CARE HOMES FOR OLDER PEOPLE
Daken House 240 Romford Road Forest Gate London E7 9HZ Lead Inspector
Sharon Lewis Unannounced Inspection 22 August 2005 at 2:45pm
nd 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. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Daken House Address 240 Romford Road, Forest Gate, London, E7 9HZ 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) 020 8221 2444 020 8221 2555 LM Kendon Settlement Ms Sultan Sadek, Acting Manager Care Home 43 Category(ies) of Dementia (24), Old age, not falling within any registration, with number other category (19) of places Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 28th January 2005 Brief Description of the Service: Daken House is a 43 bedded, purpose built nursing home. Daken House is owned by a charitable organisation, LM Kendon Settlement. Daken House primarily provides nursing care for people with dementia, living in the Borough of Newham. Permanent and respite (short term) accomodation is available. The home is divided into three separate units located on three floors. Strevens Unit on the ground floor has 9 bedrooms, The Reeves Suite situated on the first floor has 19 beds and The Glyde Suite on the second floor has 15 beds. Each unit has its own lounge, kitchen and dining area. Additional quiet lounges are available and there is a large activities/meeting room on the ground floor. Service users have access to their own hairdressing room within the building. A conservatory and range of patio areas with outdoor seating is also available. Daken House is situated on the Romford Road, in Forest Gate. Buses 25 and 86 run along this road to provide links to Stratford and Ilford. The nearest station is Forest Gate, British Rail Station. A small car park is available for visitors. A range of shops, services and amenities are situated on Romford Road and Woodgrange Road. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Unannounced Inspection was undertaken over a Monday afternoon and evening and lasted seven hours. The overall objective of this Inspection is to ensure service users are receiving the best possible care and their welfare is safeguarded and promoted at the care home. The Inspector spoke to eight service users currently living at the home and a set of relatives. Individual discussions were also held with the Acting Manager, a Registered Nurse and Care Support Worker. A group discussion was additionally held with a Registered Nurse and a group of Care Support Workers. Service users and staff files, medication and medication administration records, all health and safety records and other relevant documentation were also examined. A tour of the communal areas was also undertaken The Inspector would like to thank all service users, relatives and staff members for their assistance with this Inspection. What the service does well:
All service users related they were happy living at the home and had no concerns. Relatives also provided positive feedback during the Inspection. Service users had built up good relationships with staff. Staff were observed to interact in a friendly manner with service users and were aware of their individual needs. The home has a supportive, hard working and experienced staff team. The majority of staff are NVQ trained and specialist training is in progress. Daken House have received the Investors in People Award. The organisation has a strong commitment to staff training. Staff benefit from weekly numeracy and literacy classes. This course is available as preparation for their NVQ (National Vocational Qualification). Rolling Dementia Care training is in progress for staff.
Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 6 Regular meetings are held with the Primary Care Trust and Daken House are part of the Intermediate Nursing Homes Project. The aim of this Project is to support nursing homes through training to reduce hospital referrals. Service users benefit from person centered planning, monthly care plan evaluations, ‘getting to know you’ forms and the introduction of life story work. Daken House have service users from diverse cultural groups, reflective of the local community. The staff team are racially diverse. Collectively the staff team are able to speak a variety of languages that includes Hindi, Gujerati, Malayama, Swahili and Twi. Service users additionally benefit from culturally appropriate meals. The home has an Activities co-ordinator, service users have enjoyed trips to Margate, shopping, visits from entertainment and church groups. The Acting Manager has successfully managed the home since May 2005. This is due to the departure of the Registered Manager and a Deputy Manager. The Acting Manager demonstrated the necessary skills and experience for the role. The staff team and senior management have additionally contributed to the smooth transition process. A new Manager is scheduled to start their post on 3rd October 2005. What has improved since the last inspection?
Registered Nurses have completed NCFE Administration of Medicines training. The home now has a suggestion box located in the reception area. This enables anonymous feedback to be given to improve the service. Pictorial menus are in progress to assist service users with their meal choices. Guidance on signs effecting wellbeing have been given to all units and were found on the majority of staff files. Service users benefit from the consistent monitoring of their physical, psychological and emotional needs. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 7 What they could do better:
During this Inspection twelve legal requirements were highlighted and four recommendations. Service user risk assessments must be dated and signed. Service users must be protected by the home’s risk management system. Medication administration records must be accurately maintained. Service users must be protected by the home’s medication procedures. Weekly fire alarm tests must be undertaken and regular fire drills must be recorded. The fire risk assessment for the building must also be updated. Service users must be protected by the home’s fire safety practices. Service users must be protected by more robust recruitment and employment practices. Proof of identification must be available on staff files. The staff induction record should be consistently signed by the employee and Manager. Records should indicate the strengths of applicants and reasons for employment. A recruitment checklist should also be considered. The home should do more to preserve service users dignity. Plastic aprons should not be used to protect their clothing at meal times. Large serviettes or an appropriate alternative must be used. Service users must be provided with appropriate footwear and should not be barefoot within the home. If a service user has an aversion to wearing footwear this must be recorded on their personal file. Staff should inform service users of their meals and not just place food in front of them. Service users must be empowered with this necessary information. Supportive cushions were needed must be provided, to enable service users to sit comfortably in their chairs. Stained armchairs must be replaced. Service users must have clean comfortable furniture, which meets their needs. The home requires redecoration in the lounge and hallway areas. The 2nd floor kitchen worktop must be replaced. Stained carpets must be steam cleaned or replaced. Toilets seats must be secured in the toilet between rooms 28 & 29, in the bathrooms opposite room 35 and opposite room 22. The light bulb must be replaced in the 1st floor toilet opposite the clinical room. Service users must reside in a homely well-maintained environment. A staffing review must be undertaken. Staffing must be sufficient to meet service users high dependency needs and to enable staff to take appropriate breaks. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 8 The home should consider feedback discussions when service users leave. This will contribute to the home’s quality assurance system and improve procedures and practice. 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. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 4 Daken House demonstrated the ability the needs of a diverse service user group. EVIDENCE: Service users files evidenced that prior to admission the home undertakes their own assessment. This assessment process ensures the home is able to meet the individual needs of service users. On admission a detailed ‘getting to know you’ form is completed. Service users family details, personal history, hobbies, interests, likes and dislikes are recorded. This informs their care plan and highlights the uniqueness of each individual. The Acting Manager additionally related that the home had introduced life story work and relevant staff training would be undertaken. The Inspection highlighted the home’s ability to meet service users individual and collective needs. During the Inspection individual discussion were held with eight service users. All service users related they were happy living at the
Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 11 home and had no concerns. Relatives also provided positive feedback during the Inspection. Daken House have service users from diverse cultural groups, reflective of the local community. The staff team are racially diverse and the majority of service users have the ability to converse in their first language. Collectively the staff team are able to speak a variety of languages, which includes Hindi, Gujerati, Malayama, Swahili and Twi. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 - 10 Service users personal and health needs are generally promoted. Greater care must be taken when maintaining medication administration and promoting service users dignity. EVIDENCE: Service users plans were comprehensive and included individualised need profiles which cover memory orientation, behaviour, mood disturbance, sleep, continence, food intake, mobility, physical health, medication and skin care. Service users files evidenced daily updates by trained nurses and care assistants. Monthly care plan evaluations are additionally undertaken. Service users are supported to take risks as part of an independent lifestyle. Risk assessments have been developed for all service users and specific risk assessments were produced. It was found that several risk assessments were not dated or signed to ensure accountability. Service user risk assessments must be dated and signed. Service users must be protected by the home’s risk management system. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 13 Documentation evidenced that service users health is monitored and potential complications and problems are identified and dealt with at an early stage, including prompt referral to an appropriate specialist. Service users files evidenced GP, optician, chiropodist, audiology, dental, psychiatric, district and tissue viability nurse involvement. Service users files evidenced that their weight is recorded regularly. Service users routinely receive an influenza vaccine. Regular meetings are held with the Primary Care Trust and Daken House are part of the Intermediate Nursing Homes Project. The aim of this Project is to support nursing homes through training, to reduce hospital referrals. Daken House has additional links with the local specialist Incontinence Nurse. Guidance on signs effecting wellbeing have been given to all units and were found on the majority of staff files. Service users benefit from the consistent monitoring of their physical, psychological and emotional needs. Registered Nurses have completed NCFE Administration of Medicines training. Medication is stored in locked trolleys, in a designated locked staff office. Medication and medication administration records were examined. One gap was found in a medication administration record. On numerous occasions nurses had recorded the code ‘o’, however they had not specified the reason for recording ‘other’. Medication administration records must be accurately maintained. Service users must be protected by the home’s medication procedures. The home must do more to preserve service users dignity. Plastic aprons should not be used to protect their clothing at meal times. Large serviettes or an appropriate alternative must be used. Service users must be provided with appropriate footwear and should not be barefoot within the home. If a service user has an aversion to wearing footwear, this must be recorded on their personal file. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 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 standard(s) 12, 13 & 15 Service users lifestyle needs are individually promoted at Daken House. Staff communication during meal times however must improve. EVIDENCE: Service users are able to participate in a range of activities suitable to their individual social, religious and recreational interests and needs. The home has an Activities co-ordinator who visits the home twice weekly. Service users have enjoyed trips to Margate, shopping, visits from entertainment and church groups. Service users are encouraged and enabled to maintain contact with family, friends and representatives. Relatives were observed visiting during the Inspection. Service users are able to receive visitors in private. There is no restriction on visiting times and service users are able to choose whom they see and do not see. The home evidenced that service users receive a balanced diet. Service users choose whether they wish to dine with others in the dining area or in their rooms.
Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 15 Service users receive three daily meals. Drinks and snacks are also available throughout the day. Two choices are offered at each mealtime. African/Caribbean and Asian options are available, alongside a traditional British meal. Specific dietary needs are catered for. Pictorial menus are in progress to assist service users with their meal choices. A mealtime was observed during the Inspection. Staff were observed placing meals in front of service users without explaining what the items were. Staff should inform service users of their meals and not just place the item in front of them. Service users must be empowered with this necessary information. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 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 standard(s) 16 & 18 Complaints and adult protection are appropriately managed at Daken House. EVIDENCE: The complaints book was examined and included the nature of the complaint, response and outcome. Complaints were appropriately managed. The complaints book was examined there has been two complaints since the last Inspection. One complaint was found to be unsubstantiated and the other was partly substantiated. The Commission for Social Care Inspection had received a copy of one of these complaints from the complainant. The home has an Adult Protection Procedure in place. The home have liaised with the Local Social Services Department’s Adult Protection Co-ordinator to seek advice about local procedures and practice. A copy of Newham’s Adult Protection procedure is available. Adult Protection is covered during the staff induction process. All staff have to sign to state they have received the elder abuse policy and whistle blowing policy. The home demonstrated that incidents and accidents are monitored. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 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, 20, 21, & 25 Daken House is a purpose built home, general maintenance and refurbishment must be addressed. EVIDENCE: Daken House is a 43 bedded, purpose built nursing home. Daken House is owned by a charitable organisation, LM Kendon Settlement. Daken House primarily provides nursing care for people with dementia, living in the Borough of Newham. The home is divided into three separate units located on three floors. The John Barber Unit on the ground floor has 9 bedrooms, The Reeves Suite situated on the first floor has 19 beds and The Glyde Suite on the second floor has 15 beds. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 18 Each unit has its own lounge, kitchen and dining area. Additional quiet lounges are available and there is a large activities/meeting room on the ground floor. Service users have access to their own hairdressing room within the building. A conservatory and range of patio areas with outdoor seating is also available. Daken House is situated on the Romford Road, in Forest Gate. Buses 25 and 86 run along this road to provide links to Stratford and Ilford. The nearest station is Forest Gate, British Rail Station. A small car park is available for visitors. A range of shops, services and amenities are situated on Romford Road and Woodgrange Road. The home requires redecoration in the lounge and hallway areas. The 2nd floor kitchen worktop must be replaced. Stained carpets must be steam cleaned or replaced. Service users must reside in a homely well-maintained environment. The home demonstrated that service users have sufficient number of lavatories and washing facilities. Adapted bathrooms and hoists are available. Sluices are located separately from service users toilets and bathing facilities. Toilets seats must be secured in the toilet between rooms 28 & 29, in the bathrooms opposite room 35 and opposite room 22. The light bulb must be replaced in the 1st floor toilet opposite the clinical room. Supportive cushions must be provided to enable service users to sit comfortably in their chairs. Stained chairs must be replaced. Service users must have clean comfortable furniture which meets their needs. Rooms were centrally heated and lighting was domestic in character. Water temperatures are regularly tested. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 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 - 30 Daken House has a commitment to staff training, shortfalls relating to staffing and recruitment must be addressed. EVIDENCE: Service users had built up good relationships with staff. Staff were observed to interact in a friendly manner with service users and were aware of their individual needs. The home has a supportive, hard working and experienced staff team. The majority of staff are NVQ trained and specialist training is in progress. Daken House have received the Investors in People Award. The organisation has a strong commitment to staff training. Staff benefit from weekly numeracy and literacy classes. This course is available as preparation for their NVQ (National Vocational Qualification). Rolling Dementia Care training is in progress for staff. Staffing rotas were examined. A qualified nurse is based on each floor during the day. Staffing was observed and discussed with staff members. The staffing complement did not appear sufficient to meet the high dependency needs of service users. A large percentage of service users require assistance with feeding, two people to transfer and are doubly incontinent. Nurses were
Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 20 observed having to assist with care support tasks, service users had to wait for assistance with feeding and going to bed times were extremely busy. A staffing review must be undertaken. Staffing must be sufficient to meet service users high dependency needs and to enable staff to take appropriate breaks. Relatives are involved in interviewing prospective employees. Agency staff are not used, a bank system is provided within the organisation. A training policy and staff induction procedure is in place. Individual staff training profiles are in progress. The staff training committee investigates various courses for training and development. Service users must be protected by more robust recruitment and employment practices. Examination of staff files evidenced they were generally well maintained. One file did not have positive proof of the staff member’s identity. Proof of identification must be available on staff files. Staff induction records were not consistently signed. The staff induction record should be consistently signed by the employee and Manager. Records should indicate the strengths of applicants and reasons for employment. A recruitment checklist should also be considered. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 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) 31, 33, 37 & 38 The home is adequately managed however service users welfare, health and safety must be better promoted. EVIDENCE: The Acting Manager has successfully managed the home since May 2005. This is due to the departure of the Registered Manager and a Deputy Manager. The Acting Manager demonstrated the necessary skills and experience for the role. The staff team and senior management have additionally contributed to the smooth transition process. A new Manager is scheduled to start their post on 3rd October 2005. Service development is addressed in the home’s Business Service Plan. In addition the organisation regularly liaises with the Commission for Social Care Inspection to discuss service development proposals.
Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 22 Regularly service user meetings are held. The home now has a suggestion box located in the reception area. This enables anonymous feedback to be given to improve the service. The home should also consider feedback discussions when service users leave. This will contribute to the home’s quality assurance system and improve procedures and practice. The home evidenced that service users’ rights and best interests are safe guarded by the home’s record keeping policies and procedure. Service users have access to their records. Records are securely stored and in good order in accordance with the Data Protection Act 1998 and other statutory requirements. Fire safety was examined. Fire records evidenced no tests were undertaken between 22/7/05 – 19/8/05. The home must ensure the fire alarm system is tested every week. This requirement is repeated from the last Inspection. Weekly fire alarm tests must be undertaken and regular fire drills must be recorded. The fire risk assessment for the building must also be updated. Service users must be protected by the home’s fire safety practices. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 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 2 2 2 x x x 2 x STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x x 3 2 Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 24 No 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. 2. 3. Standard 7 9 10 Regulation 13 (4) (c) 13 (2) 12 (1) (a) Requirement Service user risk assessments must be dated and signed. Medication administration records must be accurately maintained. Service users must be provided with appropriate footwear. If a service user has an aversion to wearing footwear this must be recorded on their personal file. Large serviettes or an appropriate alternative must be used to protect service users clothing at meal times. The home requires redecoration in the lounge and hallway areas. Stained carpets must be steam cleaned or replaced. The 2nd floor kitchen worktop must be replaced. Supportive cushions were necessary, must be provided. Stained armchairs must be replaced. Toilets seats must be secured in the toilet between rooms 28 & 29, in the bathrooms opposite room 35 and opposite room 22. The light bulb must be replaced in the 1st floor toilet opposite the clinical room. Timescale for action 01.11.05 01.10.05 01.11.05 4. 10 12 (4) (a) 01.11.05 5. 19 23 (2) (d) 01.02.06 6. 7. 19 20 23 (2) (b) 23 (2) (g) 01.01.06 01.12.05 8. 21 23 (1) & (2) (j) 23 (2) (p) 01.10.05 9. 25 01.10.05 Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 25 10. 11. 12. 27 29 38 18 (1) (a) 19 (1) (b) 23 (4) A staffing review must be undertaken. Proof of identification must be available on staff files. Weekly fire alarm tests must be undertaken and regular fire drills must be recorded. The fire risk assessment for the building must also be updated. 01.12.05 01.10.05 01.10.05 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 15 29 30 33 Good Practice Recommendations Staff should inform service users of their meals during meal times. Staff records should indicate the strengths of applicants and reasons for employment. A recruitment checklist should also be considered. The staff induction record should be consistently signed by the employee and Manager. The home should consider feedback discussions when service users leave. Daken House G57 G06 S7355 Daken House V245630 220805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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