Inspection on 15/08/05 for Dury Falls

This inspection was carried out on 15th August 2005.

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

Dury Falls 10/07/07

Dury Falls 02/08/06

Dury Falls 05/12/05

Dury Falls 22/03/05

Dury Falls 21/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Dury Falls 35 Upminster Road Hornchurch Essex RM11 3XA Lead Inspector Edi OFarrell Unannounced Inspection 15 August 2005 10:40 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dury Falls Address 35 Upminster Road, Hornchurch, Essex RM11 3XA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01708 447786 Mr Barry Stack Mrs Christine Ann Stack Mrs Mary Ellen Leedham CRH Care Home 28 Category(ies) of DE(E) Dementia - over 65 (28) registration, with number OP Old Age (28) of places Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22 March 2005 Brief Description of the Service: Dury Falls is a privately owned care home for 28 older people situated in a residential area of Upminster. The property is a 16th century, grade 2 listed, two storey, building, with a garden to the front and side. Internally some of the original features, such as low ceilings and doorways and narrow corridors, have had to be retained, and this limits disabled access. There are two lounges and a dining room on the ground floor, as well as some bedrooms, toilets and a bathroom. The remaining bedrooms are on the first floor, which is accessed by a lift and by stairs. There are 8 single and 10 double rooms, five of which are ensuite. The home is situated on bus routes, and within walking distance of a tube station. Personal care is provided on a 24-hour basis, with health care needs being met by visiting professionals, such as district nurses. Regular social activities, such as quizes and exercise, are arranged in the home, and some trips to local ammenities, such as theatres are also arranged. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place on a weekday from mid morning to mid afternoon. The building and grounds were toured, and some service users were asked for their views of the service being provided. One relative and the district nurse, who were visiting during the inspection, were also spoken to. Records were checked and staff were observed carrying out their duties. Some aspects of care were discussed with managers or a member of staff. Sixteen Requirements set at previous inspections were checked. What the service does well: What has improved since the last inspection? The manager has taken action on all the things that the Commission said had to be dealt with at the last inspection in March 2005. This has improved record keeping in relation to the food that is served, which is needed to protect service users from possible infections. Some service users recently went to a local theatre, and a trip to Bedford park has been planned for the near future. Further outings are going to take place, based on what service users say they want to do. A survey of relatives has been carried out, and the manager has acted upon their comments, and this now needs to be built on so that the home has a formal quality review system. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 6 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. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 The home has full information for service users, and their representatives, to use in making decisions about where to live. This needs to be reviewed and some slight amendments made so that it is fully up-to-date. All service users have a written contract, but where the local authority is contributing this is between those two parties. These service users also need a contract with the home, so that they, and their representatives, are clear what service will be provided, at what cost. Service users are assessed prior to moving into the home, but they, and their representatives, may not always have an opportunity to visit prior to admission. This is due to the discharge system of local hospitals. The trial period provides an opportunity for service users, and their representatives, to assess if their needs can be met by the home. Intermediate care is not provided by this home. EVIDENCE: Some service users described how they were admitted to the home, and the pre-admission assessment files were examined. This included people admitted Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 9 since the last inspection, including for respite care. Where the local authority is involved in the placement community care assessments are on file, and have been used by the home in carrying out their own assessment. Initial care plans are developed based on this, and on further information gathered during admission. The need for speedy discharge from hospital sometimes means that neither the service user, nor their relatives, gets to visit the home prior to admission. This is somewhat balanced by the four week trial period, which is followed by a review, at which all views are sought. The Statement of Purpose, and the Service User Guide were examined. Some minor amendments are needed to both documents e.g. they still refer to the NCSC, which was the previous regulatory body, and there is a reference to a variation for someone under the age of 65. It is important that service users, their representatives, and placing authorities have correct information on which to makes decisions. This is Requirement 1. The home has one copy of the service user guide, which they make available to prospective service users, and their representatives. The Care Homes Regulations 2001 state that a copy should be given to each service user. This is so that they, and their representatives, can refer to it over a period of time. This is particularly important when they are making decisions about the suitability of the home to meet their needs, and also when assessing if the home is actually providing the services that they should be e.g. size of room. This is Requirement 2. Each service user has a signed contract, but where the local authority is funding this is between those two parties. These service users also need to have a contract with the home, which states such things as the services that they will be provided with e.g. meals and single or double room. This is Requirement 3. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Health, personal, and social care needs are set out in individual care plans, which staff use on a day-to-day basis to meet these needs. Service users are protected by the policy, procedure and practice in dealing with medicines. Most service users feel they are treated with respect by most staff, but the consistency of this has been a problem. Management have taken appropriate action in raising this with the staff team. EVIDENCE: Some service users were asked for their views and staff were observed carrying out their duties, in particular how they related to service users. Care plans and daily logs were examined, and compared with the care being provided. The afternoon handover meeting was attended, and accident and incident records were checked, along with the records of staff meetings and supervision. The assessment and care planning system identifies needs and how these are to be met on a day-to-day basis. They are used by care staff as a working document, and are reviewed on a monthly basis. Changes are made in Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 11 response to changing need e.g. following a hospital stay, or a bad fall. Refusal of care, such as bathing and shaving, are noted, as are further attempts to provide the care. The district nurse visited the home during the inspection, and reported that she found staff to be prompt in reporting concerns, though she had only been visiting the home for the last four weeks. The record of GP consultations details the outcome of each individual session. A random sample of the Medication Administration Charts, and medication were checked, and no problems were found. Medication administration was discussed with a senior carer, who demonstrated a sound knowledge of procedure and practice. Most service users thought that the staff were very helpful, and respectful. Observation during the inspection supported this view, with staff knocking on doors, and waiting for permission to enter, calling people by their preferred name, and knowing their preferences in relation to both choice of food, and where to eat meals. There have been some problems regarding some staff’s attitudes to service users’ choice, but the manager has responded to these promptly and appropriately. The information passed on from the morning shift to the afternoon shift during the handover was very person-centred, and included; what activities each service user had taken part in, or not; what personal and health care had been provided; what type of mood the service user was in; and what meals they had taken. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Service users’ lifestyle within the home matches their preferences, as far as is possible in a group living situation. They are encouraged to maintain contact with their families and friends. Staff support service users to exercise control and choice over their lives, as far as possible. Service users receive a wholesome, appealing, and balanced diet at times convenient to them. EVIDENCE: Service users were asked for their views, and care plans were examined and compared to the care being provided. The home employs a Hobby Therapist, who organises group activities five mornings a week. Care staff also do activities with the service users; during the inspections these were ball games for exercise and quizzes, as well as singing. Other in-house activities include monthly concerts by professional entertainers, reminiscence groups, a recent BBQ, karaoke, and a painting group. A small group of service users recently went to a local theatre, and a trip to Bedford Park is planned for the near future. The mobile library visits regularly as do both Church of England and Catholic clergy. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 13 Some service users prefer to spend most of their time in their bedrooms, and each of these were asked why this is the case, and how staff ensure that their needs are met. These service users were very clear that, when they wish to, they come out of their rooms and join in with activities. They were also clear, and written records backed this up, that staff regularly encourage them to join in, but that they prefer to pursue their own interest such as reading or doing jigsaws. Menus were examined, and discussed with service users. The fridge and store cupboard were examined as three Requirements had been set at the previous inspection relating to food preparation and storage. Each service user’s food preferences are detailed in their care plans, and the menu is ordered around these. For example, in two care plans it was noted that the service users did not like beef; on the day that roast beef was on the menu, there was an alternative of roast pork. If someone did not like either then another alternative would be provided. The evening meal always has a choice of sandwiches, hot snacks, salads and soup. Most service users take their meals in the dining room, but during the inspection meals were also served in bedrooms, and the lounges. One service user likes to eat a late lunch and this was accommodated without any fuss. One of the three Requirements set at the previous inspection had not been fully actioned so has been taken forward in this report as Requirement 4. This is that when jars, bottles, or other food containers are opened the date of opening must be written on them; this helps to make sure that food is not used past a safe date. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 & 18 The management of the home act on complaints promptly, when they are made aware of them, but the record keeping needs to be revised so as to be more comprehensive. EVIDENCE: The record of complaints was examined, and some service users were asked who they would raise concerns with. There have been no recorded complaints from service users or relatives since the last inspection, but service users were very clear that they would raise any problems with the manager, who they see on a daily basis. When complaints have been raised in the past they have been responded to promptly. Complaints are currently logged in a book, together with incidents and accidents. There must be a separate complaint log, which details the date, nature of the complaint, the name of the complainant, and the service user concerned, what action was taken to resolve the complaint, the outcome, and whether the complainant was satisfied with the outcome. This is Requirement 5. A recent complaint, made by a member of staff about an agency worker, was recorded in the current book, which is stored on an open shelf in the office. This means that any member of staff can read this information, which would breach the confidentiality of the staff concerned, whether permanent or agency. In addition service users, and relatives, may feel less inclined to complain if they think that all staff have access to any information they provide. Records of complaints must be stored so as to preserve confidentiality. This is Requirement 6, which also relates to Standard 37. Service users are registered to vote, and are assisted with this should they wish to do so. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 Service users live in a safe and well-maintained environment, with access to appropriate indoor and outdoor communal space. The use of double rooms, and lack of ensuite toilets, means that not all bedrooms suit individual need and preference. The layout of the home restricts the use of some equipment, and limits disabled access, but this is clearly stated in the Statement of Purpose. The home is clean, pleasant and hygienic. Problems with the new boiler may have affected the well-being of service users. EVIDENCE: The building was toured, both inside and out, including some of the bedrooms. The house is a 16th century listed building, which means that some of the original features have to be retained. This results in some corridors being quite narrow, and some doorways being quite low. This restricts the use of Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 16 specialist equipment, such as bulky wheelchairs, and would be taken account of in assessing potential service users. Where service users require walking aids, such as frames, arrangements are made for specialist assessment and provision. The home has a warm and cosy atmosphere, which is partly due to furniture, fittings, and decoration, being chosen to match the age of the property. There is a rolling programme of redecoration, and the bedrooms that have recently been done are to a very high standard. Some service users were in their bedrooms during the tour, and stated how much they liked their rooms; these were people who had single bedrooms. There are ten double rooms and, whilst some service users, and/or their relatives, express a preference for a shared room, this is not always individual choice. The sharing of rooms includes the use of empty beds for respite care i.e. a permanent resident sharing their bedroom with a stranger for a week or two, which is potentially very disruptive for both service users. As this home was in existence prior to the Care Standards Act 2000 and the introduction of National Minimum Standards the Commission cannot set a Requirement but a Recommendation (1) has been made that the use of double rooms be reviewed. In addition the bedrooms do not have ensuite toilets, so a commode is provided in each room. In shared rooms, even with the curtains, this provides limited privacy, and has the potential to affect the dignity of service users. One service user’s preference for a single room was discussed with the manager, who stated that this wish would be considered. This will be followed up at the next inspection. All of the double rooms seen had curtains around the beds and the washbasins and commodes, offering as much privacy as possible. All areas of the home were very clean and their were no offensive odours. The results of a survey of relatives, which the manager carried out in response to a Requirement set at the previous inspection, highlighted laundry as a potential problem i.e. items of clothing going missing or not being put away correctly. This will be followed up at the next inspection. The maintenance records in relation to gas, electrical equipment, and lift, etc. were sampled. These were all up to date, and no problems were identified. There has been an on-going problem with the temperature of the water, which has been identified in previous inspection i.e. the hot water was generally too cold. Since the last inspection a new boiler has been fitted, and there have been some teething problems. This has resulted in there being no hot water on some days. This information was not passed onto the Commission, as it Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 17 should be under Regulation 37. This Regulation requires managers to inform the Commission of any event that adversely affects the well-being or safety of any service user. Having no hot water obviously affects well being, and should have been reported. This is Requirement 7, which also relates to Standards 38. This Requirement was discussed with the manager during the visit, when other examples of the need to notify, such as falls, were also given. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Service users’ needs are met by the numbers and skill mix of staff, who are trained and competent to do their jobs. Service users are in safe hands, and are protected by the home’s recruitment policy and practices. EVIDENCE: Service users were asked for their views, staff were observed carrying out their duties, and staff recruitment, training, and supervision records were checked. The rota and the staff meeting records were checked, and recent staffing issues were discussed with the manager. Service users spoke highly of staff, saying that they did everything they possibly could for them. As well as care staff the home employs a handyman, a housekeeper, and laundry, catering and domestic staff. Where appropriate all staff attend training courses, such as a forthcoming session on dementia. Most of the staff have attended adult protection training and more sessions have been planned for later in the year. Five staff currently hold NVQ2, and two NVQ3, with a further 11 being registered to start NVQ2 in September 2005. There is an on-going training development programme for induction and basic skills/knowledge, such as food hygiene, infection control and health and safety. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 & 38 Service users benefit from the management approach of the home, which is run in the their best interests. Staff are appropriately supervised, and supported to carry out their jobs. Service users’ and staffs’ rights could be jeopardised by the way that complaints are currently stored. The health, safety and welfare of service users are not always being protected. EVIDENCE: Discussions with service users, observations of staff, and examination of the records demonstrate that this is a well run home, where the service users come first. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 20 The manager has acted on all but one Requirement set at previous inspections, and the one remaining had been partly acted upon. She is a qualified nurse and is currently doing NVQ4 in management. She was able to give examples, which were supported by written records, of having taken appropriate action where the needs of service users were not being put first. Supervision is used to develop staff skills and knowledge in key areas, such as dementia and adult protection. As stated earlier in this report the storage of complaints’ records needs to be changed. Refer to the section on Complaints and Protection and Requirement 6. In general health and safety is given a high priority, but during the visit a wheelchair was being used to move a service user from the lounge to the toilet. This wheelchair did not have footrests attached, which means that the service user’s feet were not supported. This can result in serious accidents; footrests must always be used when transferring service users by wheelchairs. This is Requirement 8. This was discussed with the manager during the visit, who confirmed that this would be attended to immediately. In response to a Requirement set at previous inspections the manager has carried out a survey of all relatives. The responses were examined, and the manager reported how she had responded to individual comments. This is a very good start to the home having a quality review system. These responses, and reported actions, now need to be collated, together with other quality control and assurance information, and a report produced. Other relevant information would include; statistics on complaints, incidents and accidents, findings of the monthly Responsible Individual’s visits/reports, views of service users and staff on the quality of the service, and views of visiting professionals and placing authorities. A copy of this report must then be forwarded to the Commission, and be made available to service users, relatives, and staff. This is Requirement 9. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 3 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 Standard No 16 17 18 Score 2 3 x 3 3 2 x x 3 2 2 Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4&5 Requirement The Statement of Purpose and the Service User Guide must be reviewed and updated, and copies forwarded to the Commission. A copy of the Service User Guide must be given to each service user, and be available for each prospective service user, and their representatives. All service users must have a contract issued by the home, which clearly states what services they are to recieve. The manager must ensure that all food containers, including jars, are marked with the date of opening. Previous timescale of 1/5/05 not met. A complaint log must be set up that includes details of each complaint, the action taken to investigate and resolve the complaint, and the outcome. All records of complaints must be stored so that confidentiality is maintained as far as possible. All events that adversely affect the well-being or safety of any service user must be reported to the Commission without delay. Timescale for action 25/11/05 2. 1 5 25/11/05 3. 2 5 25/11/05 4. 15 16 30/09/05 5. 16 22 30/09/05 6. 7. 16 & 37 25 & 38 22 & 17 23 & 37 30/09/05 30/09/05 Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 23 8. 9. 38 33 12 & 13 24 Where the notification is given verbally it must be confirmed in writing. Foot rests must always be used 30/08/05 when wheelchairs are used to transport service users. The information already collected 31/12/05 via the survey of relatives, and the action taken in response, must be collated. This, together with other quality monitoring and quality assurance information, such as complaints, incidents and accidents, must be used to produce a review of quality of care report. A copy must be forwarded to the Commission, and be given to all service users, and their representatives, and staff. 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. Refer to Standard 23 & 24 Good Practice Recommendations The use of double rooms should be reviewed, taking into account the preferences of each service user. Dury Falls G55_S0000027842_Dury Falls_V243774_150805_Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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