Inspection on 20/12/07 for Easterlea

This inspection was carried out on 20th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Easterlea 16/06/08

Easterlea 16/01/07

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 20th and 21st December 2007 10:00 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.V354424.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.V354424.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.V354424.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. 16th January 2007 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. The weekly fees range from £335.00 to £469.00. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was split over 2 days as the manager and staff were busy preparing for a Christmas party on the first day of the visit. The inspection consisted of a tour of the premises and examination of records, documents and policies and procedures. Discussions took place with the manager and with a member of the home’s management team. Two staff were interviewed in private. Staff were observed working with the residents. Several residents were spoken to. Survey forms were sent to residents and their relatives to ask their views on the service provided by the home. Four of these were returned and the information contained in them has been used in this report. The home completed an Annual Quality Assurance Assessment, which has been used for this report. What the service does well: Prospective residents and their relatives are able to come and look around the home before making a decision about moving in. There are also opportunities for new residents to have a ‘trial’ stay at the home to see if they wish to move in. Potential resident’s needs are assessed before the home makes a decision about accommodating the person. The home provides a programme of activities for the residents, including entertainment. A mobile library visits the home and residents have a newspaper delivered if they wish. Residents’ relatives made many favourable remarks about the service including the following: • “They are so kind and compassionate, the amount of care they give is excellent, they are patient and interested in the client’s well being.” • “The food is marvellous and I can honestly say I have never known my father/mother to eat as well as he/she does at Easterlea.” • “The home monitor’s individual’s health very carefully and makes sure treatment is given properly.” • “The washing of clothes and cleaning is very good.” • “The call points are always answered.” Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 6 Comments were also made that the home keeps in touch with relatives and that visitors are always made to feel welcome. One relative remarked how the home responds to any suggestions for improvement. There is a book in the hall for visitors to suggest how the home could improve. Relatives report that the standard of care is good and staff have the right level of skills and experience. The home’s environment was found to be clean and well maintained. There is a programme to make improvements to the interior. For instance, the communal areas are to be redecorated and recarpetted in the New Year. The home seeks the views of residents, and their relatives, regarding the service provided. These views are included in the home’s ‘action plan for development.’ Staff report that they work as a team to meet the residents’ needs. What has improved since the last inspection? The home has revised its care planning, which now includes greater detail of residents’ needs and how staff provide care. Daily running records are now individually maintained for each resident, so ensuring confidentiality. The home now completes an assessment of need on potential new residents so that the home can determine if their needs can be met. The procedure for dispensing medication has been improved so that staff do not predispense in advance, thereby reducing the scope for errors. A cupboard for controlled medication, which meets Royal Pharmaceutical guidelines, has been installed. Procedures for infection control have improved. A soap dispenser has been installed in the staff toilet and amendments have been made to the deployment of staff so that care and catering tasks are kept separate. Staff have received further training in food hygiene. A cleaning monitoring sheet is now used for the cleaning of each bedroom. A quality assurance system has been devised and has been partially implemented. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 7 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.V354424.R01.S.doc Version 5.2 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 Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information about the home and are able to visit the service to help them decide if it meets their expectations. The home assesses each potential resident’s needs before agreeing that the person’s needs can be met. EVIDENCE: Records were examined for those recently admitted to the home and discussions took place with the manager. Information was also obtained from residents and their relatives. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 10 Potential residents and their relatives are able to visit the home to help them make a decision about whether or not to move in. One person visited the home and then moved in on a trial basis for a week to see if he/she liked the service provided. This resulted in the person moving in on a permanent basis. Relatives and residents are given information about the service. Assessments of need are carried out and recorded by the home prior to any resident moving in. These are called ‘Prospective Client Assessment Report’ and include assessment of the following needs: falls, mobility, weight, sight, oral, sleep pattern, recreation and social needs. The home also obtains copies of assessments and care plans from referring social services departments as well as any details from hospitals when the person is moving into the home from a hospital ward. Each resident has a contract outlining the terms and conditions of staying at the home. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 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. 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. Residents’ care needs are on the whole met with the occasional exception. Care plans detail how each person’s needs are to be met but require improvement in some areas. The home’s procedures for handling and administering medication have improved but are still not safe. Residents are treated with dignity, kindness and respect. EVIDENCE: Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 12 Care plans and assessments of need were examined for 4 residents. Assessments of need are completed before the person is admitted to the home and a further assessment is carried out and recorded shortly after admission. A care plan is then completed which includes guidance for staff in how care is to be provided, including the following: communication, continence, diet and feeding, grooming, mental capacity, mobility and personal hygiene. Records show that residents have access to eyesight and oral hygiene checks. For one person greater detail is needed in assessing and recording details of the person’s mental health. There was also conflicting information about the person’s needs. For a second person, there were no details recorded about the intervention that staff should take for supporting a resident with specific equipment for pain relief. The procedure being used according to the manager was not recorded, and the survey forms suggests that the equipment was not being used when it should be. The majority of care plans and assessments are signed and dated by the person completing them with one or two exceptions such as specific plans for catheter care. Feedback from surveys indicate that the service could improve by being more specific about assessing and recording each person’s preferences for how often he/she has a bath or shower. This was discussed with the manager. Medication procedures have changed since the last inspection. Staff no longer predispense the medication in advance and now take the pharmacist’s container to the resident at the prescribed time, after which they record a signature that the medication has been taken. Accurate records of the amount of controlled medication being held are not maintained. The home has a surplus of medication due the general practitioner changing the dosage but not the prescription. The home does not have written confirmation from the general practitioner of the change in the medication. The manager is aware of the discrepancy in the recording of the total amount of controlled medication being held in the home and also agreed to contact the GP surgery to have a prescription made for the actual amount directed. Temazepam is stored as a controlled medication. The home should follow the Royal Pharmaceutical Society guidelines by recording its administration as a controlled drug. Storage of medication and controlled medication meets the guidelines of the Royal Pharmaceutical Society. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 13 Residents and their relatives state that the home upholds the dignity and privacy of the residents. Comment was made that health needs are carefully monitored and that treatment is arranged where necessary. The kindness and interest in the client’s well being is also referred to in the feedback forms. Staff are reported to always respond when a resident activates the call point system. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 14 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. The home provides a good range of activities and stimulation for the residents. A nutritious and varied diet is provided. Food is attractively presented. EVIDENCE: Residents and relatives comment that the home provides a range of activities most days of the week. One relative stated that more activities could be provided. A notice displayed the week’s activities, which included, arts and crafts, pilates, bingo and a visit by the hairdresser. Another notice gave a date for a visit to the home by the mobile library. A selection of books are on display for residents to read. Residents were also observed sitting in the lounge and in their bedrooms reading their daily newspaper. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 15 At the time of the visit the home’s staff were preparing for a Christmas party for the residents and visitors. Two relatives made complimentary remarks about how much they enjoyed the party. Relatives were observed making visits to the residents. Comment was made that the home allows visits at any reasonable time and that visitors are always made to feel welcome. One relative commented that the home’s staff help residents in using the telephone to call relatives. Several residents have their own telephone line to their bedroom. Occasional trips out are organised for the relatives in the summer. Records are maintained of the food and meals provided alongside hygiene monitoring records such as fridge temperatures. The food records show a varied and nutritious diet with evidence of alternatives at each meal. Residents are asked in advance what they would like to eat for the early evening meal and this procedure has just been introduced for the midday meal also. One relative stated that he/she asked the home to consider providing more fresh fruit and vegetables, which the home promptly responded to. The midday meal on the day of the visit looked appetising and was well presented and nutritious. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 16 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 acts upon any problems raised by residents or their relatives. Residents are protected from abuse although there is a need for staff training in safeguarding older persons. EVIDENCE: Residents and relatives state that they know how to make a complaint. One relative stated that a suggestion for improving the food was made which the home acted upon. The manager maintains a record of any complaints and how they are dealt with. Staff received training in adult protection in 2004. Staff appointed to work in the home since 2004 have not received the training. The home has a copy of the local authority adult protection procedure as well as its own literature on the subject. Easterlea DS0000011757.V354424.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 good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a clean, homely and well maintained environment. EVIDENCE: There are plans to refurbish and recarpet the communal areas of the home including the hall, stairs and landing. There is a passenger lift as well as hoists for use with bathing. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 18 Bedrooms are personalised with ornaments, pictures, photographs of family members, television, radio, music listening equipment and so forth. Several residents have their own telephone line in their room. The lounge and dining room are situated in a large open area, which has a grand piano for entertainment. The lounge overlooks the rear garden, which is landscaped. Residents said how much they enjoy looking at the garden in both the summer and winter. The front of the home has space for parking as well as containing shrubs and flower beds. The home is clean and there is an absence of any unpleasant odours. A cleaning monitoring sheet has been introduced for each bedroom. The home has a separate laundry area. Easterlea DS0000011757.V354424.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. Whilst the home provides sufficient staff to meet the needs of the residents, staff recruitment procedures are of a variable standard that fails to protect the residents. Staff generally have the skills and experience to provide a good standard of care, although additional training is needed for staff to safeguard residents’ well being and welfare. 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. Observation confirmed that the home provides these care hours. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 20 Residents’ relatives comment that the care staff have the right skills and experience for providing a good standard of care. 54.5 of care staff are qualified to NVQ level 2 or level 3. This was evidenced from the AQAA, discussions with the staff and the home’s management. Staff also confirmed that they receive training in medication procedures, fire safety, moving and handling and first aid. Records of fire safety training are held in the home, but there no records for newly appointed staff receiving an induction although the home has devised an induction pro forma which has spaces for the staff and manager to complete. Records of first aid and moving and handling training are not maintained. Records of supervision are maintained and staff confirm that this takes place. The records of supervision show that this is taking place infrequently. For instance, for one person who started work in May 2006 there is a record of one supervision session and one appraisal and for another person who started work in January 2007 there is a record of one supervision session taking place. The home’s procedures for recruiting staff were examined. The following as required in the previous report has not been consistently addressed: 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. Application forms or an employment history, have not been completed by any staff member including two staff who started work in January and March 2007, and for two other staff whose records provided the evidence for the requirement for this in the previous report. Written references have not been obtained for one person where this was required by the previous report. Two written references have been obtained for someone who started work in March 2007 and for another staff member who started work in January 2007. These are from a previous employer and from someone supplying a personal character reference. In several cases references have been supplied by the staff and are addressed “To Whom It May Concern.” References must be obtained by the home from the most recent employer and the applicant’s employment history should be checked. Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks have been carried out for each staff member. For the person who started work in January 2007, a CRB was not obtained until 16/07/07 and a POVA(first) on 13/07/07. For the person who started work in March 2007 a CRB was obtained on 18/05/07 and the POVA (first) on 27/02/07. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 21 Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 22 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, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not managed to a standard that safeguards residents or their property. The home’s management have not implemented several requirements made in the previous inspection report, which has the potential to place residents at risk. EVIDENCE: Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 23 The previous inspection report identified that the manager must review her training needs in view of the number of requirements made and in particular regarding procedures for recruiting staff. The manager stated that since the last visit that she has attended a course on the Mental Capacity Act and seminar on the Commission for Social Care Inspection Annual Quality Assurance Assessment, but no other training. The manager is an NVQ assessor and has a Certificate of Education in Health and Social Care. At this inspection several requirements have been repeated. From discussion it was clear that the manager does not agree that certain procedures need to be changed. For instance, cheques and confidential staff medical details are displayed on the notice board in the office, which is not locked, was open for duration of the visit, and was accessed by visitors when the office was unoccupied. Correspondence from the home’s management following the last inspection maintained that displaying cheques on the notice board in an unlocked office was considered safe. It was noted, however, that on the second day of the inspection that the manager had stored the cheque and the staff medical details in a safe place. A system of quality assurance is being implemented. Surveys have been carried out of residents’ and relatives’ views about the home. An action plan for improvement and a quality audit system have been devised. The quality audit will be completed in 2008. The previous report required that the manager must be able to demonstrate that she is trained to the standard required by the Health and Safety Executive for training staff in first aid and in moving and handling as required by the relevant regulations. Written correspondence was received from the home’s management, which does not confirm that the manager is trained to the standards required by the Health and Safety Executive for first aid, or to the standards as required by legislation for moving and handling training. This was discussed with the manager during this visit. It is still unclear if the training provided by the manager to the staff in first aid and moving and handling meets the relevant health and safety standards. There are no training records for three staff chosen at random in moving and handling or first aid. This was required by the previous report. The staff spoken to on the day of the inspection conformed that they have received training in first aid. It was noted that on the 21/12/07 for the period of 5pm to 8am the next day that there were no staff on duty who have completed first aid training. Since the last inspection staff have received training in food hygiene. This was evidenced from discussions with staff and the manager and from training records. Records and discussions with staff also show that fire safety training is provided. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 24 The home’s appliances and equipment are tested and serviced by suitably qualified persons. The fire logbook shows that the fire safety equipment is tested in accordance with fire safety regulations. Radiator temperatures are controlled to prevent possible burns to residents. Temperature control devices are also used to prevent possible scalds to residents from hot water. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 25 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 3 3 3 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 2 3 3 3 3 3 3 3 3 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 1 X 3 X 1 2 2 2 Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Requirement Resident’s care plans must detail the actions staff are taking to provide personal and health care. Specific reference is made to the use of pain relief equipment and mental health needs. 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. This is a repeated requirement from the previous inspection of 16/01/07. 2 OP9 13 (2) Accurate records must be maintained of all controlled medication being received by the home and of the total running stock. The above requirement will ensure that medicines are securely stored. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 27 Timescale for action 27/02/08 30/01/08 This is a partial repeat of the requirement from the previous inspection. Where a general practitioner changes the prescription of a resident’s medication this must be confirmed in writing. 3 OP29 19 Schedule 2 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. This requirement is a repeat from the immediate requirement letter and requirement made at the previous inspection. 4 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. This is a repeat of the requirement made at the previous inspection. 5 OP31 9 The manager must review her 21/03/08 training needs in view of the number of requirements in this report and in particular regarding procedures for recruiting staff. 21/02/08 27/02/08 Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 28 This is to ensure that the home runs safely and protects residents. This is a repeat of the requirement made in the previous inspection report. 6 OP35 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. This is a repeat of the requirement made at the previous inspection. 7 OP36 18 Staff must receive regular supervision. This is to ensure that staff receive support and guidance in their work with residents. 8 OP38 13 The registered manager 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 Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 29 21/01/08 21/03/08 21/03/08 handling. This is to ensure that residents and staff are protected against the risk of accidents. This is a repeat of the requirement made in the previous inspection report. 9 OP38 13 Sufficient numbers of staff must be trained in first aid must so that at least one staff member trained in first aid is on duty at any given time. This is to ensure that residents and staff are protected against the risk of accidents. 21/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The home should follow the Royal Pharmaceutical Guidelines for controlled medication when handling, receiving, storing and administering temazepam. Easterlea DS0000011757.V354424.R01.S.doc Version 5.2 Page 30 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. 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