Inspection on 31/07/06 for Eastbury House

This inspection was carried out on 31st July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Eastbury House 12/08/08

Eastbury House 30/07/07

Eastbury House 07/02/07

Eastbury House 06/01/06

Eastbury House 14/09/05

Eastbury House 11/01/05

Eastbury House 01/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Eastbury House Long Street Sherborne Dorset DT9 3BZ Lead Inspector Gloria Ashwell Key Unannounced Inspection 31st July 2006 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000048854.V303451.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000048854.V303451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastbury House Address Long Street Sherborne Dorset DT9 3BZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01935 812132 01935 814164 eastburyhouse@btinternet.com Eastbury House (Sherborne) Ltd Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places DS0000048854.V303451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2006 Brief Description of the Service: Eastbury House is situated close to the centre of Sherborne within easy level walking distance of the town amenities. The home is registered to provide care and accommodation to a maximum of 19 people over the age of 65 and offers long and short-term places. Mrs Appleyard is the previously registered owner of the home and the responsible individual on behalf of the limited company: Eastbury House (Sherborne) Ltd. The home is at present without a registered manager and is being managed by Mrs Appleyard and acting manager Miss Witt. Parts of the building date back to the 17th century, in particular the hallway and main staircase, dining room and front lounge. These areas retain many of the original features such as oak wood panelling, stonework and leaded lights. The accommodation for service users is arranged over the ground and first floor of the home. Due to the age of the building and extensions to the house made many years ago there are a number of internal stairs and steps and changes of level, therefore some parts of the accommodation cannot be easily accessed by people who experience severe mobility problems. A stair-lift fitted to the back staircase provides access to bedrooms situated on the first floor. Nine bedrooms are situated on the ground floor: two bed/sitting rooms are in a building close to, but separate from the main house. In addition to personal care and support the services provided include all meals, laundering and housekeeping. The home has mature private gardens where residents can sit and relax in the warmer weather. There is a small parking area to the side of the house and a public car park is also situated a short walk from the home and close to the town centre. Arrangements can be made for a hairdresser, chiropodists, opticians and other health and social care professionals to visit individual residents. Fees are charged weekly and at present range between £400 and £600 per person. DS0000048854.V303451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a statutory inspection required in accordance with the Care Standards Act 2000. The inspection was unannounced; the inspector arrived at 11.30 toured the premises and spoke to residents and staff. Together with responsible individual Mrs Appleyard and acting manager Miss Witt the inspector discussed and examined documentation. At present 17 permanent and 1 respite (short term care) residents are accommodated. During the inspection, particular residents were ‘case tracked’; for example, for evidence regarding Standards 3, 7 and 8, records relating to the same resident were examined, and the resident spoken with. Additional information used to inform the inspection process included the Preinspection Questionnaire completed in advance of the inspection by the previous acting manager. Since the previous inspection a number of completed Comment Cards were sent to the Commission: 8 from the relatives of residents, 8 from local doctors, 3 from health and social care professionals and one from care manager/placements officer. (No Comment Cards were received from residents of the home.) All comments indicated satisfaction; a number were very positive and one observed “Eastbury House is very welcoming and the staff are always helpful and willing to discuss any aspect of X’s care and act upon it”. During this inspection compliance with all key standards of the National Minimum Standards was assessed. What the service does well: Eastbury House is a well established home where elderly people are encouraged to remain as independent as their frailties allow. The home promotes service users choice regarding their daily lives and routines. One resident said, “ I had a friend who was here for 6 years and I think she was cared for so wonderfully”. Comments received by the Commission in advance of the inspection included “an excellent caring home for the elderly”. DS0000048854.V303451.R01.S.doc Version 5.2 Page 6 The social care provision is central to residents’ lives and reflects their individual choices. Service users said they are treated with respect at all times and their privacy is respected. The standard of food supplied to service users is very good, offering alternative options at each meal. The home is well maintained, attractively decorated and comfortably furnished, with a mature private garden where residents can sit and relax. What has improved since the last inspection? 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. DS0000048854.V303451.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000048854.V303451.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (The home does not provide intermediate care so Standard 6 does not apply) Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Prospective residents (or their representatives) are provided with information about Eastbury House and are encouraged to visit in advance of admission to establish their impressions of life at the home and the standard of available accommodation. Prior to admission, the needs of each proposed resident are assessed and the home then writes to prospective residents confirming the ability to properly care for them. EVIDENCE: The records of a recently admitted resident included details of pre-admission assessment which had been carried out by Miss Witt when she visited the prospective resident at her previous address. DS0000048854.V303451.R01.S.doc Version 5.2 Page 9 In advance of making the decision to enter the home the closest relatives of the prospective resident visited Eastbury House to view the premises on her behalf because she was too frail to do this herself. The inspector spoke to the resident and her relatives who were visiting her at the time of the inspection and confirmed their satisfaction with Eastbury House stating that in particular the food is very good and arrangements for maintaining resident’s comfort during the recent heat wave were also very good. Another recently admitted resident said “The first morning I was here I thought I’d died and gone to heaven. I’m sad to leave my own home, but on the other hand I couldn’t be happier”. Comments received by the Commission in advance of the inspection included “This is a fantastic home – X’s life has been transformed by the loving care and excellent food.” DS0000048854.V303451.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area requires improvement with regard to the management of accidents and medicine handling. This judgment has been made using available evidence including a visit to the service. The standard of care is good and in accordance with a written plan of care for each resident ensuring that staff have sufficient information upon which to base their care practice. Resident’s health needs are met although periodic audit of accidents is not reliably recorded and thereby risks of recurrence may not always be minimised. Handling of medicines prescribed by doctors must be improved to ensure the safety of residents, the correct administration of medicines and consequent provision of good care. Residents are treated with respect and their privacy and dignity is protected at all times. DS0000048854.V303451.R01.S.doc Version 5.2 Page 11 EVIDENCE: Residents believe they are properly cared for; comments made during the inspection included “I am completely satisfied; the carers are so wonderful”. Care records of 3 residents were examined and contained risk assessments forming the basis for care plans and daily records describing the care of each resident. To ensure correct identification of residents, records contain a recent photograph of each resident. Records are kept of all accidents but it is recommended that these be expanded to include details of investigation and that an accident policy and procedure with particular regard to falls management be developed and implemented. Residents wishing to do so can manage their own medicines in accord with a risk assessment process; the associated records must be improved to provide robust evidence of the assessment and findings. Medicine handling is carried out by staff trained in this work and medication administration records were in general properly kept indicating that residents receive prescribed medicines at the correct times and in correct amounts but a medicine prescribed for administration to a resident each morning had not been signed to confirm this administration on 6 occasions since 17 July 2006; it is required that each occasion of administration be confirmed in writing, or a written record made of the reason for omission. It is also required that when a medicine is prescribed for administration “as required” the reason for such administration be recorded. To improve the medicine recording systems it is recommended that each medication administration record state the allergy status of the resident, or “none known” when this is the circumstance. It is also recommended that the ‘medicines list’ recorded for each resident, include the reason for prescription of each medicine. Residents expressed satisfaction with Eastbury House and in the presence of staff appeared relaxed, confident and at ease; staff interactions with residents were of a friendly and considerate manner. Comments received from residents during the inspection included “Mrs Appleyard is a wonderful person and the staff couldn’t be nicer”. Comments received by the Commission in advance of the inspection included “Eastbury handled X’s final days very well – could not have been better” (from the relative of a recently deceased resident) and two doctors respectively stated “excellent care home – Mrs Appleyard does a magnificent job” and DS0000048854.V303451.R01.S.doc Version 5.2 Page 12 “always seems an excellent home; caring, considerate and professional – would recommend it to my relatives!” DS0000048854.V303451.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is generally good but pets must be kept out of the kitchen to ensure that good food hygiene standards are maintained. This judgment has been made using available evidence including a visit to the service. The quality of daily life in the home is good with residents assisted to maintain as much independence as possible. Social and leisure activities are suited to the preference and ability of each resident. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. Meals are appetising and of good quantity and quality. On the ground floor there is a well-appointed dining room; residents may also take meals in their bedrooms. DS0000048854.V303451.R01.S.doc Version 5.2 Page 14 EVIDENCE: Residents are very satisfied with all aspects of the home, including the range of activities, meal provision, staff and premises. The home periodically arranges local excursions, one-to-one and small group social and recreational activities. Residents enjoy the activities and consider them appropriate and of good variety; in particular a number of residents described the enjoyment received from recent excursions to Abbotsbury and a nearby farm. One resident suggested that a ‘tuck shop’ selling sweets, toiletries etc. be operated by the home for the benefit of residents unable to go out. This suggestion is undergoing consideration for implementation. Comments received by the Commission in advance of the inspection included “I am extremely pleased with the friendly informal atmosphere; more like a private house than an institutional home. (The people I visit) are treated as individuals and much care is taken to stimulate their interest in life”. Visitors are welcome at any time and the two present during the inspection said they are always made to feel welcome and placed at ease by the staff. Residents said they were satisfied with the quality, choice and quantity of food provided; one resident said ”It’s always very good; we have three choices for lunch”. During the inspection it was noted that two pet dogs were frequently to be found in the kitchen while the midday meal was being prepared. Mrs Appleyard said this was unusual because the animals normally remain in the administrative sitting room. It is required that animals are not permitted access to rooms where foodstuffs are stored, prepared or served. To further improve catering standards it is recommended that facilities be provided enabling residents and their visitors to obtain drinks and snacks. DS0000048854.V303451.R01.S.doc Version 5.2 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 the following standard(s): 16 & 18 Quality in this outcome area is good with regard to complaint management, but improvements must be made to ensure that correct action would be taken in the event of an allegation or suspicion of abuse arising. These judgments have been made using available evidence including a visit to the service. The complaints procedure provides information on the procedure to follow for persons wishing to make complaint. The home has an incorrect policy/procedure for the prevention of abuse and not all staff have received training in this subject to ensure that they remain vigilant to protect vulnerable residents from risks of abuse. EVIDENCE: Residents feel confident that if they had concerns or complaints they will be listened to and taken seriously. To ensure residents and their representatives have access to the complaints procedure it is included in the service user guide to the home and a copy is provided to each residents’ relative/representative. Residents know how to complain and feel confident that if they had concerns or complaints they will be listened to and taken seriously. Comments received during the inspection included “If I didn’t like it I wouldn’t stay here”. DS0000048854.V303451.R01.S.doc Version 5.2 Page 16 The home keeps records of all complaints received and investigated. Since the last inspection no complaints against the home have been received or investigated. The written policy and procedure for the protection of residents from abuse or neglect makes incorrect reference to in-house investigation taking place and must be amended to ensure that any allegation or suspicion of abuse is immediately notified to Dorset Social Services and the Commission, in line with established guidance from the Department of Health in the document ‘No Secrets’: www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/Publica Additionally, all staff should receive training in the understanding of abuse, and their role in protecting residents from abuse in its many forms, including neglect. DS0000048854.V303451.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 19, 25 & 26 Quality in this outcome area is generally good although some improvements to specified safety aspects are required. This judgment has been made using available evidence including a visit to the service. The premises are comfortable and clean. EVIDENCE: The home has two separate lounges and a separate dining room on the ground floor; these rooms and the hallway contain many of the original features of the 17th century house. Some bedrooms have been redecorated and re-carpeted since the last inspection, and all bedroom doors are now fitted with locks of approved type. Bedrooms vary in size and several exceed the recommended standard. DS0000048854.V303451.R01.S.doc Version 5.2 Page 18 Due to the age and layout of the building the home is not suitable for people with restricted mobility: some doorways and corridors are narrow and there are steps up to the front door. The two apartments in the rear courtyard have level access and are large enough to accommodate a person with a physical disability. The first floor is accessed via the main staircase or by a stair-lift fitted to the back stairs; there are various changes of level with steps throughout the home. The home has four communal bathrooms. A portable bath seat is available and one ground floor bathroom has an installed mobility aid. (It is recommended that the discoloured seat cover of the portable bath seat be replaced at the earliest opportunity.) One ground floor bathroom has a ‘hip bath’ that is currently used by residents but the Commission does not recommend this type of bath for use. There are six communal toilets in the home; these are close to communal rooms and bedrooms. Four bedrooms have en-suite bath/shower rooms and four have en-suite toilet and wash hand basins. Risk-assessments regarding hot water supplied to wash hand basins used by residents have been recorded but safety actions must be taken where identified; Mrs Appleyard stated it is her intention to display ‘hot water’ warning notices. Mrs Appleyard confirmed that she has developed an action plan for the guarding of radiators and the fitting of temperature control valves to washbasins to protect residents from harm. The home was clean throughout and cleaning products were safely locked away as required. Temporarily stored on a first floor corridor were two large glass panels, being the double-glazing of a set of French windows. It is required that these items be removed to another location, where they will not present risk of injury to persons who might accidentally fall against them. DS0000048854.V303451.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good with regard to the number of staff and their competency but improvements must be made to employment processes to ensure the protection of residents against the employment of unsuitable staff who may place them at risk of harm. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Staffing levels are provided in accordance with the assessed needs of residents to ensure that at all times sufficient staff are available to properly meet their needs. All staff spoken to during the inspection were enthusiastic about their work and felt that they provided a good standard of care to residents. Employment records of two recently employed staff were examined; for one of the staff there was no evidence of any reference having been obtained in advance of employment and the CRB disclosure had been obtained a month after the person had commenced work in the home. The history of employment recorded by the other staff member included no dates. There were no records for a young relative of Mrs Appleyard who is occasionally employed in the home in a variety of ‘non care’ tasks. For all new staff, in advance of employment, the home must obtain at least two written references and an accurate history of past employment to ensure residents are not placed at risk by the employment of potentially unsuitable DS0000048854.V303451.R01.S.doc Version 5.2 Page 20 staff. An Immediate Requirement in this regard was issued during the inspection. For all staff, in advance of employment, the home must obtain written references and POVA 1st/CRB disclosure to ensure residents are not placed at risk by the employment of potentially unsuitable staff. For all staff members there must be comprehensive records including all dates of previous employment. At present 55 care staff currently employed by the home hold a National Vocational Qualification in care; the home thereby exceeds the standard for at least 50 of the care staff to hold an NVQ in care. Notwithstanding the weaknesses in their employment records, the two staff whose records were examined had received induction training and had attended training in fire safety. An external training provider is engaged by the home to supply training to staff in a variety of relevant subjects. To further assist the training of care staff there is available a range of opportunities including www.picbdp.co.uk (the Partners in Care web site), www.skillsforcare.org.uk (the Skills for Care web site), www.traintogain.gov.uk (a programme and funding stream supported by the Learning and Skills Council and Business Link) and www.lsc.gov.uk/bdp/employer/eggt_intro.htm (the Employer Guide to Training website, which is aimed at assisting employers to choose the most suitable training provider to meet their workforce needs by the use of a search facility). DS0000048854.V303451.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is generally good but the home should be in the charge of a registered manager, arrangements for obtaining the opinions of residents should be improved and the home should operate in accord with a comprehensive set of policies/procedures. This judgment has been made using available evidence including a visit to the service. The home is well managed and staff understand their work and receive training appropriate to their needs. Residents are satisfied with the home and feel staff care for them well and put them at their ease. The home does not manage the finances of residents. The premises and equipment are properly maintained in good condition. DS0000048854.V303451.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home has been without a registered manager since the departure of the previous post-holder during November 2006. At present the home is jointly managed by responsible individual Mrs Appleyard and acting manager Miss Witt, who intends to apply to the Commission to become the registered manager. The home has held the Investors In People award since 1997; the associated 3 yearly review is to take place during this year. It is recommended that systems for obtaining the opinions of residents and other service users be improved to ensure their continued satisfaction with all aspects of the home. To ensure continuity of approach the home operates in accord with a selection of policy and procedure documents; it is recommended that at the earliest opportunity these are extended to include all those referred to by the Commission in the pre-inspection questionnaire, including the subjects of pressure relief, clinical procedures and risk assessment. With the exception of safe keeping some amounts of cash (for which all transactions are confirmed by receipt), the home does not manage the finances of residents. Staff trained in First Aid are on duty in the home at all times. The premises are well maintained and there are regular checks/tests of all equipment. Details of equipment servicing and maintenance were provided to the Commission in advance of this inspection. The inspector examined a sample of fire safety records to verify this information. For excursions residents are transported in cars driven by Mrs Appleyard and staff. It is recommended that to ensure the safety of passengers the designated drivers receive associated training and work in association with a specific policy/procedure giving guidance on accompanying residents on excursions. The home permits residents to smoke in their bedrooms (but not while actually in bed); it is recommended that an associated policy and procedure be developed and implemented to include risk assessment for each resident to whom this aspect applies. DS0000048854.V303451.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 DS0000048854.V303451.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement Records of self administration of medicines (by a particular resident) must be improved to provide robust evidence of the assessment and findings. Each occasion of medicine administration must be confirmed in writing, or a written record made of the reason for omission. Records must be made in ink, not pencil. When a medicine is prescribed for administration “as required” the reason for such administration must be recorded in the directions. Animals must not be not permitted access to rooms where foodstuffs are stored, prepared or served. The home must develop and implement a suitable policy and procedure for the understanding of abuse and correct response to any allegation or suspicion of abuse. Timescale for action 01/09/06 2. OP9 13 01/09/06 3. OP9 13 01/09/06 4. OP15 13 01/09/06 5. OP18 13 01/10/06 DS0000048854.V303451.R01.S.doc Version 5.2 Page 25 6. OP25 13 7. OP25 13 (4) 8. OP29 19 & Schedule 2 The glass panels must be 01/09/06 removed from the first floor corridor where they are presenting risks of accidental injury. The arrangements for 01/09/06 safeguarding residents from risks associated with hot water supplied to washbasins must be completed. (Timescales of 31/10/05 and 28/02/06 not met). There must be evidence that the 01/09/06 home operates a robust recruitment procedure. New staff must not commence work in the home without evidence of suitable CRB and POVA disclosure. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP8 OP8 OP9 OP9 OP15 OP18 Good Practice Recommendations It is recommended that accident records be expanded to include details of investigation and outcome. It is recommended that an accident policy and procedure with particular regard to falls management be developed and implemented. It is recommended that each medication administration record state the allergy status of the resident, or “none known” when this is the circumstance. It is recommended that a list of all prescribed medicines be recorded for each resident, together with the reason for prescription. It is recommended that facilities be provided enabling residents and their visitors to obtain drinks and snacks. It is recommended that all staff receive training in the understanding of abuse and their role in its prevention and detection. DS0000048854.V303451.R01.S.doc Version 5.2 Page 26 7. 8. 9. 10. OP21 OP31 OP33 OP38 11. OP38 12. OP38 It is recommended that the discoloured seat cover of the portable bath seat be replaced at the earliest opportunity. It is recommended that the acting manager apply to the Commission to become the registered manager. It is recommended that systems for obtaining the opinions of residents and other service users be improved. It is recommended that to ensure the safety of passengers the designated car drivers should receive associated training and work in association with a specific policy/procedure giving guidance on accompanying residents on excursions. It is recommended that at the earliest opportunity written policies and procedures be developed and implemented for all subjects referred to by the Commission in the preinspection questionnaire. It is recommended that a ‘smoking’ policy and procedure be developed and implemented to include risk assessment for each resident to whom this aspect applies. DS0000048854.V303451.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000048854.V303451.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!