Inspection on 21/05/07 for Dunollie Care Home

This inspection was carried out on 21st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dunollie Care Home 27/04/10

Dunollie Care Home 15/01/10

Dunollie Care Home 26/09/09

Dunollie Care Home 31/03/09

Dunollie Care Home 11/08/08

Dunollie Care Home 05/11/07

Dunollie Care Home 27/11/06

Dunollie Care Home 11/05/06

Dunollie Care Home 07/12/05

Dunollie Care Home 19/05/05

Dunollie Care Home 02/11/04

Dunollie Care Home 13/07/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Dunollie Care Home Dunollie Nursing Home 31 Filey Road Scarborough North Yorkshire YO11 2TP Lead Inspector Mrs Rosalind Sanderson Key Unannounced Inspection 21st May 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 DS0000043116.V335131.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. DS0000043116.V335131.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunollie Care Home Address Dunollie Nursing Home 31 Filey Road Scarborough North Yorkshire YO11 2TP 01723 372836 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) dneuropeancare@aol.com www.europeancare.co.uk European Care (SW) Ltd Post Vacant Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58), Physical disability (58) of places DS0000043116.V335131.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home with nursing - Code N to services users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical Disability - Code PD of the following age range : 40 years and over The maximum number of service users who can be accommodated is: 58 Service Users to include 58 OP and 58 PD up to a maximum of 58 service users. Service Users in the category PD to be aged 40 years plus and require nursing care. 2. 3. 4. Date of last inspection 27TH November 2006. Brief Description of the Service: Dunollie Care Home provides nursing care, social care and accommodation for a maximum of 58 people. Some of these people may be admitted from the age of 40 years old and may have a physical disability requiring nursing care. The service consists of the main house that can accommodate 49 people and The Lodge that can accommodate 9 people. The home is owned by European Care (SW) Limited and is located on Filey Road in Scarborough, a seaside resort. It is within walking distance of the local shopping area and close to the Italian gardens and Spa complex. It is about a mile away from the town centre. Access to the home is via a steep driveway with car parking facilities outside the main entrance or via steps for pedestrian access. The home is accessible on a level approach from the car park. It is set in extensive, well maintained, grounds that have several patio areas for residents and visitors to enjoy. These are reached from several points around the home without the need to negotiate any steps. DS0000043116.V335131.R01.S.doc Version 5.2 Page 5 The accommodation in the main house is divided into the garden wing, which is specifically designed for people with a physical disability, and the main house. There is passenger lift access to all floors in the main house, the garden wing and The Lodge People are provided with information about the service in the form of a service user guide. The most recent inspection report from the Commission for Social Care Inspection is made available in the home. The current scale of charges range from £387 -£636 per week. Additional charges are made for hairdressing, chiropody and newspapers. DS0000043116.V335131.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection has used information from different sources to provide evidence for the report. These sources include: • • • • • Reviewing information that has been received about the home since the last inspection. The findings of a Commission for Social Care Inspection Pharmacy visit to the home. Information provided by the registered manager on a pre inspection questionnaire (the manager has now left and the post is vacant) Comment cards returned from12 service users, 9 relatives, 1 care manager and 2 GP’s. A visit to the home carried out by two inspectors that lasted for seven hours. During the visit to the home ten service users, six visitors, and seven staff were spoken with. Records relating to six service users, four staff members and the management activities of the home were inspected. Care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspectors to gain an insight of what life is like at Dunollie for the people living there. The manager from another home owned by European Care was present for part of the day and was available to assist the inspectors. Feedback was given at the close of the inspection. What the service does well: The home provides a pleasant environment for people to live in. The grounds are well maintained and the level access at various points around the home offer people the opportunity to enjoy them. Activities are provided and people are able to take advantage of these if they wish. Similarly if they wish to spend time in their private rooms then they are encouraged to do this also. People said, ‘There is always something to do if you want to take part’. Another said, ‘I like to sit in my bedroom and watch TV’ DS0000043116.V335131.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Peoples care plans must give clear information to staff and direct them as to how care needs must be met. Where the risk assessment and care plan indicate that access to healthcare professionals is needed then this must be sought. This will ensure that people have their current care needs met. Care staff must be deployed in sufficient numbers and appropriately in the home to meet the needs of people living there at all times. The care staff must be supervised on a day-to-day basis. This will help to ensure that care is delivered in a safe way that promotes people’s safety, dignity and respect. The care staff must have access to training that will help them to care safely for people living at this home. Care staff must be able to hear the call bells in all areas of the home to enable them to respond to calls for assistance. Communication must be improved with people using this service and their relatives or representatives. This will help people to feel more confident in the organisation as they will be kept informed of important decisions that may affect them. Peoples views on the services offered must be sought and where appropriate acted upon. People must have access to a robust complaints procedure that they know how to instigate. Fire safety measures must be robust and include the weekly testing of the fire alarm and making sure that all fire doors are functioning correctly. A notice was left with the organisations representative to require them to attend to the fire issues and the inappropriate moving and handling of people immediately. DS0000043116.V335131.R01.S.doc Version 5.2 Page 8 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. DS0000043116.V335131.R01.S.doc Version 5.2 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 DS0000043116.V335131.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. 6 is not applicable. People who use the service experience poor quality outcomes in this area. People are not given sufficient information about the facilities available at the home. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People are visited prior to admission where possible. Detailed information is obtained about their care needs. This is agreed with them before a place is offered. There was evidence on the case files that people are issued with a contract/ statement of terms and conditions of residence. Service user guides are available in each bedroom. Accommodation that is to be offered does not appear to be discussed with people before they move into the home. One person who had been admitted to a shared room said they had been unaware that they would have to share a DS0000043116.V335131.R01.S.doc Version 5.2 Page 11 bedroom and would not have chosen to do so. They had since requested a move to a single room but this had not happened. On the day of the inspection there were two single rooms vacant. During the inspection another person sharing also requested that they have a single room. DS0000043116.V335131.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use the service experience poor quality outcomes in this area. People do not have their needs met in a timely way that promotes their dignity and respect. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The care records of five people were looked at in detail and one looked at in specific areas. The care plans contained risk assessments and care plans for activities of daily living. The records looked at were lacking in some areas in relation to specific needs of people. Where risk assessments had identified a risk there was not always a plan in place to direct staff how this need should be met. Nutritional risk assessments directed staff what to do at certain trigger points, for example a large weight loss. However this had not always been put into place. There was no evidence that advice from the dietician had been sought where this was advised and where it advised to monitor weight more closely this had not always been carried out. People needing special DS0000043116.V335131.R01.S.doc Version 5.2 Page 13 diets were sometimes documented as having a ‘normal’ diet. Similarly with tissue viability assessments these did not have a care plan in place where a risk had been identified and so staff did not have any guidance as to how the problem would be addressed. Where there had been tissue damage the progress of the recovery was not always documented and so staff are unaware of the progress if any. Continence assessments were in place but many had not been reviewed and in one case not since 2004. One person who was assessed as being ‘at high risk of falling’ did not have a plan in place. They had recently had a fall and complained of pain yet no medical assistance had been sought for four days. The GP had visited for another reason but had not been informed about the fall. The relative had requested that the doctor be told. One relative said, ‘I come regularly because I feel I have to to make sure that ….is alright’ People said that call bells are not always answered quickly. One person said, ‘We need more staff, you have to wait a long time for them to answer the bells’. A relative said, ‘I always have to go and hunt for staff’. During the morning of the inspection the call bells were constantly ringing. Carers that work on the top floor of the main house are unable to hear the call bells ringing from any location in the building. They are provided with intercom devices that other staff contact them on should a call bell be activated on their floor. However if they are already engaged in giving care to somebody this will mean that they have to leave that person or ignore the call bell. At one point a person needed care staff to help them with their toilet needs. The inspector had to go and search for staff to assist this person. One person had been left sitting in a wheelchair and was uncomfortable. Two staff were asked to assist them to a chair. They did this by using a lift that is classed as an unsafe system of work and has the potential to cause injury to people or to staff using this lift. A notice was left with the representative that this practice stop immediately. People and their relatives commented on the care staff at the home. While some commented that staff were good, some were not satisfied. Comments received included, ‘The care staff are generally good but some of the younger ones don’t know about older people and they are rough at times giving me personal care.’ A relative said, ‘The new staff don’t seem to have any training for the elderly and are always rushing in and out, they say they will come back and never do’. Staff feel that they have only got enough time to give basic care to people. Supervision records that were looked at also gave an insight into staff attitudes. Comments indicated that staff were selective over who they cared for. One record highlighted on two occasions that a staff member had raised concerns about another staff member swearing in front of people they were caring for. Generally comments received from people living in The Lodge or visiting there, were on a more positive note. However because the staff team is no longer dedicated to this area people do not know the staff as well and this has caused some people to feel unsettled. At times there is only DS0000043116.V335131.R01.S.doc Version 5.2 Page 14 one carer available in The Lodge to care for 8 people and do the domestic chores as well. During the morning the medicine round was taking place. This did not finish until 11.45. At times the trolley was left unattended in communal areas. Although it was locked there were ointments, liquid medication and eye drops left on the top of the trolley. Some medicines that were waiting to be returned to the pharmacy were left in a corridor, not all of these were empty. Recommendations made from the pharmacy inspection of 20/3/07 were checked and it was found that there were some issues outstanding. DS0000043116.V335131.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People who use the service experience adequate quality outcomes in this area. People are assisted to follow the lifestyle they choose and are provided with a well balanced diet. They are not, however, helped to access these in a way that promotes their dignity, choice and respect. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The meals provided at the home give a good choice to people and are nutritionally balanced. Special diets are catered for where the cook is aware of these. There is a system in place to record what food people have taken. Somebody commented, ‘It’s good grub and you get a good bed, what more do you want?’ Staff do assist people needing help at mealtimes, however the way that this is done is not respectful or dignified. A staff member was assisting four people sat on two different tables at the same time. She had to do this standing over people. Additional staff were present but made no attempt to help. During DS0000043116.V335131.R01.S.doc Version 5.2 Page 16 afternoon tea a person asked for a biscuit and was handed one from the biscuit tin, not given the choice to make their own selection or provided with a plate. There is an activities organiser that coordinates the activities in the home. People are able to join in if they wish but do not feel pressured to do so. One person said, ‘There is always something to do if you want to take part’. Activities organised include knitting, card making, carpet bowls and a therapy ball game. People enjoyed a sing a long in the afternoon of the visit. One person commented, ‘I like to sit in my bedroom and watch TV’ Visitors reported that they can visit at anytime and are made to feel welcome. However one person said that they feel concerned that their relative is not checked on sufficiently as when they have visited at different times they can still be found in their nightclothes. DS0000043116.V335131.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use the service experience adequate quality outcomes in this area. Policies and procedures are in place to protect people, however people do not feel they have easy access to the complaints procedure. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The complaints procedure is displayed in the entrance hall and contained within the service user guide. The procedure for making a complaint is to speak to the manager of the home or the person in charge. However approximately half of people who completed surveys did not know how to make a complaint. The organisation does not provide complaints forms for people to complete and people felt that it was difficult to complain because, ‘there is never a manager around’ or ‘staff are too busy to discuss things’. The complaints log did not always have the full details of complaints recorded and outcomes for people and whether they were satisfied were not recorded. Not all complaints that the Commission for Social Care Inspection were aware of had been documented. Since the last inspection five complaints had been received. These relate to care practices at the home. The manager looked into four, one complainant was not satisfied with the response and wrote to the Responsible Individual. The last complaint was referred to the Adult Protection Team for consideration under their procedures. DS0000043116.V335131.R01.S.doc Version 5.2 Page 18 The adult protection policy has been reviewed and now provides clear guidance for staff to follow in the case of a disclosure of abuse being made to them. Staff have received training in this area. There have been five referrals made to the adult protection team since the last inspection. One of these has resulted in staff being dismissed or disciplined. The last referral is ongoing. DS0000043116.V335131.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience good quality outcomes in this area. People live in a safe and comfortable environment. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home is clean, well maintained and pleasant. The well-kept grounds are accessible from various points around the home and people are able to enjoy the gardens and sitting out with their relatives, weather permitting. Some service users have access to patio areas outside their bedrooms. One commented, ‘I love sitting out in the gardens when I can it is so peaceful.’ There is a programme of renewal and redecoration in order that the home continues to be decorated to a high standard. However a carpet that had DS0000043116.V335131.R01.S.doc Version 5.2 Page 20 needed to be lifted following a leak outside the medical room had not been relaid. This had been like this for a ‘couple’ of months. Equipment used for the care of service users is used in a way that promotes service user safety. Laundry facilities are on site and the equipment is suitable for its purpose. Staff are provided with personal protective equipment and are fully aware of their responsibilities for infection control. A recent outbreak of a stomach ‘bug’ was referred to the infection control nurse and Environmental Health Officer. DS0000043116.V335131.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use the service experience poor quality outcomes in this area. People would benefit if staff had received appropriate training and were supervised in their work. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff are recruited in accordance with the homes policies and procedures that are in line with legislation. This means that all pre employment checks are in place before staff are able to care for people. The duty rotas supplied suggests that there are sufficient staff on duty at any one time. However care staff feel that they do not have enough time to give any more than the basic care to people and do not have time to sit and chat with people. Care staff in the Lodge stated that at times there is only one carer on and they are expected to clean and deliver care to people living there. The programme manager has since advised that staffing in this area has increased. At times staff were not available to assist people needing help. A new member of staff had started working at the home on the day of the inspection. She was asked to work alongside another carer. She had been shown around the home but had not been told about the fire procedures, DS0000043116.V335131.R01.S.doc Version 5.2 Page 22 evacuation plans or where the assembly point was so was unaware of what to do should the fire alarm sound. The training matrix was provided and showed that there are gaps in staff training in all areas with the exception of the Protection of Vulnerable Adults training and fire safety. Some training was planned for the moving and handling of clients. 26 of carers hold a qualification at NVQ level 2 or above. DS0000043116.V335131.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. People who use the service experience poor quality outcomes in this area. People living at the home and the staff working there would benefit from strong management and leadership. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The service is currently without a manager although somebody has been recruited to this position and is due to commence their employment in June. There has been a high turnover of managers in the last two years and this has led to a lot of the problems that the service is experiencing at the moment. The current arrangements are that the deputy manager has taken charge of the home under the guidance of the programme manager and a manager from DS0000043116.V335131.R01.S.doc Version 5.2 Page 24 another service. A relative commented, ‘There is no atmosphere about the place, only complacency’. The organisation has a quality assurance system but this has not been implemented at this home. People said that they do not know what is happening at the home and are not kept informed. One relative commented, ‘the home could improve by being more transparent about some of the internal affairs, managers come and go and no explanation is forthcoming’ Essential health and safety issues have not been attended to. This includes day to day maintenance in the home and checking of the fire alarm system which should be done on a weekly basis. A notice was left with the services representative on the day of inspection that the alarm system was tested immediately and the weekly testing resumed. A fire door had a broken closer fitted so the door was ineffective, the notice also required that this be repaired immediately. The nurses at the home have carried out care staff supervision, however where issues have been raised or identified these have not been followed up. Effectively this has become a ‘paper exercise’. Where the staff at the home look after peoples personal allowances robust records are kept of all transactions and receipts are available. DS0000043116.V335131.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 DS0000043116.V335131.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 12(1(a) 14(1(c)) Requirement People must be given the choice of whether they wish to share a bedroom or not and must be told if this is to be the case. This will ensure that people are able to exercise choice and maintain their privacy. People must have care plans in place to address all their identified needs and assess any identified risks. These must clearly direct staff as to how these needs are to be met within a risk assessment framework. They must be kept under review. This is with specific reference to: • Tissue viability • Nutritional needs • Continence • Falls • Moving and handling People must not be moved or handled using unsafe practices. To ensure their safety they must be moved in accordance with their risk assessment. Where the care plans and associated risk assessments indicate that advice is needed DS0000043116.V335131.R01.S.doc Timescale for action 21/06/07 2. OP7 12(1-4) 13 15 21/06/07 3. OP8 13(5) 21/05/07 4. OP8 12(1-4) 21/06/07 Version 5.2 Page 27 5. OP8 23(2(c)) 6. OP9 13(2) 7. OP10 OP14 12(3) 18(1(c(i)) from relevant healthcare professionals, this must be actioned as soon as possible. Care staff must be able to hear the call bell system when working on the top floor. This will mean that people are attended to when they need assistance. The medication trolley must not be left unattended in communal areas of the home and with medicines accessible to service users. Medication that is to be disposed of must be kept securely until it is possible to dispose of it. People accommodated must at all times be treated with respect and their right to choice upheld. (Previous timescale 31/12/06 and 20/4/07). People must be given individual assistance to take their diet when this is required. People must be able to choose their own snacks. People must have access to a robust complaints procedure. Full records of all complaints made must be kept along with outcomes and timescales for response. To reduce the potential for an accident the carpet that has been lifted outside the medicine room must be refitted. Care staff must be deployed appropriately in the home to make sure that people are able to get access to staff when they need them. Care staff must be provided with day-to-day supervision to ensure that they can fulfil the aims of the home and meet the changing DS0000043116.V335131.R01.S.doc 31/05/07 31/05/07 31/05/07 8. OP15 12(4(a)) 31/05/07 9. OP16 22 21/06/07 10. OP19 13(4(a)) 23(2(b) 18(1,2) 31/05/07 11. OP27 31/05/07 12. OP30 12(1)(a)1 8(1)(c) & 18(2) 31/05/07 Version 5.2 Page 28 needs of residents. Previous timescale 31/12/06 and 20/4/07 not met 13. OP30 18(1) Care staff must receive training in the following areas: • First aid • Health and safety • Moving and handling • Food hygiene The quality assurance system that is available must be implemented. The views of people that are involved with the service must be sought and their views acted upon. Communication with this group must be improved in order that they are kept fully informed of decisions that may affect them in their day-to-day lives. Issues identified by staff during supervision sessions must be acted upon and documented. Regulation 26 visits must be carried out in line with the regulations. A copy of the record of these visits must be forwarded to the Commission for Social Care Inspection monthly. The fire alarm must be tested with immediate effect and the weekly testing resumed and maintained weekly thereafter. The door closer that is fitted to the fire door outside room 33 must be repaired immediately. 30/06/07 14 OP33 24,26 30/06/07 15. OP38 23(4) 21/05/07 DS0000043116.V335131.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP9 OP9 OP9 OP9 OP9 OP24 OP28 Good Practice Recommendations Up to date photographs of residents should be attached to the MAR charts. Clear descriptions of the reasons medication was not administered must be recorded. A risk assessment should be done for those residents who wish to self-administer their medication. The medication rounds should be done at times during the day that allow for evenly spaced times between doses. Medication no longer in use should be immediately disposed of. Residents should be provided with lockable facilities in which to keep their valuables. Care staff should be encouraged to achieve a qualification in care at NVQ level 2 or above. DS0000043116.V335131.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000043116.V335131.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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