Inspection on 16/01/07 for Easterlea

This inspection was carried out on 16th January 2007.

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

Other inspections for this house

Easterlea 16/06/08

Easterlea 20/12/07

Easterlea 21/09/05

Easterlea 04/05/05

Easterlea 20/09/04

Easterlea 26/04/04

Easterlea 02/10/03

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

CARE HOMES FOR OLDER PEOPLE Easterlea Hambledon Road Denmead Hampshire PO7 6QG Lead Inspector Ian Craig Unannounced Inspection 16th January 2007 09:30 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 Easterlea DS0000011757.V323193.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. Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Easterlea Address Hambledon Road Denmead Hampshire PO7 6QG 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) 023 9226 2551 Mr David Mitchell Miss Carol Boyce-Flowers Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A minimum of three care staff are on duty between the hours of 8.00am to 8.00pm whenever service users numbers exceed 15. These care hours must be in addition to any management hours. 21st September 2005 Date of last inspection Brief Description of the Service: Easterlea is registered with the Commission for Social Care Inspection (CSCI) to provide care and support for up to 19 Older People. The home is situated on the outskirts of the village of Denmead in Hampshire and is set back from the busy main road. Accommodation is provided over two floors, ground and first floor and a lift is provided. There are 14 single rooms, 9 of which are en-suite and 2 double rooms, with 1 en-suite. There is a large rear garden, which is accessible through the lounge and parking is available at the front of the home for up to 10 cars. The village centre is a short distance away where local shops, a post office and GP surgery are situated. The local bus stops a short distance from the home and there is also a local ring and ride bus service available. Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection consisted of a tour of the building, examination of records, documents and policies and procedures as well as interviews with two staff members. The home’s manager was fully involved and consulted about the findings of the inspection. A relative of a resident was interviewed and five residents were spoken to regarding their views about the home. Prior to the inspection a review of the home’s recent history was undertaken as well as examination of the pre inspection questionnaire, which was completed by the home. The weekly fees for the home range from £335.00 to £455.00. What the service does well: What has improved since the last inspection? The manager stated that there have been no improvements to the home since the last inspection. There is an ongoing training schedule for staff. Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Easterlea DS0000011757.V323193.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 Easterlea DS0000011757.V323193.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information about the home and have a chance to visit the service before deciding whether or not to move in. The home needs to improve the system of assessing potential resident’s needs in order that an informed decision can be made about the person’s suitability. EVIDENCE: A relative of a resident, and a resident, described how a decision was made about moving into the home. This involved several visits to the home by the relative and resident together. During these visits the prospective resident was able to join the residents for a meal as well as spending time meeting the staff Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 9 and having a look around the home. Following admission to the home, the resident had a 2-week period to decide if the placement was suitable. The process used by the home to assess a potential resident’s needs before he or she moves into the home was discussed with the manager and relevant records were examined. An assessment care plan form is completed on the day the person moves into the home. Several of these documents were seen. It was noted that they had not been signed or dated by the person completing them. The manager explained that on some occasions she visits the prospective resident at his or her home, or in hospital, before the person moves into the home in order to assess their needs. For the sample of residents’ records that had been recently admitted to the home there was no record of this pre admission assessment. A copy of the referring care manager’s assessment had not been obtained either. It was not possible to tell how the home is assessing potential residents’ needs before they are accommodated in the home. This is important if the home is to admit only those people whose needs they know can be met. Easterlea DS0000011757.V323193.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst resident’s personal and health care needs are detailed in care plans, improvements are needed to the care plans so that health needs are included. Procedures for the administration of medication are a potential risk to residents. Residents are treated with dignity and respect. EVIDENCE: Each resident has a file containing relevant documents about their stay at the home. These include the assessments and care plans. As previously stated in the Choice of Home section of this report, an Assessment Care Plan Form is Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 11 completed on the day the person is admitted to the home. This serves to act as both an assessment of need and a care plan. These cover a variety of needs including, medial history, toileting, communication, dressing and so on. As previously stated, these documents had not been signed or dated by the person completing them. Records showed that individual resident’s needs are reviewed each month and that an annual review takes place also. It was noted that residents’ care and health needs are not always recorded in the care plans. For instance, for one person there was no record of the responsibilities and procedures of the home regarding a person’s catheter. Details of health needs were obtained by the manager from the district nursing notes and not from the home’s own records. The home needs to review the information recorded in each person’s records to ensure that they include health and personal care needs. Records showed that residents have an eyesight check. The provision of dental checks for residents is not clear and records do not demonstrate that this being addressed. The manager stated that there are difficulties in obtaining agreement from a dentist to visit the home to carry out checks, but that some of the residents are taken to their own dental surgery. This needs to be explored by the home by liaising with the Primary Care Trust. Daily running records are maintained for each person in a diary. These are collectively recorded and are not transferred to each person’s own records. This was discussed with the manager and it was highlighted that personal records must be confidential for each individual, which also allows needs to be monitored more effectively. Residents and relatives spoke to on the day of the inspection stated that the standard of care provided was “good” and that personal care needs are met. Residents are aware that they have a care plan but did not have a copy of it. There was confirmation from residents and relatives that they are involved in annual reviews. Care staff described how they have a role as a keyworker to specific residents and that this involves responsibility for ensuring that monthly reviews take place. Medication procedures were examined. Both the written procedure and the practices of dispensing medication need to be changed. Medication is dispensed into lidded pots in advance. These pots have the name of the respective resident. At this point the staff member dispensing the medication into the pots, signs a record to say the medication has been taken by the resident. It is not until some time later that the medication is dispensed to the resident. On the day of the inspection this was observed to be approximately one hour after medication was placed in the pots and the records signed. This practice was confirmed by the manager as well as being detailed in the written procedure. Medication must only be dispensed from the pharmacist container immediately prior to the prescribed time the resident takes it. The current Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 12 practice does not adhere to pharmaceutical guidelines and places both the residents and home at risk of receiving the wrong medication to residents. Medication administration sheets had been completed each time the above procedure was followed. Procedures for the handling and administration of controlled medication are satisfactory, although the home’s written procedure does not detail each of the steps being followed by staff. Appropriate records are kept, including those of a witness and the running balance of the quantity remaining. The home needs to check that the medication cupboard meets the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973, which gives specific criteria regarding the controlled drug cupboard. Residents and relatives described the approach of the staff and management as friendly and kind. The staff and the manager were observed to interact with the residents with warmth and humour. Residents confirmed that their privacy is promoted. It was noted, however, that the sliding bathroom door on the ground floor was not working properly and compromised the user’s privacy. This was discussed with the manager who stated that the door is due to be repaired. This will be checked at the next inspection. Easterlea DS0000011757.V323193.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a variety of stimulation and activities. Meals are of a good standard and there is a choice at each meal. EVIDENCE: Whilst there is ample evidence that residents have access to a variety of stimulation and activities, care plans should give greater details about individual’s needs and preferences for social and recreational activities. A resident described how she was able to bring her pet dog with her to the home. Several residents referred to the numerous activities that are provided, such as parties, arts and crafts, musical entertainment, bingo and gentle exercise. The home maintains a record of activities. The inspector observed an activities coordinator engaging residents in the afternoon. A relative confirmed Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 14 that there are trips out in the summer months although this can be difficult to arrange due to the demands on the staffing levels. One resident stated how he likes to spend time in his room reading his daily newspaper. Relatives are able to visit the home at any reasonable time and a relative described how she is always made to feel welcome in the home. Residents are able to have their own telephone line in their room, which was confirmed for one resident. Residents are able to exercise choice in a number of ways, such as how they spend their time. There was evidence that there is choice at each of the meal times from records, which clearly showed residents having different meals. One relative, however, stated that choice is only available at the early evening meal. It would be beneficial for the home to communicate to relatives the choices available at the midday meals. The midday meal on the day of the inspection was: salmon fillet with Hollandaise sauce served with sautéed potatoes, peas and carrots. The dessert was apple pie and custard. The meals were served to the residents who were seated at dining tables. Each resident is asked in advance what he or she would like for the early evening meal. A record of this is made. Food stocks included fresh fruit. Easterlea DS0000011757.V323193.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home takes account of the views of the residents. Whilst the staff receive training in protecting older persons from abuse, recruitment procedures fail to protect residents. EVIDENCE: A relative of a resident described the home’s management as approachable and that she felt that any difficulties could be resolved before resorting to the complaints procedure. This relative stated that she is aware of the home’s complaints procedure. There is a logbook to record any complaints made. There have been no complaints in the recent past. The home has a copy of the local authority adult protection procedure as well as its own literature. Staff confirmed that they have received training in adult protection. There was a record of this training for 2004. The manager explained that further training has been provided, which was confirmed by the staff, but acknowledged that a record of this training had not been made. Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 16 Procedures for the recruitment of newly appointed staff do not include the required checks, which are designed to protect residents. This is described in greater detail in the staffing section of this report. Easterlea DS0000011757.V323193.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally clean, well maintained and promotes the dignity of the residents. Additional measures need to be taken to ensure satisfactory hygiene in the home. EVIDENCE: Part of the inspection involved a tour of the premises. The home was found to be clean and well maintained. There are plans to refurbish the ground floor bathroom. The manager also stated that the faulty sliding door on this bathroom will be repaired as it compromises the privacy of anyone using it. As Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 18 this work has been scheduled to take place a requirement has not been made. Progress on completing this will be checked at a future inspection. The home has a passenger lift as well as hoists for use with bathing. Bedrooms are personalised with ornaments, pictures, photographs of family members, television, radio, music listening equipment and so forth. A resident described how he likes to spend time in his bedroom and talked of the photograph and medals displayed on his bedroom wall. The lounge and dining room are situated in a large open area, which has a grand piano for entertainment. The outside of the home includes a front garden with parking for staff and visitors and there is a landscaped garden to the rear. The home has a separate laundry area. Infection control measures need to be addressed as there is no soap dispenser in the ground floor staff toilet and staff undertake a mix of care and cooking duties at lunch time (this is raised in greater detail in the Staffing section of this report). Easterlea DS0000011757.V323193.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home provides adequate staffing levels but the roles of staff compromise the control of infection. Whilst staff confirmed that they receive induction and training, records of training are poorly maintained. Staff recruitment procedures fail to protect residents. EVIDENCE: The home provides 3 care staff from 8am to 10 pm each day, with the manager supernumerary from 8am to 1pm. Four staff, including the manager, are therefore on duty from 8am to 1pm from Monday to Friday. This was confirmed from the staff rota. However, the home has a condition attached to the certificate of registration that, 3 must be on duty from 8am to 8pm when resident numbers exceed 15 and that these hours are in addition to Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 20 management hours. The home is only meeting this if management hours are from 8am to 1pm each day. All three care staff, and the manager, also undertake care, catering and cleaning duties. This includes staff carrying out care and catering duties during the period of preparing and serving food. This was confirmed by the manager and was observed by the inspector. The increased risk of infection from not having clearly defined roles for staff at meal times was discussed with the manager. Policies and procedures, and/or a risk assessment for staff working in these circumstances should be recorded as a minimum measure to address infection control risks. The deployment of a designated cook, or staff member with that role only during meal times, would reduce the infection control risks, and is preferable in a home accommodating up to 19 residents (18 on the day of the inspection) . The manager stated that the home employs 22 staff and that 17 have attained NVQ level 2 qualification or above in care. Care staff interviewed confirmed that they have completed NVQ training and other training courses, such as adult protection. The manager acknowledged that the home did not maintain records of staff training. There were some training certificates for staff, but there is no system of recording training completed by staff. It was the same situation for the induction of newly appointed staff; staff stated that received an induction but there was no record of this. Procedures for the recruitment of new staff need to be addressed as a matter of priority. These procedures were checked for three staff who had recently started work in the home, and for a longer standing employee. An urgent action letter was issued immediately following the inspection as staff had been recruited without the necessary checks being carried out. Three staff had recently commenced work at the home without criminal record bureau (CRB) checks being applied for and without a Protection of Vulnerable Adults (POVA) ‘first’ being obtained. The manager explained that staff sometimes bring a CRB from a previous employer. The system of checking an applicant’s employment history also needs addressing. These 3 staff had also started work without an employment history being obtained and the home does not ask applicants to complete an application form. For one of these staff there were 2 references, which had been provided by the staff member, and a third reference addressed to the manager of the home. For another staff member the manager stated that the staff member had brought her own written references. The home needs to ensure that it obtains an employment history from each person before they commence work and that two written references are obtained before the person starts work. References must be obtained by the home and be from the most recent previous employer. Easterlea DS0000011757.V323193.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to be better managed to meet standards identified throughout this report in order to safeguard residents. It was not possible to tell if the home uses any systems for quality assurance and future planning. Additional measures need to be taken to safeguard resident’s property and the home’s records. The home takes measures to promote the health and safety of staff and residents, although the manager needs to clarify that she is qualified to train staff in health and safety. Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has qualifications in NVQ assessment. The number of requirements made in this report, particularly relating to staff recruitment, indicate that the manager of the home would benefit from additional training. There was evidence that the home seeks service users’ views about the home. Questionnaires for each resident are held on their files. A resident and a relative confirmed that they are asked to comment on the service. The owner completes reports following a monthly audit visit to the home. The manager stated that the home has a business plan for the year, but this was not available as it is on a computer disc. An annual audit of the home does not take place. The home does not handle any resident’s finances or valuables. It was noted that two cheques for large amounts of money were pinned to the notice board in the office and that staff and residents’ records were not securely stored in the office. For the duration of the inspection the office door was left open. This lack of security was raised with the manager. Details of the servicing of the home’s appliances were sent to the Commission prior to the inspection. The manager stated that each staff member has received training in food hygiene and staff also verified this. There are no training records for this training for staff other than a certificate for one staff member. The manager has attended training courses in first aid and moving and handling, qualifying her to train staff in these areas. However, the details on the training certificates about this were not clear. The manager needs to check that she is qualified to the standard approved by the Health and Safety Executive for training staff in first aid. Clarification is also needed regarding the manager’s qualifications to train staff in moving and handling to the standard required by relevant legislation. There were no records to show that staff had received training in first aid or moving and handling. Easterlea DS0000011757.V323193.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 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 3 3 X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 X 2 2 Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14 Requirement The manager must ensure that prospective residents’ needs are assessed prior to agreeing to admit them to the home. This must take the form of an assessment by the home or by the referring care manager. Copies of pre admission assessments must be held. This is to ensure that the home admits only those persons whose needs it can meet. Assessments must be signed and dated by the person completing them. Resident’s care plans must detail the actions staff are taking to provide personal and health care, such as catheter care. This is to demonstrate that the home is meeting resident’s personal and health care needs. Care plans must be signed and dated by the person completing them. Medication must only be dispensed from the pharmacist’s container at the time prescribed times to be taken. Staff must sign a record when DS0000011757.V323193.R01.S.doc Timescale for action 16/02/07 2 OP7 OP8 15 16/03/07 3 OP9 13 (2) 16/02/07 Easterlea Version 5.2 Page 25 the resident takes the medication. The written procedure for the handling of controlled medication must be amended to include the actions being taken by staff for signing, witnessing and counting any balance. The home must check that the storage cupboard meets the requirements of a controlled drug cupboard as requited by the Royal Pharmaceutical Society guidelines. The above requirements will ensure that medicines are securely stored and administered to residents. 4 OP29 19 Schedule 2 17/02/07 Staff must not be employed in the home until the following have taken place: • An employment history has been provided • A POVA (first) has been obtained • A CRB has been applied for • Two written references have been obtained by the home, one of which is from the most recent previous employer. This is to protect residents. 5 OP26 13(3) A soap dispenser must be provided in the ground floor staff toilet. The home must review he staffing arrangements during the time when meals are prepared. Care and catering roles should be clearly defined and the home Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 26 17/02/07 must devise a clear procedure for this, which includes an assessment of the risks associated with infection control. This is to ensure that risk of infection is minimised. 6 OP30 18 schedule 2 and 4 The home must maintain a record of the induction, training and qualifications for each staff member. This is to ensure that staff are suitably trained and competent. 7 OP31 9 The manager must review her 17/04/07 training needs in view of the number of requirements in this report and in particular regarding procedures for recruiting staff. This is to ensure that the home runs safely and protects residents. 8 OP33 24 The home must be able to 17/04/07 demonstrate that there is a quality assurance and monitoring system including an annual development plan. This is to show that the home operates in the interests of service users. 9 OP35 OP37 17 and 16(l) Resident’s records, staff records and resident’s valuables must be securely stored. This is to ensure the safe storage of valuables and confidential records. 10 OP37 17 Daily running records maintained for each resident must be in accordance with the Data Protection Act 1998. These must DS0000011757.V323193.R01.S.doc 17/03/07 17/02/07 17/02/07 Easterlea Version 5.2 Page 27 be confidentially maintained in separate records for each person rather than collectively in a diary logbook. This is to ensure the confidentiality of resident’s records, and for the purposes of monitoring each person’s needs. 11 OP38 13 The registered manger must be able to demonstrate that she is qualified to train staff in first aid. This qualification must be approved by the Health and Safety Executive as suitable for the purposes of training staff in first aid. Records must be maintained of staff training in first aid. The registered manager must be able to demonstrate that the training she has received qualifies her to train staff in moving and handling as required by the relevant legislation. Records must be maintained of staff training in moving and handling. Records must be maintained to show that staff have received training in food hygiene and infection control. This is to ensure that residents and staff are protected against the risk of accidents and the spread of infection. 28/02/07 Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Easterlea DS0000011757.V323193.R01.S.doc Version 5.2 Page 30 - 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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