CARE HOMES FOR OLDER PEOPLE
De Lacy House De Lacy House 42 De Lacy Way Winterton North Lincolnshire DN15 9JX Lead Inspector
Beverley Hill Unannounced Inspection 7th March 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service De Lacy House Address De Lacy House 42 De Lacy Way Winterton North Lincolnshire DN15 9JX 01724 733755 01724 735491 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) North Lincolnshire Council Carol Mobbs Care Home 30 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (24), of places Physical disability (6) De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. That the Intermediate Care Services provided to promote short-term intensive rehabilitation are sited in a designated area. That the mixed age range of 18-65 years and over 65 years applies only to the six places registered for Intermediate Care Services. That care staff receive appropriate training in relation to techniques for rehabilitation. Service users occupying the new bedrooms and accessing bathing facilities in the main unit do so on a temporary basis until the new bathroom is completed in July 2005 within the Poirier Suite. 26th October 2005 Date of last inspection Brief Description of the Service: De Lacy House is owned by the local authority and situated in Winterton. Part of the building includes the Poirier Suite, a designated unit providing intermediate care services offering short-term rehabilitation to a mixed age range of people 18-65years and over 65 years. The unit is managed as part of De Lacy House and staff members provide personal care. Clinical support for the service is via the Primary Care Trust Intermediate Care Service Team consisting of a GP, qualified nurses, occupational therapists and physiotherapists. It has six single bedrooms, two of which have en-suite shower rooms and two en-suite bathrooms. Two of the rooms have ceiling tracking hoists into the bathrooms and equipment to aid people with disabilities. The suite has a kitchen, sitting room and a dining room. The main part of De Lacy House has twenty-four beds and delivers personal care to older people, four of whom may have needs associated with dementia. The home also offers a day care service for up to six people. De Lacy House is a purpose built unit with four lounges and a large dining room. One of the lounges has a ‘Loop System’ installed to aid those service users who have a hearing impairment and one of them is designated for activities used by day care services. All the bedrooms are single and personalised to varying degrees. The home has ten single toilets strategically placed, two bathrooms and one shower room. Both bathrooms have been fitted with Parker Baths to aid
De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 5 access. A further bathroom is situated in the section designated for day care services. The home surrounds a courtyard patio area that has shrubs and plants and a covered area at one end. A further patio area is outside the separate entrance to the Poirier Suite. The home has ramps to all entrances. There are gardens to the front, side and rear of the building and adequate car parking facilities. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The Local Authority was still completing a management review of De Lacy House and hoped to have this completed in April. A senior manager was responsible for overseeing the management of the home during this process. A manager from another local authority home had interim management responsibility and senior care officers had taken on a more management role. Senior managers had ensured that CSCI had been kept informed of the management review. The Inspector spoke to the interim manager, one senior care officer, three care staff, and four catering staff who were on duty at the time of the inspection. Throughout the day the Inspector spoke to several people who lived in De Lacy House and attended for respite care. The inspector looked at a range of paperwork in relation to management plans, assessments and care plans, medication, activities, meals, complaints, policies and procedures, staff rotas, staff recruitment and training and quality monitoring. The Inspector also checked that people who lived in the home had the opportunity to suggest changes and were listened to. The Inspector completed a tour of the building. Towards the end of the visit three staff members disclosed a potential adult protection issue and this was to be referred to the adult protection team for consideration. See the section on complaints and protection. What the service does well:
The home supports people who need a short stay due to an emergency at home or the need for a carer to have a break. This high turnover of admissions and discharges creates a lot of organisation and paperwork for staff but they manage well. There was a core group of staff that had worked at the home for several years and knew the service users well. People who lived at the home said that the staff members were friendly, respected their privacy and made their relatives feel welcomed. They knocked on doors and provided personal care sensitively. The home provided a pleasant environment. It was clean and tidy and had a welcoming, homely feel. There was lots of space and different lounges and quiet areas to sit in De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 7 People spoken to liked the food stating they had enough to eat and there was variety at each meal. If they didn’t like what was on offer the staff would find them something else. The dining room was spacious with individual tables. The home has a comprehensive complaints procedure. What has improved since the last inspection? What they could do better:
The home still did not always ensure they received assessments for the people funded by care management. These were really important because all staff needed to have information about the people living at the home and when changes occurred in their needs so they could support them fully. They did receive care plans from care management. As some of the assessments are now available electronically the staff need to have training in how to access them. Risk assessments could be updated more often when people’s needs changed and in some instances they needed completing when risks had been identified. There were still concerns with the way the home managed medication as on three occasions they ran out of medication and another person did not receive important medication they were prescribed for.
De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 8 The home did not provide sufficient stimulation to some service users and there had been a reduction in planned activities. The home is recruiting an activities coordinator, which should address this shortfall. The home needed to make sure that catering staff had full information about new service users nutritional needs, special diets, preferred foods, portion size etc so that mistakes are avoided. The home need to make sure that all staff members receive training in the protection of vulnerable adults from abuse and that staff at all levels use policies and procedures if potential adult protection issues are referred to them. When recruiting staff the home needed to make sure that an up to date criminal records bureau check and/or povafirst check was in place prior to staff transferring from agency work to contracted employment. The home needed to make sure that staff completed relevant training and updates so they were skilled for their role. Some care staff were receiving at least six supervision sessions a year but not all. Supervision was important to make sure that staff were aware of their role and tasks, were completing their jobs properly and could discuss any issues with their line manager. Senior managers need to make sure that the review of management arrangements are completed quickly and a new manager is appointed. They also need to forward reports of their monthly visits to the home. 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. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 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 the following standard(s): 3 Although there had been some improvements noted regarding the home obtaining assessments completed by care management, prior to admission, this was not the case in all the care files examined, which could mean that vital information is missed and the required care not provided. EVIDENCE: Some improvements were noted in obtaining assessments completed by care management but this was not the case in all the care files examined. Three care files were examined in detail, one of which was a recent admission. The assessment for the most recent admission was via the single assessment process and the manager confirmed it could be obtained electronically. The home managed to do this on the day of the inspection, two weeks after the service users admission. The obtaining of assessments in this way could be a training issue for senior staff in order for them to obtain the information prior to the admission of the service user. The service user did have a care plan produced by care management. The senior care officers completed in-house assessments following admission. Both assessments were important initially in determining whether the home
De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 11 was able to meet the needs of the person and in providing vital information for the care planning stage. This was particularly important as the home admitted people for short stays in times of crisis at home and to give the main carer respite. There was some duplication of information noted in the initial form used for senior staff to obtain information about the service user prior to admission, usually over the phone, and other documentation following admission. This could be streamlined. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 10 Improvements in care plans were noted and care provided maintained privacy and dignity. However service users could be at risk of inadequate care and monitoring as a result of care plans not consistently assessing all needs and risks. Deficiencies in the management of medication could mean service users do not receive the medication they are prescribed for. EVIDENCE: There was a definite improvement noted in the care plans produced by the home and it was evident that a lot of work had gone into their formulation. There was clearer identification of needs and tasks for staff to meet the needs, and better documentation of the care provided. The care plans reflected the need to maintain independence, privacy, dignity and choice and service users spoken to confirm they were supported in ways that maintained their privacy and dignity. However in one care file examined of a service user admitted for respite, two areas in need of monitoring due to fragile skin and loss of weight were mentioned as important on the care management care plan. These had not
De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 13 been addressed on the homes care plan and risk assessments had not been completed. There was some evidence of partial monitoring of food intake during the first few days of admission. It is acknowledged that the high turnover of service users admitted for respite at the home generates a large amount of paperwork for staff, nevertheless, all needs identified in assessments and care plans need to be addressed. The need to assess risk was evident in the care files examined although not all elements of risk were covered. For example one service user was at risk of developing pressure sores but did not have a risk assessment for this. However good standards of care ensured that they had not developed a sore and prevention was mentioned throughout various sections of the care plan. The same service user had a restraining lap belt but there was no indication of the decision making involved in why this was required. In one file examined one service user, admitted for respite due to a fall at home, had a further fall after admission. Although a falls screening form had been completed this was not signed or dated and there was no risk assessment for falls completed on admission or after the fall in the home. Moving and handling guidance had not been fully completed on admission nor updated after the fall, which affected their mobility and the amount of staff support required. At the last inspection the home received an immediate requirement for the management of medication. This was subsequently checked and the home was compliant. However during this inspection the medication management was checked again and some areas caused concern. Three service users had ran out of a part of their medication, some prescribed creams were not signed on application, a system used for recording the opening of time-limited eye drops was not consistently used and one service user who was prescribed antidepressants had not been receiving them with no explanation as to why. Contact with the service users GP was made on the day of inspection. Stock control must be addressed and policies and procedures followed. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Deficiencies in the provision of activities meant that service users needs in relation to social stimulation were not consistently met within the home. A lack of communication between senior care staff and catering staff could mean that service users nutritional needs were not met. EVIDENCE: Very little service user activities were recorded since November and December 2005. Prior to this various activities were recorded weekly. Staff confirmed that some activities were recorded on individual service user files but when two were examined the recordings were of quality/key worker time spent with service users and this mainly consisted of chatting during personal care tasks. Staff stated that recent staffing issues had resulted in less arranged activities for service users. There was no overall service user activity plan with participation records and satisfaction/outcome records. Service users spoken to stated they played bingo and attended church services. One person liked to talk to their friend within the home and another stated they ‘clock watched’ and, ‘at my age I don’t like to join in games’. Three service users continued to visit a day centre weekly to use a balance master machine and there was some evidence of visiting entertainers and sing-a-longs organised.
De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 15 One staff member is currently undertaking training to be able to complete chair-based exercises with service users and the manager confirmed they were in the process of recruiting an activity coordinator for fifteen hours a week. When in post this will address deficiencies in the provision of activities. Their induction was to include day centre activities. Service users spoken to stated they were able to make choices about their lives. Some people made the decision to come for respite care and they confirmed they could bring in items to personalise their bedrooms but tended to limit the amount brought in. Routines were flexible and visitors were welcomed at any time. Staff spoken to described ways in which they supported people to make choices. These included ensuring service users were aware of alternatives at mealtimes, the opening of wardrobes during personal care tasks so service users could choose what they wanted to wear, and asking if they were ready to get up or go to bed and where they would like to sit rather than making assumptions. A staff member described how they had to be aware of body language for one person who was unable to verbally make choices. Standard 15 was assessed fully at the last inspection and on this occasion discreet monitoring of staffs intervention and support to service users at mealtimes indicated that improvements had been made. Discussions with several catering staff highlighted deficiencies in communication about new service users nutritional needs and in some cases even their names. Information regarding special diets, preferred foods, portion size etc. was obtained via the admission process and a system of disseminating this to catering staff members must be improved. This is especially important as the home has a high turnover of respite service users and people who attend for day care. Important information could be missed and nutritional needs not met. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Deficiencies in adult protection training for staff and the follow through of potential adult protection issues places service users at risk. EVIDENCE: The local authority had a comprehensive complaints procedure. It had appropriate timescales for resolution, various stages to the process and included contact details of other agencies. The complaints procedure was displayed in the home. Since the last inspection a new complaints file had been produced to collate information about complaints investigated by the home. One formal complaint had been investigated and addressed. Service users spoken to stated they would complain if they needed to. Service users stated they would tell the person, ‘in charge’ or, ‘the one who gives out the tablets’ if they had a complaint. One person stated they did not like to complain, another stated they liked the home and had no complaints at all. Staff members were aware of the documentation process regarding complaints and tried to sort out minor issues before they became formal complaints. Since the last inspection three issues highlighted in the suggestions box had been addressed and the comments book near the signing in book had a positive comment about staff and the changes to the environment. The home had a, ‘comments for action log’ used to collate comments from any visitor to the home, for example, service users, relatives, professional visitors and from reviews held. This was to be used as part of the quality monitoring system within the home.
De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 17 The local authority policy and procedure for protecting vulnerable adults from abuse was available in the home. Not all staff had completed training in the protection of vulnerable adults from abuse however in discussions staff members were aware of what to do if they suspected abuse had taken place. During the inspection it was reported to the inspector that one staff member allegedly spoke to some service users in an inappropriate and uncaring way, and ‘bullied’ others so that the service users declined to be supported by them. They had allegedly reported this to senior staff but were unaware of the outcome. This issue was discussed with the manager who was unaware of the allegations and was to be reported to the adult protection team for consideration and action. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Service users were able to personalise their bedrooms and lived in a clean and safe environment. EVIDENCE: Standards 19 and 26 were assessed and met at the last inspection. Since then further improvements to the environment have been completed, for example, a new conservatory to seat approximately six people, a new bathroom on the Poirier Suite, the car park has been resurfaced, new furniture and soft furnishings, ornaments and pictures have been purchased, new trolleys provided for the laundry and medication rooms and a new freezer has been ordered. Service users spoken to were happy with their bedrooms and those examined were personalised to varying degrees. The home was clean and tidy throughout. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 19 De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not all staff had up to date certificates in mandatory training and on two occasions recruitment practices had not been adequately implemented which means that service users could be placed at risk of inadequate care. EVIDENCE: Two recruitment files were examined of newly appointed staff. Generally documents were in place, however there was an issue regarding criminal records bureau checks in both cases. Both had previously worked as agency staff for the home and therefore had CRB clearance with the company they worked for at the time in 2004 and early 2005. However during recruitment for the local authority CRB checks were received after the start of employment and the inspector could not find evidence of povafirst checks. The local authority had a comprehensive training plan and staff members were encouraged to participate. The training plan included mandatory and service specific training. Via examinations of records it was evident that not all staff had completed training or updates in mandatory training. Some staff members were overdue fire training and a large percentage of staff required training in the protection of vulnerable adults from abuse. Out of twenty-four care staff eight had achieved NVQ Level 2, which equates to 33 . Two further staff members were progressing through the course. Five ancillary staff had completed an NVQ in Housekeeping. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 21 The homes induction had been updated in line with Skills for Care and the manager confirmed that all new staff would complete mandatory training during the induction process. Service users spoken to were complimentary about the staff. Comments made to the inspector ranged from, ‘very nice girls’, the staff are alright, no problems at all’, ‘yes the staff are very good’, ‘nothing is too much trouble for the staff’ and ‘they have a good attitude’. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36, 37 and 38 Some improvements have been noted in management systems within the home and, as a result, staff morale. To ensure service users receive consistent quality care and staff members receive regular formal supervision the management review needs to be completed quickly and a manager appointed. EVIDENCE: The registered manager is no longer working at the home. The management review commenced last year, although in the latter stages, is still to be completed. Interim management arrangements have been sufficient in the short term and have introduced a level of stability and support for staff, however the management review process needs to be completed quickly. Staff stated that the interim manager was supportive and they were able to approach them with issues. However some staff stated that they reported issues to senior care staff but did not receive any feedback and were unsure if they had been dealt with. Staff members need to be sure that any issues raised are dealt with appropriately.
De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 23 The home had a comprehensive quality monitoring system that included questionnaires and self-audits, however this will be assessed in detail at the next inspection. The home managed service users finances in an appropriate way. Individual records were maintained and the finance department audited the system on 8.2.06. Staff supervision logs were examined and although formal 1-1 supervision sessions had not been completed for all staff to ensure six sessions a year, staff had received support and 1-1 sessions during the management review. Staff spoken to stated they felt very supported by the interim manager and were able to approach them with issues. Now the management review is nearing completion the home needs to address shortfalls in formal supervision sessions. The home secured information in line with data protection legislation and most information required by the home was in place and up to date. The manager confirmed that the Responsible Individual visited the home to complete visits under Regulation 26 of the Care Homes Regulations, however reports of these unannounced visits have not been completed and forwarded to CSCI since September 2005. The interim manager ensured that staff practiced safely in a way that promoted the health and wellbeing of service users, and risk assessments for individual service users had improved. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X 3 X X STAFFING Standard No Score 27 X 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X 3 2 2 3 De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 25 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 The registered person must ensure that all assessed needs are included in care plans (previous timescale of 30/06/05 not met) The registered person must ensure that the home consistently receives assessments completed by care management prior to admission (previous timescale of 26/10/05 not met) The registered person must ensure that the management of medication is in line with pharmacy regulations and inhouse policies and procedures (previous timescale of 27/10/05 not met) The registered person must ensure that all staff members are aware of service users dietary needs. Communication must be improved between care staff and catering staff (previous timescale of 26/10/05 not met) The registered person must ensure that all care staff receive
DS0000033109.V285439.R01.S.doc Timescale for action 30/04/06 2. OP3 14 30/04/06 3. OP9 13(2) 30/04/06 4. OP15 12(1)(a) 14/04/06 5. OP36 18(2) 30/04/06 De Lacy House Version 5.1 Page 26 6. OP8 13(4) 7. OP9 13(2) 8. OP12 16(m)(n) 9. OP18 13(6) 10. OP18 13(6) & 18 11. OP29 19 12. OP30 18 a minimum of six formal supervision sessions per year (previous timescale of 28/02/06 not met) All staff to have had at least one formal supervision session by timescale for action date. The registered person must ensure that one specific service user has a risk assessment for a restraining lap belt and risk assessments for falls are completed consistently and updated as required. The registered person must ensure that service users do not run out of medication, they receive the medication that is prescribed for them, prescribed creams are signed after application and the system for documenting time-limited medication is followed. The registered person must ensure that service users have the opportunity to participate in activities suited to their choices, needs and abilities. The registered person must ensure that all staff members participate in the protection of vulnerable adults from abuse training. The registered person must ensure that staff members at all levels use adult protection policies and procedures with regards to alerting, referral and investigation. The registered person must ensure that CRB’s and/or povafirst information are in place prior to the start of employment for staff transferring from agency work to permanent contracts. The registered person must ensure that all staff complete mandatory training and updates
DS0000033109.V285439.R01.S.doc 07/04/06 07/04/06 30/04/06 30/04/06 07/04/06 07/04/06 30/06/06 De Lacy House Version 5.1 Page 27 as required. 13. OP31 8 The registered person must ensure that a manager is appointed to the home and they seek registration with CSCI. The registered person must ensure that reports of visits to the home under Regulation 26 are forwarded to CSCI on completion of the visit. 30/06/06 14. OP37 26 07/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP31 OP3 OP28 Good Practice Recommendations Senior managers should complete the management review quickly to enable the home to regain stability. The manager should consider streamlining some of the care file information to avoid duplication especially during the initial contact and admission stage. The home should continue to work towards 50 of staff trained to NVQ Level 2. De Lacy House DS0000033109.V285439.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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