Safe Handling of Medicines) It is recommended that the complaints procedure be amended so as to assure complainants that all complaints, oral and written, are investigated to the same standard. It is recommended that the registered manager establish a programme of individual staff supervision and appraisal Culwood House Version 1.10 Page 26 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR 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 Culwood House Version 1.10 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. 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