Inspection on 30/10/07 for Douglas Court

This inspection was carried out on 30th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Douglas Court 1 Douglas Street Ivy Square Derby DE23 8LH Lead Inspector Steve Smith Unannounced Inspection 30th October 2007 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 Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Douglas Court Address 1 Douglas Street Ivy Square Derby DE23 8LH 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) 01332 346060 01332 208525 Douglas Court Care Home Limited Debra Patience Meynell Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Douglas Court Care Home Limited is registered to provide personal care and accommodation for service users whose primary care needs fall within the following categories: Old age, not falling within any other category (OP) 24 The maximum number of persons to be accommodated at Douglas Court is 42. 2. Date of last inspection Brief Description of the Service: Douglas Court Care Home provides personal care for 42 people aged 65 years and over. It is located close to Derby City Centre and is on a major bus route from Derby. It is a purpose built two-storey building with an extension provided to the lounge. The first floor is accessed via a shaft lift and the stairs. Residents accommodation is provided all in single rooms, which are located over both floors. Communal areas are primarily located on the ground floor with a small seating/lounge area on the first floor near to the lift. The Home also has a reasonably sized well-tended garden. The charges made for a room at Douglas Court range from £344.00 to £395.00 a week. These charges are dependent on the size of room, the facilities provided and whether the Resident is sponsored by a Social Services Dept or is privately funded. Details of previous inspection reports can be found on the Commission for Social Care Inspection’s website: www.csci.org.uk Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over a period of 6.5 hours. An ‘Expert by Experience’ assisted with this unannounced visit, who in the main spoke with Residents. Discussion was held with twelve Residents, and three relatives/visitors, and the records of four Residents were ‘case tracked’. Discussion was also held with the Manager and with two members of the care staff. A number of records were examined, the bedrooms of four Residents were also examined, and all public areas of the Home were looked at. The Commission’s Annual Quality Assurance Assessment questionnaire, sent to the Manager, was examined. The Commission’s Residents questionnaire was also sent to ten Residents, but only 2 were returned at the time of this visit. They both commented most favourably on the Home. What the service does well: What has improved since the last inspection? Residents are now informed, in the Residents Guide, of where to obtain a copy of the last inspection report on the Home. The statement of purpose also sets out the physical environment standards met by the Home. The terms and conditions of residency or contract have been improved. The recording of medication had also been greatly improved. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 6 Residents files are now much better maintained and contain almost all the information required. Staffs consideration of Residents needs has been considerably improved. The information required from new employees has been improved. The items required by the Quality Assurance section of the inspection report were also now fully completed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a detailed statement of purpose for the Home together with a Resident’s Guide, which was available in each Residents bedroom. The Guide was well completed, and included information from Residents on what life was like in the Home. The Residents Guide also contained information on how contact could be made with the Commission, the local Social Services Dept and the local Health Authority. The records of four Residents were examined during this inspection and a copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, was found in each file. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 9 When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. The Manager also assessed all Residents sponsored by Social Services Depts. If the Residents were self-funding from the outset, the Manager completed her own summary of needs, which were also seen during the inspection. Standard 6 does not apply to this Home. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met, as demonstrated within care plans and by comments made by Residents. Medication was also administered appropriately to meet Residents needs. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. That was, their name and date of birth, their preferred name, their next of kin, their GP, their Social Services Dept Care Manager and their date of entry into the Home. Records of the Manager’s initial assessment of each Resident were found in each file, together with completed Individual Plans of care for each Resident. All these records were found to be up to date and of a good Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 11 standard. Records of the risk assessment on each Resident were also available. However, the Manager had not provided required information for those Residents suffering with dementia. As a result, in one of the four files examined, there were no records of the Resident’s possible limitations of choice, freedom and decision making, despite this Resident suffering with dementia. The Manager was found to be recording the 6 monthly reviews of care of each Resident, which entailed re-writing the Individual Plan of Care. All of the files were easy to read and satisfactory entries had been made by the care staff. The Manager had reviewed the records of each Resident at regular intervals. The files were well organised, with different sections, although a confidential records section was not found in any of the files examined. The funeral arrangements of each Resident were also detailed. Staff were observed talking and assisting Residents with meals and in the lounge of the Home. This was seen to be done very positively, with a relaxed atmosphere, which was enjoyed by the Residents. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents was examined, and a good system was found to be in use. Discussion was held with Residents about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being. One Resident had been in five homes, prior to this one, and said that ‘…Douglas Court was the best…’ Another Resident said that she was ‘…very contented… Staff are brilliant… Management are top notch…’ A relative visiting said that he could see his mother wherever he wished in the Home, and he was always offered coffee and lunch. He said that his mother was always treated well, and, should a Doctor be needed, was always informed. All staff were observed to be very caring in their dealing with Residents, and spoke to them in a caring manner. Discussions were also held with Staff, and very positive ways were described of assisting Residents within the Home. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, and Residents were given a wholesome and appealing diet in pleasant surroundings, that enhanced Residents well being. EVIDENCE: Residents were asked about the activities provided in the Home. Those spoken with said that activities tended to take place in the afternoons when such things as games, quizzes and painting events were organised. One Resident said that there was ‘…lots of entertainment…’, and another said that he regularly went out of the Home to play bowls. Outing were also regularly planned to such places as zoos and restaurants. Staff said that activities included such things as music and movement, general exercises, games, quizzes, table hockey and table football, craft events and special occasion events such as halloween and Christmas. The Home was very well decorated to mark the halloween event later in the week of this visit. Relatives were invited to take part in all activities and trips out of the Home. Residents said that there was a monthly newsletter that told them what had been planned for the coming month, and this was also discussed at the Residents Meetings, held Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 13 on a three monthly basis. Residents Meeting were also the place where decisions were made about how to spend money from the Residents Fund. Residents said that they decided when they got up and went to bed, although one said that staff decided on when Residents went to bed. Residents also said that they could have a bath or a shower at least twice a week. Relatives and friends of Residents were able to visit at any time, and could always be seen in private. The staff spoken with also said that relatives could visit at anytime. It was said that Residents could chose where they wanted to see their relatives, in one of the lounges, or in the Resident’s bedroom. The Home had a number of large print books for Residents to make us of, and a member of staff was seen taking a talking newspaper tape to a Resident. Residents commented that staff helped them complete forms, whenever this was necessary. They also said that they were able to take part in national and local elections, via a postal vote. Residents said that one of the members of staff was an ‘Avon rep’, and that this member of staff regularly brought in a catalogue for Residents to choose cosmetics. One Resident said that a church service was held on a Thursday, at which any Residents could attend. Residents were able to say that the Home provided good meals and that a choice was available at breakfast, dinnertime and teatime meals – ‘Meals are very good, and there is always a choice of at least two meals at every meal’ Staff also confirmed this. The Residents and staff said that drinks and snacks were always provided between meals, and that Residents could also ask for additional drinks at anytime. Mealtimes were never rushed, which was witnessed during this visit to the Home. Staff were also seen to assist Residents with meals, which was done in a caring and helpful way. One Resident said that her diet limited what she could eat, but she said that staff always produced something specially for her at mealtimes. However, the board in the entrance area of the Home, informing Residents of what was on the menu for the main meal of the day was not accurate for the day of this visit. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. Complaints made to the Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: One Resident commented that if she had a complaint to make she would tell the Manager. She said that it would not worry her to do this as she knew it would be addressed properly by the Manager. The Commission had not received any notice of complaint since the last visit to the Home, in December 2006. Since that visit, the Manager had recorded one verbal complaint. This complaint was examined and a good system was found to operate. Good procedures were seen for both written and verbal complaints. Since the last visit to the Home, the Manager has set up a ‘surgery’ that was held once a month, where Residents and relatives could voice concerns about the operation of the Home. The Registered Providers complaints procedure detailed that all complaints would be responded to by the Registered Providers or Manager within at least 28 days. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. The Manager said that a copy of the Public Interest Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 15 Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’ were available in the Home. The Manager also confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Providers ensured that all staff understood physical and verbal aggression by Residents. The Manager said that a policy was available to staff stating that they could not benefit from Residents wills, which was also understood by the staff, with whom discussions were also held. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the public areas of the Home, and included the four bedrooms of the Residents whose care was reviewed at the time of this visit. The Home was attractively decorated throughout, and the lounges and dining rooms were pleasant to sit in, and were provided with appropriate items for the Residents. The bedrooms seen provided sufficient space and provision for each Resident. The Registered Providers had provided appropriate furnishings in all locations seen during this visit. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 17 Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. A call system was also available throughout the Home. All bedroom doors were provided with locks, which Residents could choose to use. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. However, the following issue needed attention: One bedroom, discussed with the Manager, had an unpleasant odour that needed attention. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Recruitment practices were always followed when recruiting new staff, so that Residents welfare was always safeguarded. EVIDENCE: Levels of care staffing were examined for the 3 weeks beginning 7 October 2007. This showed that the Home was providing staffing below that recommended by the Residential Forum, although the attention to Residents and their needs was commended. At the time of this visit to the Home it was found that 50 of care staff had a qualification of at least NVQ level 2 in Care, and a further 8 staff where currently undertaking the course. The records of two new staff employed during the past 12 months were examined to see whether the Manager had obtained all relevant information about them. It was found that almost all information had been obtained. However, the history of employment of one of the staff had only been taken over the previous 10 years, and not back to when they had left school. This was needed to allow the Manager to check whether the potential member of staff had worked in care in the past, to allow an additional reference to be obtained. All other information was found to be satisfactory. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 19 The Manager said that new staff would be provided with induction and foundation training, which was confirmed by staff. She also said that all care staff were provided with at least three paid days training a year. The records of some of this training was seen. All staff also had an individual training and development assessment and profile. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were in place to ensure that Residents care was maintained at a positive standard. EVIDENCE: The Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management and Care. The records of the monthly ‘inspections’ of the Home, carried out by a senior manager or Registered Provider, were examined and a number of months had passed between some of the ‘inspections’. Therefore, the ‘inspection’ of the Home was not taking place on a monthly basis as required by Regulation 26. The Manager was able to show the annual development plan for the Home, completed in conjunction with a senior manager/Registered Provider, that Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 21 reflected the aims and outcomes for Residents. Surveys had been undertaken of Residents opinions of the operation of the Home, and these had been published. The Manager also said that she discussed with Residents the operation of the Home at Residents meetings, as confirmed by Residents, the minutes of which were posted on one of the Home’s notice boards. She also stated that she and the staff would be able to demonstrate the Home’s commitment to lifelong learning and development of each Resident in the Home, which was also confirmed by staff spoken with during the visit to the Home. The opinions of Residents families and friends or of GPs and District Nurses were obtained on how well they thought the Home was achieving goals for Residents, during reviews of the care provided for each Resident. These were again published and posted on a notice board of the Home. The Manager stated that the Home did not hold any savings money on behalf of Residents. Residents purchases and hairdressing etc were paid by the Home and relatives were then billed for these amounts. A staff member was asked about the supervision she received from the Manager or other senior staff in the Home. She said that this was done on approximately a 2 monthly basis, when her own needs and the needs of the Residents, were discussed. The Manager confirmed that supervision was provided by herself or senior staff, for all care staff working in the Home. The training required by the Regulations was examined. This showed that 3 staff needed Moving and Handling training, 4 staff needed Fire Safety training, 7 staff needed First Aid training and 8 staff needed Food Hygiene training. A further 7 staff were also in need of Infection Control training. The Manager also said that no senior staff had received training to become a qualified First Aider. However, a staff member spoken with said that she had received all of this training within the required timescales. In addition to the above areas of training, the Manager said that training was offered in Nutrition, Medication, Dementia Awareness, Bereavement, Challenging Behaviour, Incontinence Awareness, Pressure Area Care, Prevention of Falls, Diabetic Needs and the Effects of Ageing. The Registered Providers had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Manager was able to show that the Registered Providers had provide risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff. The Registered Providers had also provided a written statement of the policy, organisation and arrangements for maintaining those safe working practices. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 22 Finally, the Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 17 Sch 3 No 3(q) Requirement Each Resident suffering with dementia, or their representative, should have the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome needs to be recorded in each Resident’s records, at least on a 6 monthly basis. (This issue is outstanding from the inspection report dated 7 December 2006) The Manager must ensure, when appointing new staff, that all the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004, are obtained. Of two staff’s records examined, it was found that a full history of employment had not been obtained, dating back to when the member of staff had left school. If the person had worked in any form of care before, an additional reference would need to be obtained. Timescale for action 31/12/07 2 OP29 19 & Sch 2 31/12/07 3 OP31 26(3),(4) & The Registered Providers must DS0000069431.V351959.R01.S.doc Version 5.2 31/12/07 Page 25 Douglas Court (5) ensure that the Home is inspected on an unannounced basis, at least once each month in line with the requirements listed in Regulation 26. Mandatory training must be provide for the 3 staff requiring Moving and Handling training, the 4 staff requiring Fire Safety training, the 7 staff requiring First Aid training, the 8 staff requiring Food Hygiene training and the 7 staff requiring Infection Control training. 28/02/08 4 OP38 13(3) & 18(1)(c) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP7 No. 1. Good Practice Recommendations Each Resident’s file should contain a ‘confidential’ section. This section should be used for records made by staff that the Resident should not see and for information passed to the Home by professionals to which the Resident had not been made party. The Manager needs to ensure that Residents can go to bed at time of their choosing, and not at time set down by staff. (One Resident said that staff decided on Residents bedtimes). The notice board, on which the meals for the day are displayed, should be kept up to date with the correct days meals. The bedroom with the poor odour, identified during the visit, should be regularly cleaned to ensure that the odour is removed and does not return. First Aider training should be provided for all senior staff DS0000069431.V351959.R01.S.doc Version 5.2 Page 26 2. OP12 3. OP15 4. OP26 5. Douglas Court OP38 left in charge of a shift, for both daytime and nighttime shifts. (This issue is outstanding from the inspection report dated 7 December 2006) Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Douglas Court DS0000069431.V351959.R01.S.doc Version 5.2 Page 28 - 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. 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