Inspection on 08/06/05 for Eardley House

This inspection was carried out on 8th June 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

Eardley House 02/01/09

Eardley House 21/02/08

Eardley House 21/08/07

Eardley House 05/02/07

Eardley House 30/05/06

Eardley House 29/11/05

Eardley House 30/11/04

Eardley House 11/05/04

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Maple Lodge

Heathlands

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Eardley House Moorland View Bradeley Stoke on Trent Staffordshire, ST8 7NG Lead Inspector Lorraine Mavengere Unannounced Wed 8 June 2005 09.00am 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. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Eardley House Address Moorland View Bradeley Stoke on Trent Staffordshire ST6 7NG 01782 235901 01782 234530 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) Stoke on Trent City Council Mrs Susan Mountford Care Home 44 Category(ies) of DE 5 registration, with number DE(E) 44 of places MD 6 OP 44 PD (E) 44 Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 30 November 2004 Brief Description of the Service: Eardley House is a care home providing both long term and respite care for up to 46 older people with dementia. The home is owned by Stoke on Trent City Council, a unitary authority, and care is directly provided by the councils staff team from the social services department. The home is located on the outskirts of the City of Stoke on Trent, in the village of Bradeley. Ity has ready access to community facilities and, including shops, pubs, post office and public transport. The home was originally purpose built to the standards current at the time, and consists of two storeys. Because of its large size, and to meet up to date good practice in care provision, it is now divided into four group living arrangements. Each area has its own living/ dining area. Assisted bathing and toilet facilities are strategically provided throughout the home, and other facilities include a smoke room and separate quiet room with a pay phone. All bedrooms are single.None of the bedrooms have en suite facilities. Access to the enclosed rear garden is from two lounge areas with ramps and hand rails provided for safety. The garden has a patio area with seating, flowers and a summer house. Overall the accomodation is generally comfortably appointed and welcoming, although there are still some areas of the home that need decorating. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on a Wednesday during the day. The registered manager was attending a training course ands was unable to be present for the inspection. The member of staff assisting the inspection is an Assistant Manager. During the inspection, nine service users and four relatives were spoken to. The feedback received from the discussions held with them will be included in the inspection report. What the service does well: What has improved since the last inspection? What they could do better: The home is still without a contract. This has been going on for a number of years now and must be rectified as a matter of urgency. The assistant manager spoken to confirmed that this was being addressed at a corporate level. The statement of purpose has been amended since the last inspection but this has been carried out in a shabby and unclear manner whereby items have been crossed out in ink and others added on as such. A requirement was therefore made for the statement of purpose to be made more presentable. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 6 Records seen showed that the risk assessments carried out were not adequate. Risk assessments did not include all areas of risk, including key holding and catches on wardrobes. Records showed that one service user with extremely high mobility needs had not been risk assessed for this. The risk assessment must now be carried out as a matter of priority. It was extremely disappointing to note that staff were not readily available for service users at some points during the day and relatives were being put in the compromising position of having to assist other service users. The member of staff summoned by the inspector did not respond therefore leaving service users vulnerable. This is not acceptable and must not be practiced in the home. Although the home was clean and comfortable, there were some areas that held very offensive odours. A requirement was therefore made for continence aids to be reviewed to alleviate the smell. Discussions with service users and relatives highlighted that the level of activities in the home was just not enough. It was a recommendation of this inspection that the home reviews its activity programme. 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. Eardley House E51 E09 S28913 Eardley House V232252 080605 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 Eardley House E51 E09 S28913 Eardley House V232252 080605 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) 1, 2, 3, 4 People who use the service receive information, although this is unclear, to enable tem to make a choice about whether they wish to live in the home. The home does not provide a contract for service users. Service users are therefore unaware of the terms and conditions under which they can live in the home. A comprehensive needs assessment is carried out on all service users prior to them moving into the home and their needs matched with the home’s stated purpose. This enables service users to be placed appropriately and ensures that their needs are met. EVIDENCE: Both the statement of purpose and service user guide were seen during the inspection. The Statement of Purpose has been amended to include all items highlighted in the national minimum standards and the care homes regulations. The statement of purpose was amended in ink and many items were crossed out and written over creating confusion as to what information the statement of purpose held. The registered manager must ensure that the Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 9 information in the statement of purpose is presented in a clear and concise manner. Both relatives and service users spoken to verified that they had been provided with the service user guide upon admission into the home. One short term resident said, “They tell us everything we need to know when we first come here.” The home, as with all other Stoke on Trent homes, is still without a statement of terms and conditions. This has been going on for a number of years now and must be rectified as a matter of urgency. The assistant manager spoken to confirmed that this was being addressed at a corporate level. Action must be seen soon as this has been ongoing for far too long. It was evident from information seen in the statement of purpose that service users are only admitted into the home following a comprehensive needs assessment. The home also has an admissions policy, which was seen during the inspection. All care files sampled showed that service users are assessed fully prior to being admitted into the home. Discussions with the assistant manager also confirmed that this is the case. The home is able to demonstrate its ability to meet service users needs through the statement of purpose. Discussions held with staff evidenced that they are aware of the issues surrounding older people and those with dementia. One member of staff spoken to, however, said that she sometimes felt that residents who were taken on in the past had growing nursing needs. The assistant manager confirmed that this had happened in the past where a service user was admitted and later developed nursing needs and the process of placing them in a more suitable home had been slow due to extenuating circumstances. The assistant manager stated that all the necessary training is provided for all staff in the home to meet service users needs. The training records were viewed and seen to cover the relevant areas of training needs. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 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, 10, 11 All service users have in place a care plan enabling needs to be identified and met. Some of the information in these care plans could be further developed to be more specific and clear in the targeted area of need. Service users’ health needs are identified and fully met enabling service users to experience maximum health benefits in accordance with their needs. Service users are treated with respect and their right to privacy is upheld. Service users’ wishes concerning death and dying are not clearly evidenced in their records. The home has a clear policy and procedure document enabling staff to refer to it for guidance on dealing with issues surrounding death and dying. EVIDENCE: The care files sampled showed that all service users have a care plan in place that details their care needs and how these are to be met. The files showed regular reviews of these care plans. The assistant manager stated that the service users are involved in as much as possible in the care planning and reviews but this is not always possible due to their deteriorating conditions. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 11 Care plans were seen to be signed by either the service user of their representative. Many of the service users spoken to stated that they were not aware of what was in their care plans but were aware that documentation about them was kept by the home, and they could ask to see these if they so wished. A relative spoken to said that he had once been invited to a review. Service users are risk assessed as part of their care planning. Records seen showed that the risk assessments carried out were not adequate. Risk assessments must be developed to include all areas of risk, including key holding and catches on wardrobes. Individual risk assessments are unique documents and one service users’ risk assessment must not be used for another service user without being amended. Records showed that one service user with extremely high mobility needs had not been risk assessed for this. The risk assessment must now be carried out as a matter of priority. Service user plans sampled showed that the registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. Records showed regular G.P appointments, visits to the chiropodist, dentist and opticians as required. Observations made during the inspection showed that staff encourage service users to mobilise regularly hence promoting light exercise. The assistant manager stated that occasionally someone will come in to do gentle exercise with service users. The records for this were not seen on this occasion. Discussions with the assistant manager and records seen verified that no service users had any pressure sores at the time of inspection. A detailed tour of the premises evidenced that the appropriate aids and equipment were made readily available for service users in accordance with their assessed needs. The service users spoken to spoke very highly of the staff. One service user said, “They are very good to us here, they look after us well.” Service users felt that their privacy and dignity was well respected. One relative, however, mentioned that their privacy was respected “too well”. When I asked him to explain further he stated that sometimes when members of staff were needed they were no where to be found. This was quite evident from just looking around. This was also further highlighted when during the conversation with this relative, another relative had to repeatedly stand up to assist a service user who needed help. The inspector alerted a member of staff who was sitting in the next room doing some notes of this. It was extremely disappointing to note that the member of staff did not respond at all. It is a requirement therefore of this inspection that members of staff are available at all times to meet the assessed needs of the service users and not rely on relatives to do so. The home has a policy and procedure document for dealing with death and dying and training offered upon request. The policy and procedure was seen during the inspection. It is detailed and outlines what staff need to do in the Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 12 event of terminal illness of death. The Policy is a Stoke on Trent policy and is used in all their City of Stoke care homes. Records seen show that not all service users’ wishes concerning death and dying are documented, or indeed sought. The registered manager must ensure that all service users’ wishes concerning death and dying are sought and documented. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 13 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, 15 The home undertakes some activities for service users but these are not varied and flexible to suit service users’ expectations, preferences and capacities. Service users receive meals that are varied, appealing, wholesome and nutritious. EVIDENCE: Discussions with service users and their relatives highlighted that the home does not provide enough activities. One service user said, “we don’t do much.” When asked about the activities that are available to them. The home has a rota of activities that the service users are notified of. The assistant manager explained that it is not always possible to stir up interest among the service users for the activities offered. It is recommended that the registered manager regularly reviews the levels of activity offered by the home. An observation of mealtime made during the inspection showed that service users were offered a varied, wholesome and nutritionally balanced foods. Service users themselves confirmed that choice of food was always offered. The home’s cook was able to demonstrate that she caters for individual dietary needs. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 14 The kitchen was very clean, tidy and free of hazards when it was inspected. The cook confirmed that the dry food stores are rotated with each new delivery and all foods are checked for expiry dates regularly. Both the refrigerator and the freezer were inspected. The Refrigerator has a thermometer for recording temperatures but the freezer does not. Meats and other perishable foods are kept in there. The registered manager must ensure that that a thermometer is put in place and daily temperatures recorded. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 15 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 Service users are provided with clear information on how to complain if they needed to do so. Service users’ legal rights are protected. EVIDENCE: A copy of the home’s complaints procedure was inspected on this occasion. The procedure gives clear information on how to make a complaint and how this will be followed through. Both the service user guide and the statement of purpose include a summary of the complaints procedure. All the service users spoken to stated that they were sure of how to make a complaint if they were unhappy with the service provided. Discussions with the relatives also confirmed that the complaints procedure was readily available. Discussions with the assistant manager and records seen evidence that no complaints have been made since the last inspection. The complaints log book was examined during the inspection. The registered manager must ensure that all entries into the complaints logbook are specific, stating clearly what the complaint was about, action taken and outcome. Discussions with the assistant manager verified that service users were assisted in voting if they expressed the desire to do so. Service users could either do a postal vote or vote in person dependent on personal preference. All the service users spoken to stated that voting was not a priority for them but they knew they could if they wanted to Eardley House E51 E09 S28913 Eardley House V232252 080605 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) 23, 24, 25, 26 The home provides accommodation for each service user, which meets minimum space. Service users’ bedrooms are safe, comfortable and highly personalised enabling service users to feel as much at home as possible. Rooms were well ventilated but some restrictions were in place that may affect this. The home is hygienic, clean and free of offensive odours. EVIDENCE: A detailed tour of the building showed that three rooms had been closed due to fire regulations. A copy of the last fire inspection report was made available during the inspection. There is still one gentleman residing in the fire zone, plans are being made to move him. Room sizes are adequate to meet the service users’ needs. One service user uses a wheelchair permanently and his Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 17 room size suites this need. All room sizes meet the national minimum standards. All the bedrooms were inspected. They were all highly personalised with service users bringing some of their own things to make the rooms more homely. Most of the rooms had the minimum bedroom furniture as stated in the standards. However, this was not the case for all of them. The assistant manager stated that the reason for this was because there was an associated risk, especially with service users who have dementia. The care records did not show that these associated risks had been assessed. The registered manager must ensure that risk assessments are carried out for service users who items of relevant furniture is perceived a risk. One of the bedrooms, bedroom 16, was seen to have a double socket that was taped over. This looked shabby and dangerous. The registered manager must ensure that this is rectified with immediate effect. All rooms seen had radiators. Some of the rooms, however, had exposed pipes. The registered manager must ensure that all exposed pipe work is guarded to reduce risk of burns. All windows have restrictors as per risk assessment. Some windows in Hawthorne way had an additional screw in place which makes it difficult to open windows. This may affect ventilation. The registered manager must ensure that these restrictive screws are either removed or risk assessed. The home’s infection control was viewed during the inspection. Discussions with the assistant manager highlighted that the home practices infection control by wearing protective clothing when helping with personal care. A tour of the building showed hand washing reminders all over the building and different colour coded aprons for helping with feeding. Records show that all staff do the infection control training as part of their mandatory training. This is done once a year. It was, however, disappointing to note that in Bluebell and in Willow Walk, there were some rooms that had an overbearing smell of urine. The registered manager must review the continence aids used by the home in order to eliminate this unpleasant odour. Eardley House E51 E09 S28913 Eardley House V232252 080605 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 Staff numbers and skill mix only meet the service users assessed needs in part. The home carries out a rigorous recruitment procedure enabling service users to be looked after by individuals who are safe and adequately experienced. EVIDENCE: On the day of inspection, observations showed that there were five members of staff on duty. This tallied with the staff rota that was also seen during the inspection. Rots showed that there were five members of staff at any given time during the day shifts, and only two members of staff to cover the night shifts. During some interviews with relatives, it became apparent that they felt that staffing levels were not adequate as no staff could be found when they were needed. As a result, relatives were having to help other service users that needed assistance. This is not acceptable. The registered manager must therefore review staffing levels with immediate effect. Records show that the home currently has three staff vacancies. Discussions with the assistant manager highlighted that the home carries out a rigorous recruitment procedure and will only employ a candidate following a Police Clearance and two satisfactory references. Staff files were seen during the inspection. Not all of them had CRB clearance, two references, statement of terms and conditions and a job description. The registered manager must ensure that this is complied with, even in the event of a transfer from another City of Stoke home. The assistant manager confirmed that all staff are provided with a General Social Care Council code of conduct. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 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 The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. EVIDENCE: Many of the difficulties highlighted in the last inspection report have since been resolved. The registered manager is qualified to NVQ4 and staff spoken to stated that they had every confidence in her management style and leadership abilities. Service users and relatives also said that they felt they could approach the manager whenever they needed clarity about something. The assistant manager and three of the members of staff spoken to clarified that the way the home is run is clear and transparent and all lines of accountability are clear. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 20 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 1 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION x x x x 2 2 3 2 STAFFING Standard No Score 27 3 28 x 29 2 30 x 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 x x x x x x Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 21 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 OP1 Regulation 5(1) Requirement The registered manager must ensure that the information in the statement of purpose is presented in a clear and concise manner. The home must provide all service users with a contract/ statement of terms and conditions Risk assessments must be developed to include all areas of risk, including key holding and catches on wardrobes. Individual risk assessments are unique documents and one service users’ risk assessment must not be used for another service user without being amended. One service user with high mobility needs had not had a moving and handling risk assessment carried out. This must be done as a matter of priority. The registered manager must ensure that all service users’ wishes concerning death and dying are sought and documented. It is a requirement of this Timescale for action 31/10/05 2. OP2 5(1) 31/10/05 3. OP7 13(4) 31/08/05 4. OP7 13(4) 31/08/05 5. OP7 13(4) Immediatel y 6. OP11 12(2)(3) 31/10/05 7. OP10 12(4)(a) immediatel Page 22 Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 8. OP15 13(4) 9. OP16 17(2) 10. OP24 13(4) 11. OP24 13(4) 12. OP25 13(4) 13. OP25 12(2)(3) 14. OP26 16(2)(j) 15. OP29 schedule 2 16. OP27 18(1) inspection that members of staff are available at all times to meet the assessed needs of the service users and not rely on relatives to do so. The registered manager must ensure that that a thermometer is put in place for the freezer and daily temperatures recorded. The registered manager must ensure that all entries into the complaints log book are specific, stating clearly what the complaint was about, action taken and outcome The registered manager must ensure that risk assessments are carried out for service users who items of relevant furniture is perceived a risk. The registered manager must ensure that the bedroom in Hawthorne Way with a double socket taped over must be repaired with immediate effect. The registered manager must ensure that all exposed pipe work is guarded to reduce risk of burns. The registered manager must ensure that these restrictive screws on the windows in Hawthorne Way are either removed or risk assessed. The registered manager must review the continence aids used by the home in order to eliminate the unpleasant odour of urine The registered manager must ensure that candidates only start emploment following the receipt of a CRB clearance and two statisfactory references. The registered manager must therefore review staffing levels with immediate effect. y Immediatel y 31/08/05 30/11/05 Immediatel y 31/10/05 31/10/05 31/08/05 31/07/05 Immediatel y Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 23 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 OP12 Good Practice Recommendations It is recommended that the level of activities offered by the home is reviewed. Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. Extracts may not be used or reproduced without the express permission of CSCI Eardley House E51 E09 S28913 Eardley House V232252 080605 Stage 4.doc Version 1.30 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!