Inspection on 06/01/06 for Eastbury House

This inspection was carried out on 6th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 31/07/06

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 Rosie Brown Unannounced Inspection 10:30 6 January 2006 th 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 Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 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. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 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 Miss Deborah Jayne Morgan Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2005 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. Parts of the building date back to the 17th century, in particular the hallway and main staircase, dining room and front lounge: all retaining many of the original features such as oak wood panelling, stonework and leaded lights. The old stable outbuildings in the side courtyard have been converted to provide bed-sitting room accommodation in two separate units. Miss Morgan the registered manager has ceased employment in the home since the last inspection. Mrs Appleyard the previously registered owner of the home and is the registered as the responsible individual (RI) on behalf of the limited company: Eastbury House (Sherborne) Ltd. 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 rooms 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 service 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. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 6th January 2006 and was undertaken by inspector Rosie Brown: it was the second of two statutory unannounced inspections planned to take place this year. The inspection commenced at 10.30am and concluded by approximately 4.45pm. On the day of the inspection there were 18 residents accommodated in the home and one prospective resident visited the home for lunch and to meet with other residents. When the inspector arrived Mrs Appleyard was attending the funeral of a recently deceased resident, however, she came to the home to assist with the inspection at approximately 11.30am. There were eight members of staff on duty and these included the administrator, social care coordinator, three care assistants, the cook, kitchen assistant and a domestic/cleaner. The inspector assessed 14 of the National Minimum Standards and the requirements and recommendations set out in the report of the previous inspection dated 14th September 2005. The communal areas and the majority of bedrooms were viewed: residents’ care records, staff records and some of the home’s policies and procedures were also examined. The inspector used observation skills while viewing the environment and observing staff interaction with the residents. She also spoke with the administrator, the social care co-ordinator, and five members of staff, six service users and three visitors. Prior to this inspection Mrs Appleyard wrote to the inspector explaining that the registered manager was leaving and the temporary management arrangements. Mrs Appleyard has recently recruited a new manager and an application pack for their registration with the Commission has been provided. It is recommended that the report of the previous inspection be read in conjunction with this report so that a fuller ‘picture’ of the home is obtained. 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’m very happy here”. The social care provision is central to residents’ lives and includes their individual choices. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 6 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 high, offering alternative options at each meal, includes residents choices and preferences and caters for special diets. The home is well maintained, attractively decorated and comfortably furnished, there is a mature private garden where residents can sit and relax outside. The homes recruitment and employment practice is good with the appropriate checks undertaken to ensure residents are not placed at unnecessary risk. What has improved since the last inspection? What they could do better: The home’s statement of purpose should include more specific detail about access to bedrooms by describing those rooms where steps and stairs are negotiated. Residents care plans must be reviewed each month and at times of significant change in care needs, eg following a fall. The home must routinely notify the Commission of incidents and accidents that may directly affect the well-being of a resident and demonstrate the actions taken to prevent recurrence. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 7 The Medication Administration Record (MAR) charts must accurately reflect the prescribed details of all medicines and make clear why and changes to the original instructions have been changed. It is recommended that the home’s medication storage and administration arrangements be improved by the introduction of a monitored dosage system. The risk-assessment for residents who self-administer their own medicines must be updated each month and at times of change. A programme of guarding or protecting central heating radiators and fitting fail-safe hot water control valves to washbasins must be implemented to ensure the safety of vulnerable residents. A call facility should be fitted in the home’s dining room and nearby toilet as identified. The staff rota should include the complete name of each staff member, the hours they work, their role and the management arrangements for the day. The staff-training programme should continue to be developed. 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. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 8 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 Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 9 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): 1 and 3 The home has a statement of purpose and guide but this does not accurately describe access to some bedroom accommodation, which may be difficult due to steps or stairs and uneven floor levels. Therefore an informed choice about living in the home cannot be made by prospective service users’ who are physically frail. A pre admission assessment is undertaken for each person before they are accommodated to ensure that the home can meet their identified needs. EVIDENCE: The home’s statement of purpose is kept in the home’s policies and procedures file and this is readily available to residents, their representatives and staff. However, it could not be found on the day of the inspection. Mrs Appleyard thought a member of staff who is undertaking their NVQ training might have removed it. It was agreed that Mrs Appleyard would ensure that the statement of purpose has been updated and supply a copy to the Commission: an addendum should be attached to explain that the new manager has yet to be registered and approved by the Commission. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 10 The pre admission assessments for two residents were examined. The assessments were detailed and enabled a basic care to be drawn up prior to admission thereby demonstrating that the home could met each persons identified needs. One of the recently accommodated residents spoke with the inspector and confirmed that they are gradually settling in and that their care needs are being met by the home. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 11 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 and 9 Each resident has a care plan that identifies the care being provided to meet identified needs. The home’s medication storage and administration arrangements are adequate and some residents continue to take care of their own medicines. Standards 8 and 10 were met at the previous inspection. EVIDENCE: The care plans for two residents were seen and demonstrated how their identified care needs are to be met by staff. Risk assessments are in place in relation to moving and handling and the prevention of falls. The information documented is detailed and informative. The accident record book needs to routinely record the action taken to prevent recurrence and this information must then be included in the person’s care plan. Care plans and care related risk assessments must routinely evidence monthly review: records seen demonstrated review in October and November 2005. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 12 The medication storage and administration arrangements were briefly examined. Residents’ prescribed medication is kept in a locked cupboard, which has a smaller lockable cupboard inside where controlled drugs (CD) can be safely stored. Mrs Appleyard or senior staff holds the keys to the medicine cupboard. The home draws up a medication administration record (MAR) chart for each resident and these are signed when medication is administered. The minority of residents continue to manage their own medication. Although a general riskassessment concerning the arrangements in the home when a resident selfadministers medicine were documented, the individual risk assessment for one resident had not been reviewed each month. While examining the MAR charts it was noted that the details of prescribed medication are not accurately copied by staff, eg take with food or do not take more than 8 in 24hrs. When the time of day a certain tablet is given was changed or the number of tablets administered the record did not reflect who had made this decision, eg GP and name. The daily record for one resident noted that tablets had been found in their room but care records did not evidence how this incident was followed through to prevent recurrence and ensure the person was safe: for example discussion with the GP or District Nurse (DN). The matter was not reported to the Commission, as an untoward incident that may affect the well being of a resident. Some time was spent in discussion with Mrs Appleyard about the introduction of a blister pack system and how this safer system would improve the current arrangements. The CSCI pharmacy inspector has been asked by the inspector to visit the home to provide advise and guidance on the home’s medication arrangements. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 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 and 14 Residents’ confirmed that their social, recreational and cultural needs are promoted and that they enjoy the lifestyle they experience in the home. The home promotes individual choices and residents’ confirmed that they feel they have control over their daily lives. Standards 13 and 15 were met at the previous inspection. EVIDENCE: There was evidence that the home provides regular and varied activities and these are noted in each resident’s care records and the home’s diary: a notice advertising a musical event was displayed for information on the dining room door. One resident who did not join in with the morning gentle exercise session said, ‘ I never feel I must join in and when I do, it is a genuine choice The home’s visitors’ book demonstrates that visitors call into the home on a daily basis. Two residents confirmed that they receive weekly visits from family members and friends while one other said they go out to lunch once a week with their daughter. Care records note that some residents are taken out to Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 14 church and the home’s social care co-ordinator said, ‘residents’ are always taken out of the home for appointments, unless they are unwell or too frail’. A prospective resident visited the home on the day of the inspection and enjoyed a pre-lunch sherry in the dining room with other residents before eating lunch in the home’s dining room: they later told the inspector that ‘lunch was delicious’. Discussion with residents and care records demonstrated that they are actively encouraged to maintain their individuality and make choices about their daily lives, eg time to get up or go to bed or whether to stay in their room. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 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): 18 The home has a policy concerned with adult protection to ensure that allegations of abuse would be properly responded to, thereby protecting the residents who live in the home. Standards 16 and 17 were met at the previous inspection. EVIDENCE: The home has a policy and procedure concerned with the protection of vulnerable adults and holds a copy of the local ‘No Secrets’ guidance for staff to follow should such a situation arise. A copy of the Protection of Vulnerable Adults (POVA) guidance issued by the Department of Health is kept for reference. The home also has a documented ‘Whistle Blowing’ policy and this is easily accessed in the home’s policy and procedures file. The ‘No Secrets’ document and the POVA guidance should be kept in the home’s policy and procedures file. Some senior staff have undertaken training in the recognition of abuse and local ‘No Secrets’ procedures. The social care co-ordinator and one other staff member confirmed they are due to attend a POVA training course on the 12th January 2006 with other care staff: this was evidenced by paperwork. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 The home is very clean, comfortably furnished and maintained to a good standard, it provides a pleasant homely environment for the residents who choose to live there. The environment will be safer for residents when central heating radiators are guarded and the temperature of the hot water supply to washbasins controlled. EVIDENCE: As described in the previous report, 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. New stair and corridor carpets have been fitted since the last inspection. The bedrooms vary in size and several exceed the recommended standard. The home has one double room but this is currently used as a single. Approved door locks are fitted to some bedroom doors, but have yet to be fitted to all: these are made available to new residents on request. Due to the age and layout of the building the home is not suitable for people Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 17 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 that is 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. 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 and 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. The temperature of the hot water to one washbasin was tested and found to be 62 degrees. Risk-assessments are drawn up but safety actions must be taken where identified, eg hot water warning notices posted and/or temperature control valves fitted. A very hot towel rail was also noted in one first floor bathroom. Individual risk assessments are in place concerning each resident’s vulnerability to the hot surface temperature of central heating radiators because they are not guarded. However, an action plan regarding the protecting of radiators and the fitting of temperature control valves to washbasins must be supplied to the Commission so that service users who are at risk or prone to falling are safe from harm. Since the previous inspection a new call system with staff handsets has been installed in the home. One toilet near to the dining room and the dining room do not have a call facility and Mrs Appleyard has agreed to remedy this matter. The home was clean throughout and cleaning products were safely locked away as required. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 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 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): 28, 29 and 30 Staff who work in the home are subject to proper recruitment and employment checks so that residents are protected. The home is providing care staff with induction and NVQ training to ensure that residents are properly cared for by qualified staff. Standard 27 was met at the previous inspection. EVIDENCE: The recruitment records for two new members of staff were examined and these detailed that all necessary checks and information was obtained before these persons commenced working in the home. Records showed that new staff are subject to induction training and that this is progressed to an NVQ 2 training programme. Mrs Appleyard explained that because the previous manager was the home’s training officer and NVQ Assessor she is seeking a way of continuing the training programme for staff. Training records also demonstrated that staff have been provided with training in manual handling, Stoma care and fire safety since the previous inspection in September 2005. The homes staff rota should contain more detail. For example, the full name of staff, the hours they work, their work role and the management arrangements for each day. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 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 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 and 38 The registered manager designate is supported by Mrs Appleyard, the registered individual (RI); the deputy manager and the staff team to ensure that residents receive consistent care. The views of residents and others are obtained to help ensure the home is run in their best interests and good quality care is provided. However, a proper quality assurance system has yet to be fully established. Arrangements are in place to ensure that the health, safety and welfare of residents and staff are promoted and protected. Standards 31 and 35 were met at the previous inspection. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 20 EVIDENCE: The home’s registered manager has ceased employment since the previous inspection. Mrs Appleyard (RI) has recently appointed a part-time registered manager designate who will commence working full time when their business degree is completed: this is anticipated to be in May-June 2006. In the meantime, Mrs Appleyard also manages the home assisted by the deputy manager and senior staff. Care staff are supplied with induction training and mandatory training that meets NTO specifications and the manager is developing the training provision in the home to incorporate other subjects. Maintenance records demonstrate that there are proper arrangements in place for the regular servicing of the fire precautionary system and staff are supplied with fire safety training. A programme of covering or guarding radiators in the home must be commenced; this will ensure that service users who are likely to inadvertently hold onto them or fall against them are safe from harm. Likewise the hot water supply to washbasins must be governed and supplied at a safe temperature to prevent scalding. The home keeps documentary evidence to demonstrate that moving and handling equipment, central heating system and gas and electrical installations are routinely serviced. The home’s water supply is tested to prevent the risks of Legionella developing. A quality assurance system is being developed so that service users continue to contribute to future developments in the home. Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 Page 22 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. Standard Regulation Requirement The homes statement of purpose and guide must include information about access to bedrooms. Eg where there are steps and level access is not achieved without use of the stairs. (Previous timescale of 1/4/05 and 31/10/05 not met in full). Care plans and associated riskassessments must be reviewed each month and routinely include more detail regarding each service users wishes/needs for their care when dying and in the event of death. Residents’ MAR charts must include all details on prescribed medicines, eg with food or no more than 8 tablets to be taken in 24hrs. The MAR charts must be signed to note when the GP changes the prescribed details, no of tablets administered or time of day given. Risk-assessments for residents who self administer their own medication must be updated monthly and at times of change The home must notify the DS0000048854.V272483.R01.S.doc Timescale for action 1. OP1 4&5 28/02/06 2. OP7 14 & 15 28/02/06 3. OP9 13 (2) 14/02/06 4. OP9 13 (2) 14/02/06 5 6 Eastbury House OP9 OP9 13 (2) 13 (4) & 14/02/06 14/02/06 Page 23 Version 5.0 37 7. OP19 23 8. OP25 13 (4) Commission of all incidents or that may directly affect the well being of a resident and demonstrate the actions taken to prevent recurrence. Locks of approved style must be fitted to all bedrooms doors. (A programme of fitting approved locks has commenced but timescale of 31/10/05 not met in full). A programme of fitting fail-safe hot water temperature control valves to washbasins and protecting of central heating radiator surfaces must be commenced using a riskassessment process, eg the hot towel rail in the communal bathroom on the first floor. (Timescale of 31/10/05 not met). 31/03/06 28/02/06 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. Refer to Standard OP7 OP7 OP9 OP29 OP29 Good Practice Recommendations When accidents are reviewed the action taken to prevent recurrence should be routinely included into the residents care plan. All documents should be signed by the writer. (Repeated from previous report). Consideration should be given to improving the current medication administration and storage arrangements by the implementation of a monitored dosage system. The staff rota should detail the complete name of each staff member, the hours they work and note the management arrangements for each day. The home’s staff training programme should continue to develop and all staff supplied with local adult protection training, as planned. DS0000048854.V272483.R01.S.doc Version 5.0 Page 24 Eastbury House 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 Eastbury House DS0000048854.V272483.R01.S.doc Version 5.0 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. 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