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Inspection on 13/05/05 for Eagle View Care Home Ltd

Also see our care home review for Eagle View Care Home Ltd for more information

This inspection was carried out on 13th May 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides bright, clean and airy surroundings. Visitors are welcomed at any reasonable time. The cook provides a choice of menu daily. The manager gives staff a clear sense of direction, and residents said that they liked the staff. Comments from residents about the staff included that they were `marvellous`, whilst visiting relatives said that `nothing was too much trouble`.

What has improved since the last inspection?

The manager has only been working at the home for four weeks, but they are already improving systems at the home. The staff said that they felt happier at work. Staff now have access to medication for residents over a 24 hour period, in case it should be required. Some improvements have been made to the care plans, which will be looked at again at the next inspection, when the manager will have had a better opportunity to review each of them. Staff are now receiving more training about the work that they do. For reasons of fire safety, a key pad has been fitted to the front door to replace the mortice lock.

What the care home could do better:

Three matters which needed to be dealt with immediately were: lack of staff; storage of denture cleansing tablets, and fire doors wedged open by unauthorised means. An official letter was left at the time of the inspection which told the management that these matters must be dealt with straight away. Other matters which will be looked at again at the next inspection included that: the care plans need to be improved upon so that the care of the residents, and any associated risks are better understood; complaints need to be better recorded; staff need to have training in abuse awareness, and staff recruitment needs to be more robust.

CARE HOMES FOR OLDER PEOPLE Eagle View Care Home Seamer Mount Newcoln Road Scarborough YO12 4BN Lead Inspector Anne Prankitt Unannounced 13th May 2005 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. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Eagle View Care Home Address Seamer Mount Newcoln Road Scarborough YO12 4BN 01723 366236 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) Eagle View Care Home Ltd Post Vacant Care Home 40 Category(ies) of DE(E) Dementia- over 65 (31), OP Old Age (9) registration, with number of places Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4th October 2004 Brief Description of the Service: Eagle View is a care home providing personal care and accommodation for 31 older people who have a dementia, and 9 older people. The home is owned by Executive Care Management Limited. The home was purpose built in November 2003. It is situated on the outskirts of Scarborough. The accommodation is provided on three floors. All bedrooms provide en suite facilities, and there is a passenger lift to each floor. The home has access to grounds. Due to the position of the building, some of the garden area is not suitably accessible. However, plans include the provision of outdoor seating to a patio area. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over seven and a half hours, and was undertaken by two inspectors, Mrs Anne Prankitt and Mrs Ros Sanderson, with a previous days preparation having taken place prior to the inspection. The newly appointed manager of the home, Mrs Carol Lowe, and the responsible individual, Mrs Joan Finley, assisted during the course of the inspection. A full tour of the premises was completed, and staff were spoken to. Time was also spent talking with residents in private, and also in communal areas of the home. The views of two visitors were also sought. Some records were inspected, including care plans of specific residents identified at the time of the inspection. What the service does well: What has improved since the last inspection? The manager has only been working at the home for four weeks, but they are already improving systems at the home. The staff said that they felt happier at work. Staff now have access to medication for residents over a 24 hour period, in case it should be required. Some improvements have been made to the care plans, which will be looked at again at the next inspection, when the manager will have had a better opportunity to review each of them. Staff are now receiving more training about the work that they do. For reasons of fire safety, a key pad has been fitted to the front door to replace the mortice lock. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 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. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 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 Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 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) 3 The inconsistencies in information gathered prior to admission could result in the home being unclear as to whether service users needs can be met. EVIDENCE: The information obtained prior to admission was inconsistent. Three of the four care plans seen had a completed pre admission assessment, which contained good information from which a care plan could be developed. In some cases, care management care plans had been obtained prior to admission. In one case, there had been no documentation completed prior to admission, and no care plan developed following admission. In a further case, there had been no care management care plan obtained. The newly appointed manager stated that these inconsistencies have been addressed, and that future admissions will not take place prior to sufficient information being obtained. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 9 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 and 10 Whilst there are good developments being made, there is not yet a consistent care planning system in place to adequately provide staff with the information that they need to satisfactorily meet the holistic needs of service users. Whilst the medication systems are generally well managed, staff practice with regard to the disposal of medication is poor, and subjects service users to unnecessary risk. There has been good and positive relationships developed between staff and service users. EVIDENCE: The newly appointed manager has introduced new care plan documentation, which, upon completion, will provide a good basis from which care can be delivered. Previously, the care plans have not been reviewed on a regular basis. In one case, review had not taken place since October 2004. Plans, which will be reviewed monthly, are in the early stages of completion, and the manager is aware that there is still work to be done. Five care plans were seen. These were of differing quality. In the case of one Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 10 service user who had lived at the home for one month, there had been no documentation completed. However, another included good information about the service user’s health, personal and social care needs. The new care plan documentation draws attention to the psychological needs of service users. One care plan included a life history, which had been completed with the help of a relative. Information about risk assessment was not always available, or did not provide sufficient information about risks associated with for example moving and handling or falls. Rather than recording regularly within the daily records, staff have been using a ‘communications book’ as a means of communicating the day to day needs of service users, resulting in the records being incomplete. This was brought to the attention of the manager, who gave assurance that this practice, of which they were unaware, would stop. The night staff currently complete the daily reports. This is not appropriate where they have not been on duty. There was evidence to support that professionals within the community are contacted where advice is needed with regards to specific problems. This included involvement from the Macmillan Nurse, District Nurse, General Practitioner and Chiropodist. At the time of the inspection, the manager was in the process of making a referral to the continence advisor. The manager confirmed that night staff now have full access to medication for service users. At the time of the inspection, staff were observed to follow up with the General Practitioner an issue they had with regard to a query about medication. An audit of the medication has recently been completed by a pharmacist from the supplying chemist. This concluded that medication systems at the home were well controlled. The report also identified that the Controlled Drugs cupboard, which is locked within an outer cupboard, requires a lock. This work must be completed. Staff are currently attending ‘distance learning’ medication training. Within the medicine trolley there was a tablet decanted into a pot, which also contained two nebules. Medication must not be secondary dispensed - staff must ensure that they destroy any medication which has been refused by service users, and record on the Medication Administration Chart that this is the case. Medication is supplied to the home in blister packs on a monthly basis. There is insufficient room to lock the drugs not yet in use away. They are currently stored in the medication room. Service users spoken to were satisfied with the care provided at the home, and of the attention offered them by staff members. Comments included that ‘staff Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 11 are marvellous’, and that service users are ‘well looked after’. Other comments included ‘staff treat me very well – all very kind – always knock on the door’. Two relatives were spoken with. Their comments included that they ‘cannot fault the care’, ‘staff are absolutely brilliant’ and that their ‘generosity cannot be faulted’. One service user also said that ‘staff deliver post and ask if I need it opening – they don’t look at it’. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 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 and 15 A wider range of social activities are available, but have not yet been properly linked with the individual needs of service users within the care plans. Unrestricted visiting arrangements results in service users maintaining good links with their family and friends. The cook provides meals, including specialised diets, which offer choice and variety. EVIDENCE: There are a range of activities available for service users to enjoy. In addition to this, one staff member explained that the manager encourages staff to sit and chat with service users. Care plans are now being developed, to include a detailed social assessment, and there was evidence within one care plan to support that staff had attempted to make the life profile more meaningful, by involving a relative in its development. Advertised future activities included both in house entertainment and also day trips away from the home. The receptionist explained that they organise ‘dial a ride’ trips where requested. Residents meetings are held, to which relatives are invited to join. All service users chose to attend the most recent meeting. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 13 The sitting and dining room to the ground floor is not used, nor is this floor provided with continued staff supervision. Service users join those on the floor above at mealtimes. Those service users spoken to stated that they were happy with this arrangement, and were satisfied that, should they wish to eat on the ground floor, this would be accommodated. Visitors confirmed that they are made to feel welcome at the home at any time. On the day of the inspection, there were visitors in both the communal areas and also service users’ bedrooms. Visitors stated that they could visit at any time. The receptionist, whose office is located at the entrance of the home, meets and greets visitors during office hours. Comments from visitors included about the staff, that their ‘generosity cannot be faulted – it’s a fact’, and ‘always offered a cup of tea’, and that they can ‘visit anytime’. The cook explained that there is a four weekly menu in operation. Service users are offered a choice of menu on a daily basis. There was an advertised choice of lunch and tea displayed in the foyer area of the home. The cook stated that they ensure that they prepare sufficient of each choice for the eventuality where service users may change their mind. Special diets are being provided. These include diabetic and pureed meals. Two of the three dining areas are used at mealtimes. These are situated on the middle and first floor. The lower ground floor is not used. The cook serves all meals. Those service users on the middle floor are served first, and then subsequently those on the first floor are served. There were staff available on each of the two floors on the day of the inspection. Comments from service users included that the ‘food is good’, ‘ food is OK’, and that they ‘choose where to eat meals’. Another service users stated that there were ‘no complaints’ about the food, and that there were ‘usually two or three fresh veg given’. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 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 and 18 Complaints are dealt with, but are poorly recorded. The home has a stringent abuse policy for protecting service users, and staff spoken to had some knowledge of their responsibilities, which must be reinforced through training in order that service users are protected. EVIDENCE: The complaints procedure available at the home is appropriate. There were three complaints recorded since the last inspection in the complaints book which was kept at the front of the building. These related to issues around the laundry system, and also the care of one specific service user. The subsequent investigation and action taken is unclear, and needs to be improved upon. A ‘Comments and Suggestions’ card has replaced the previous book, which recorded complaints collectively, and which was kept in the foyer of the home. A visitor used a card on the day of the inspection to record their satisfaction about the care received by their relative. There were seven recorded commendations since the last inspection, which included reference to the care provided by staff, the quality of the food, and about keeping relatives informed. The abuse policy at the home links in well with the Local Authority multi agency policy for the protection of vulnerable adults. Details about advocacy services were advertised in the home. Abuse training has not yet been provided. However, training with the Alzheimers Society and dementia awareness training is planned. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 15 The responsible individual had produced a risk and restraint policy, which is also linked in with the local authority multi agency policy for the protection of vulnerable adults, and both the manager and the responsible individual were clear that there is a ‘no restraint’ policy operating at the home. Staff have not yet undergone training with regard to this policy. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Service users live in a clean and pleasant environment. EVIDENCE: The environment was clean, bright and airy. The premises were free from obvious obstacles. New housing is being built near to the driveway that leads to the home. The drive was busy with builders’ machinery. The responsible individual explained that the site officer has been consulted with regard to this matter, and they have consulted with the emergency services, who will inform them should they need access to the home. The manager gave assurance that the driveway is kept clear at night. The responsible individual explained that it is the policy of the company that, should a newly admitted service user not like the colour of their room, this can be quickly remedied, and the room painted in an alternative colour. In addition to this, the maintenance man explained that they are able to access petty cash in order that small maintenance matters may be addressed quickly. One Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 17 service user stated that their room is sometimes cold at night. The manager stated that they would investigate this. The fire officer visited the home in January 2005. There were no outstanding matters recorded in the subsequent correspondence following the visit. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 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) 27,29 and 30 Staffing levels were not maintained adequately to ensure that the service users’ needs could be properly met. The appropriate checks were not always carried out during recruitment of staff, potentially leaving service users at risk. Progress has been made in the provision of staff training, which has improved staff morale. This is having a positive effect on the attitude of staff towards care practice. EVIDENCE: The duty rotas evidenced that the home has not provided sufficient care staff to meet the interim staffing agreement whilst occupancy is maintained around 32 service users. Conversation with staff confirmed that this was the case, and that weekends were particularly problematic, where it was perceived that they were unable to access agency services in the absence of management. The responsible individual assured that they were available at all times by telephone. An immediate requirement was issued, and a follow up visit to the home has confirmed that the interim staffing agreement is now being met. Care staff are allocated to kitchen duties at the weekend. There is no kitchen assistant. The responsible individual stated that they had been unsuccessful recruiting into this position, which is currently being advertised. It is important that this is achieved, in order that the cook is supported in keeping the kitchen in a clean and tidy state. The manager was also required to ensure that Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 19 sufficient staff were provided in the kitchen, and in order that care staff are not allocated to kitchen duties whilst working a care shift. Staff complete an application form as part of the recruitment process. The manager explained that where a completed Criminal Records Bureau check has not been returned, a POVA First check would be completed. In these cases, the manager must ensure that the staff member is supervised at all times, and that this arrangement is recorded. It was not possible to check the CRB disclosures, as it is the policy of the company that they are destroyed, and a copy of the CRB Disclosure Number recorded. The responsible individual stated that this was in accordance with CRB guidelines. However, CRB checks must be kept from the point of recruitment until after the subsequent inspection. Two staff files contained two written references. The third contained only one reference, which was obtained after the member of staff had been deployed. A member of staff has now been allocated the responsibility of ensuring that new staff undergo a programme of induction. One recently appointed member of staff had not received a TOPSS induction file, had not been shown the fire procedure and had been instructed inappropriately about moving and handling techniques. An induction pack was organised at the time of the inspection. Staff were very enthusiastic about the training that they are now attending, and for which they are paid. Staff responsible for medication are undertaking medication training. Some staff also stated that they have undertaken training in infection control and moving and handling. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 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 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 and 38 The manager communicates a clear sense of direction for staff, who demonstrate a good awareness of their roles and responsibilities. Whilst the home is well maintained, there were some practices which do not ensure the health and safety of service users. EVIDENCE: Staff meetings now take place, and staff spoken to were very positive about the appointment of the new manager, who is currently undertaking their registered managers award. Staff meetings are held monthly, and formal supervision is in the early stages of development. Staff said the manager is approachable, and stated that good progress has been made at the home since their appointment. Staff feel that the manager listens to their concerns, and takes them on board. The responsible individual visits the home on a weekly basis in order to provide supervision and support. One staff member stated Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 21 that they are enjoying their job since the appointment of the new manager, who must now make application to the Commission for Social Care Inspection to become registered manager of the home. Staff have completed training in infection control, and first aid training is organised to take place on 3rd June 2005. A number of maintenance records, including fire records, were inspected, which identified that the premises are kept maintained. The fire safety risk assessment for the home was incomplete and was not signed. Discussion took place with regard to fire training, which currently takes place twice yearly. It is recommended that this is provided more frequently for night staff, and must be provided for new starters. The manager also intends to carry out six monthly fire drills. The doors to two communal rooms and to the staff smoking room were held open by unauthorised means. An immediate requirement was issued that fire doors must be kept shut in the absence of an automatic device, used following the recommendations of the fire authority. The kitchen cooker was not cleaned to a satisfactory standard. The responsible individual stated that this would be dealt with forthwith. It was not possible to make a full inspection of the accident records. The manager explained that there were three books in circulation, and one could not be found. It is imperative that a better system is organised, in order that the accident records are complete, and available for inspection. Some service users kept their Steradent tablets in their bedroom, but not within their lockable facilities, and in the absence of a risk assessment. An immediate requirement was issued which stated that Steradent must be kept for service users in locked facilities unless their risk assessment deems that it is safe for them to keep the Steradent, which in turn must be kept in their lockable facility. Written confirmation has been received that this matter has been addressed. Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 1 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 1 x STAFFING Standard No Score 27 1 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 2 3 x x x 2 x 1 Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 23 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 3 Regulation 14 Requirement Prior to admission, a pre admission assessment must be carried out for all prospective service users, and a copy of the most recent care plan obtained from the care manager where the service user is funded through local authority arrangements The manager must review all care plans at the home, during which the following points must be considered: (i)All service users must have a completed detailed care plan, which identifies their individual needs (ii)Service users with a dementia must have a care plan that identifies their mental health needs (iii)The care plans must contain risk assessments, wherever risk has been identified, for example, falls and moving and handling risk assessments (iiii)Wherever practicable, the care plan must be drawn up with the involvement of the service user and/or their representative Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 24 Timescale for action 13 May 2005 and maintained thereafter 2. 7 13,15 31 July 2005 (iv)Care plans must be further developed wherever service users needs change 3. 7 15 Use of the communication books fo the collective recording of service users personal details must cease (i)In accordance with the instructions given by the visiting pharmacist, the controlled drugs cupboard inner lock must be repaired (ii)Lockable storage must be provided for medicines during the changeover period when new supplies are received from pharmacy Medication must not be secondary dispensed The record of complaints must include details of the subsequent investigation, and any action taken All staff must receive training in Adult Protection issues (timescale of 30.06.04 not met) Staff must be provided with training linked to the risk and restraint policy developed by the company The manager must investigate the cause of the cold room identified at the time of the inspection, and take remedial action accordingly The registered person must ensure that suitably qualified, competent and experienced persons are working in the care home in such numbers as outlined in the staffing notice provided by Executive Care Ltd (timescale of 06.10.04 not met) Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 25 4. 9 13 13 May 2005 and maintained thereafter 31 May 2005 5. 6. 9 16 13 Regulation 17(2) Schedule 4 (11) 13 5 May and maintained thereafter 31 May 2005 31 July 2005 7. 18 8. 25 23 13 May 2005 9. 27 18 13 May 2005 and maintained thereafter 10. 29 19 Schedule 2 Sufficient staff must provided in the kitchen, and in order that care staff are not allocated to kitchen duties whilst working a care shift The registered person must not employ staff to work at the care home until the necessary legal checks have been carried out (timescale of 06.10.04 not met) Criminal Record Bureau disclosures must be kept for staff and other workers until the commission has completed its next inspection following their recruitment The manager must ensure that newly recruited staff are informed about the fire procedure, and are provided with appropriate training about the work they are to perform The manager must make application to the Commission for Social Care Inspection to become registered manager of the home (i)The fire safety risk assessment for the home must be completed and signed (ii)fire doors must be kept shut in the absence of a closer which has been authorised by the fire authority The kitchen cooker must be kept cleaned to a satisfactory standard Steradent tablets must be kept for service users in locked facilities unless their risk assessment deems that it is safe for them to keep the Steradent tablets, which then must be kept in the service users’ locked facilities 13 May 2005 and maintained thereafter 11. 30 18 13 May 2005 and maintained thereafter 30 June 2005 12. 30 8 13. 38 13,23 13 May 2005 14. 38 13 13 May 2005 and maintained thereafter Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 26 15. 38 17 The registered person must ensure that the missing accident book is found, and that all accident records are available for audit at future inspections 13 May 2005 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. Refer to Standard 7 36 Good Practice Recommendations Care plans should be reviewed on a monthly basis It is recommended that formal supervision be introduced for all care staff to take place at least six times each year, to cover: (i)All aspects of practice (ii)Philosophy of care in the home (iii)Career development needs It is recommended that fire training is provided for staff as follows: (i)Day staff - six monthly (ii)Night staff - three monthly (iii)Newly recruited staff - twice during the first month of employment 3. 38 Eagle View Care Home J53-J04 S46580 Eagle View V223500 110505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Unit 4, Triune Court Monks Cross York YO32 9DG 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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