Inspection on 06/12/07 for Eastwood House

This inspection was carried out on 6th 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

Eastwood House 30/05/08

Eastwood House 19/10/06

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

CARE HOMES FOR OLDER PEOPLE Eastwood House 7 Eastwood Avenue Grimsby North East Lincs DN34 5BE Lead Inspector Sarah Sadler Key Unannounced Inspection 6th December 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 Eastwood House DS0000067250.V356134.R02.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. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastwood House Address 7 Eastwood Avenue Grimsby North East Lincs DN34 5BE 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) 01472 278073 Mrs Christine Lyte Position Vacant Care Home 16 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (8) of places Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2006 Brief Description of the Service: The home is situated in a residential area of Grimsby. It is a converted domestic house and has been extended; there is large conservatory to the rear of the house and a small garden. The home is easily accessible and is on a bus route. The home provides care for 16 elderly people, some with dementia. Bedrooms are provided on both the ground and first floors; there is a lounge and the conservatory is used as a dining room. Fees for living in the home vary from £329 to £400 a week with additional charges for toiletries. This information was on display within the home. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 19th October 2006, including information gathered during a visit to the home. Since the last inspection the CSCI has not received any new information about the home from the registered provider and there have been no letters or complaints to us from other people. As part of the inspection we send out an Annual Quality Assurance Assessment (AQAA), which is a self-assessment document which the registered person must complete and return to the Commission. It should show how well the home is meeting regulations and national minimum standards, what has been done to improve the service since the last inspection and what still needs to be done. On this occasion the provider did not return the AQAA to us so we did not have the necessary information to help us check what relatives of people living in the home or professionals working with then think of the service. This affects the judgements we are able to make about the service. The site visit took place on 6 December 2007, beginning at 9.10 am and ending at 5.00 pm. The provider was not told in advance of the date or time we planned to visit. The deputy manager was available for part of this visit, we spoke to the manager via the telephone to feedback at the end of the visit, and, at other times a senior carer assisted us. As well as talking with the deputy manager we talked to two staff members and to some of the people living in the home. We looked round the home including people’s rooms and the shared areas of the home, and we inspected records of people’s care, staff files, health and safety documents and other records. One comment received was ‘The girls are nice and friendly and chat to me’. What the service does well: Observations of conversations between the staff and the people who live in the home were positive. People were relaxed and appeared comfortable throughout the visit. People receive support to make sure that their health needs are met; this includes visiting professionals such as the GP and being able to use mobility equipment. People are supported to maintain contact with their family, who can visit and telephone as they wish. People also told us that they can make choices in their Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 6 lives, the staff support people with this by encouraging people to manage their own monies. The home was very clean and comfortable throughout offering a pleasant environment for people to live in. What has improved since the last inspection? What they could do better: Assessments must be in place for every person admitted to the home prior to them being admitted so that the home are fully aware of people’s needs and know that they are going to be met within the home. At present this is completed for some people who are admitted and but not everyone. Following this care plans must be completed which fully reflect all of the person’s needs including religious, cultural and dietary needs. Care plans must include an assessment of risks to help to make sure that people are kept as safe as possible, assessment of nutritional needs and be kept up to date with accurate records reflecting an up to date picture of the individual. Medication practices must be improved to make sure that the storage makes sure that medication is locked securely and recording of medicines is up to date with no gaps and does not place people at risk of their medication needs not being met. Activities within the home must be offered and preferably to include activities specific to individual needs with staff receiving training on this. The complaints systems must be improved to make sure that complaints are correctly recorded and their outcomes to show that people are happy with the responses and actions taken by the home. The registered person must provide a varied and wholesome diet to people with choices to support them with making choices in their lives, whilst meeting their dietary needs. The requirements of the environmental health officer must be met to make sure that people’s food is stored at the correct temperatures and does not pose a risk to their health. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 7 There must be enough bathrooms in the home to meet the needs of the number of people living there. Water supplies must be adequate so that they do not make meeting personal care needs more difficult and people must be given the option of locking their bedroom doors to maintain their privacy. Radiator covers must be maintained to make sure that they continue to protect people from the risk of burns and window openings must be restricted to prevent the risk of accidental falls. Doors should only be held open by authorised means so that if a fire occurred this would not increase a person’s risk of harm. The registered person must make sure that all staff are employed correctly with the necessary checks being completed to so that only people who are suitable to work with vulnerable people are employed. When employed staff must receive the correct induction into the home and training to national standards. This will help to make sure that they have received training appropriate to meet the individual needs of the people living in the home. The registered person must make sure that there is quality assurance system in place which is used to help make sure that people living and involved with the home are able to raise comments and be involved in the development of the home. The management of the home must also undertake their own quality monitoring visits to make sure that the home continues to meet people’s needs. The manager must make sure that the CSCI is notified of occurrences in the home that may affect the well being of the people living there. Electrical and fire systems including risk assessments must be kept up to date to help maintain people’s safety. 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. Eastwood House DS0000067250.V356134.R02.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 Eastwood House DS0000067250.V356134.R02.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): 3&6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some people are assessed before moving into the home, however this should be completed for all people considering moving into the home to make sure that the home can meet their needs. EVIDENCE: The files of three people were examined, two contained a detailed assessment completed within the home. The third person has lived in the home for a few weeks and the manager told us that they have not yet received the care plan/ assessment from the placing authority. However no assessment and care plan have been completed by the home, this would provide the staff with a picture of the needs of the individual and how these are to be met. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 10 The deputy manager told us that intermediate care is not provided in the home. Eastwood House DS0000067250.V356134.R02.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, & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People are supported by basic care plans to meet most of their needs with respect and dignity. However procedures do not make sure that people are safe and that their medication needs are met. EVIDENCE: Of the files examined two out of the three included plans of care, these were one from the local authority and one developed in the home. The care plans developed in the home contained the basic needs of the individual and how the staff were to meet these. The plans did not include reference to the person’s religious or cultural needs and although there is a person with specific cultural needs the staff team have not received any training to raise their awareness with this. There were forms, which detailed Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 12 that the care plan had been reviewed in the home, but there were no review minutes or notes from any formal reviews with the placing authority. Keeping these records up to date provides staff with written information relating to the latest needs of the person and how these needs are to be met. One complaint was recorded in a persons care notes. This was regarding their personal care and the response from the home included that there were difficulties with this due to lack of toiletries. However this persons care notes regularly recorded that their personal care needs had been met. The care files included some risk assessments, for example moving and handling and pressure care but these were limited and the risk assessment for the use of bed rails had the review dates written on it with the last date being 2005. Staff members when asked about their understanding of risk assessments commented ‘I’ve heard of them and ‘Yes they have them for falls’. In addition there were duplicate risk assessment documents in place, some being completed and some not. This does not make sure that there are clear and accurate records which help staff to identify risks and protect people. The care files included details of people’s health needs, with diary notes including details of medical appointments and follow up actions. One person told us that one of the people living in the home has recently received a mobility aid. When spoken to not all staff were aware of the details of people’s health needs and care plans. The deputy manager told us that when medication is received into the home it is checked to make sure that it is correct, but no records of this are kept. Medication is initially stored in a lockable filing cabinet, and then transferred to a medication trolley, which is not locked correctly to make sure that the medicines are kept safe. The records for the administration of medicines were found to be up to date and correct, although the Medication Administration record (MAR) chart has hand written entries for the prescribed medicines for one individual. There was a requirement that this must be addressed at the visit of October 2006 but has not been actioned as this could lead to errors in medication. Medicines which are described as ‘controlled’ are stored in a locked container but this does not have a double locking device to make sure that they are safely and correctly stored. Records for the administration of ‘controlled’ drugs had correct balances, but there were several entries were a date only had been written and the rest of the information was missing. This does not make sure that adequate and up to date records are kept and may allow for errors to occur. The one person available to talk to told us that they felt that the staff respected their privacy, that they felt that the staff treat them with dignity and observations of staff and people in the home reflected positive relationships. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 13 When asked staff gave good examples of how they maintain people’s privacy that includes closing doors when assisting with personal care. Appointment cards with details of people’s hospital appointments are fastened to a communal notice board in the office. This is a walk way to the smoking area for staff and people in the home and leaves these documents open to be read other than the people these concern. This does not protect people’s privacy and should be addressed. Eastwood House DS0000067250.V356134.R02.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 & 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People are supported to meet some of their social needs and choices, however the practices in the home do not make sure that people’ s dietary needs are fully met. EVIDENCE: People’s files contained basic pen pictures and some details of their social wishes. One staff member is employed for 6 hours per week to undertake activities with people and one person told us that there are dominoes and bingo sessions available within the home. The staff told us that people could play bingo, dominoes and skittles. The activities person was in the home putting up Christmas decorations and talking with people in the home whilst they completed this. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 15 However the staff also confirmed that they have not received any training specific to the needs of people with dementia and no reminiscent work is undertaken within the home for those people who suffer with dementia. People’s records included details of their contact and visits from family members. One person told us that their relative could visit anytime they wish and staff also told us that there are no restrictions on visitors. They also told us that they help people to maintain relationships by helping them to keep in touch and ring their relatives. One person told us that they live their life as they wish. They told us that they prefer to spend time on their own and that the staff respect this. They also told us that when they wish to go out there are staff available to assist them with this. One person was having their own telephone installed in their room at the time of the visit. Staff told us that people could choose what to wear and what to eat, and what to do. People’s notes included that people chose whether to eat the meal of the day and when to go to bed or get up. We joined the people in the home for lunch. The meal was well presented and of a good quality. One person told us that they are not happy with the food usually provided in the home and purchase their own food to supplement that offered in the home. The staff told us that the home regularly runs out of bread and milk with staff purchasing these out of their own monies, as there is none available within the home. One staff member also told us when asked that people in the home do at times say that they are hungry. An immediate requirement was issued to the home to make sure that there is at all times sufficient foods or funds provided to make sure that people’s dietary needs are met and this was responded to within the timescale given. There are menus available within the home, but the staff told us that should someone not like the meal being provided there is not a second choice. This does not meet people’s dietary needs or respect their right to choices and dignity. Staff thought that people’s weights were monitored but did not know if records were kept, there are no nutritional risk assessments in place to monitor the meeting of people’s nutritional needs. The local environmental health officers last visit highlighted the need for the recording of the temperatures of the fridge and the freezers. This is to make sure that food is being stored at the correct temperature and does not pose a risk to health and safety. These records were intermittent and had not been completed for some time. Eastwood House DS0000067250.V356134.R02.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 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People feel confident to raise concerns, however practices do not fully support people when concerns are raised or to be fully protected from harm. EVIDENCE: There is a complaints policy within the home. No records of any complaints were available and a staff member told us that they were unsure if there were any formal records kept. Staff told us that they would refer any complaints to the manager or the owner of the home. One person living in the home told us that they would raise any concerns with the manager, and another person’s notes included a concern raised by their relative but as no formal records are kept of this it is unclear if this was dealt with appropriately or if the complainant was happy with the outcome. There are two policies regarding the protection of vulnerable people one of which hold the incorrect details for managing allegations and the incorrect version must be removed. Some staff have attended training on Safeguarding people and when asked they responded that if a potential incident of abuse occurred they would refer this to the manager. One allegation of harm had occurred and although this had been referred to the local authority this had not Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 17 been reported to the CSCI. This does not make sure that the home will follow the correct procedures and that people are protected if an allegation of this type is raised. Staff recruitment is not undertaken in a way that protects people and is discussed further in the report. The deputy manager told us that the home does not manage people’s monies for them and that the majority of people either manage their own money or are helped by a family member or solicitor. Sometimes the home will ‘hold’ people’s money at their request and a receipt is kept for this, which is handling personal monies. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 18 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, 21 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a comfortable and warm home but it does not provide fully for their personal care or safety needs. EVIDENCE: The home was very clean and tidy throughout. It was very warm, people appeared comfortable and some were sleeping. People are able to personalise their rooms reflecting their personalities. Radiator guards are fitted in the home, one was broken and in pieces in one bedroom and must be replaced to prevent the risk of injury to the individual. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 19 The water supply to upstairs bedrooms is extremely slow and staff told us that they have to turn on the supply and complete other tasks for a few minutes before they can use this supply. There is a bathroom and a shower room but the shower room is not working and this has been the case for some time. At the visit of October 2006 it was required that the right amount of bathing facilities are available to the people living in the home but this has not been addressed. Throughout the home fire doors were held open by unauthorised means and this may place people at risk in the case of a fire. An immediate requirement was issued to the home to address this within 24 hours of the visit and this was responded to appropriately. There are currently 4 double rooms, with three being used as double rooms. There are no dividing curtains in place to allow people privacy in their rooms. Some of the bedrooms have locks fitted, however no risk assessments have been completed to assess if an individual is able to hold a key to their room. One person told us that they requested a lock for their room door several months ago and are still waiting. Window restrictors are in place in some but not all of the rooms in the home. This potentially places people at risk of falls and must be addressed. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 20 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, & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are adequate numbers of staff to support people. However people are not fully safeguarded as staff are not correctly recruited and fully trained to be able to meet people’s needs. EVIDENCE: Duty rotas reflected that there are 2 staff on duty 24 hours a day with the manager being available in addition to this. This provides 336 care hours per week. When the cook is absent from the home the deputy manager assists in this role. Staff recruitment does not make sure that people are safe as staff are employed without 2 references and a Criminal Records Bureau check (CRB) or POVA first check being completed. Two people who work in the home told us that they have not had a CRB check undertaken on them. These checks help to make sure that the person is suitable to work with vulnerable people and does not hold a criminal conviction, which may prevent them from doing so. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 21 Staff told us that they have received an induction into the home that includes being told what their job involves. Staff files included a section for induction but only 1 of the 3 files examined included information that people had commenced or completed their formal induction. One file included details of the training that had been undertaken, this included medication, fire, safeguarding and food safety. Staff have recently attended first aid training and a safeguarding adults training course was booked for the day of the visit. However staff told us that all of their certificates were now out of date and require renewing. A further staff member told us that they thought that 50 of the staff team held a National Vocational Qualification (NVQ) level 2 or equivalent, but no evidence was available to confirm this. Staff also told us that they have not received training specific to the needs of people with dementia. This would assist staff to understand people’s needs with dementia and best practice for the meeting of these needs. Eastwood House DS0000067250.V356134.R02.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, & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People live in a home that is not well managed, does not offer them the opportunity to participate in its development and does not fully make sure that their health and safety needs are met. EVIDENCE: The manger is not registered with the CSCI. This was a requirement in the inspection report of October 2006 and has not been met. A staff member told us that the manager has recently completed a National Vocational Qualification (NVQ) level 3 in care and is to commence level 4. The manager has not made Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 23 sure that notifications of incidents in the home have been forwarded to the CSCI, with only one being received in the last year, this was also a requirement in the inspection visit of October 2006. The manager did not make sure that the AQAA was no returned completed to the CSCI. Staff told us that there can be long gaps between the visits from the senior management/owner of the home. Only one of the monitoring visits of the home as is required in regulation 26 of the Care Homes Regulations 2001, has been completed, this was a requirement of the inspection report of October 2001. Staff told us that there have not been any quality assurance audits completed since the last visit. There has been one staff meeting in the last year and one is planned in the near future. There was no evidence of any meetings for the people who live in the home to raise their views regarding the development of the home. The lift was serviced and portable appliance testing was undertaken in February 2007. There is a landlords Gas Safety Certificate in place and the fire alarm was tested in October of this year to confirm that it was in full working order. There was not a 5 year electrical wiring certificate, a completed fire risk assessment, or weekly testing of the hot water, fire alarm and emergency lights. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 24 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 1 X 2 X X X X 3 STAFFING Standard No Score 27 1 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement Timescale for action 06/01/08 2 OP7 3 4 OP7 OP7 5 6 OP7 OP7 7 OP9 The registered person must ensure that people are only admitted to the home following a full assessment of their needs, so that these are known and can be met. 15 The registered person must make sure that each person has a comprehensive care plan, completed whenever possible with the individual 15 The registered person must make sure that care plans are kept up to date. 15 The registered person must make sure that the person’s care plans include a comprehensive risk assessment. The previous timescale of 01/02/07 was not met. 15 & 17 The registered person must make sure that risk assessments are kept up to date. 17 The registered person must make sure that people’s records, including diary notes are kept up to date. 13, 18, 19 The registered person must make sure that consultation is DS0000067250.V356134.R02.S.doc 06/01/08 06/01/08 06/01/08 06/02/08 06/02/08 06/02/08 Eastwood House Version 5.2 Page 26 8 OP9 13 9 OP9 13 10 OP9 13 11 OP12 5, 12, 16, 23 12 OP12 5, 12, 16, 23 13 OP15 16 14 OP15 16 15 OP15 16 16 OP16 22 undertaken with the supplying pharmacist as to the use of hand written MAR sheets. The previous timescale of 01/02/07 was not met. The registered person must make sure that medicines are stored correctly to reduce the risk of error or loss. The registered person must make sure that ‘Controlled Drugs’ are stored safely and as per the guidelines. The registered person must make sure that the record for administration of ‘Controlled Drugs’ are up to date and correct with no gaps, to help ensure that errors do not occur. The registered person must make sure that people are given the opportunity to partake in meaningful activities. The previous timescale of 01/02/07 was not met. The registered person must make sure that people’s cultural and religious need are catered for. The previous timescale of 01/12/06 was not met. The registered person must make sure that people’s nutritional needs are assessed and monitored to make sure that they are met. The registered person must make sure that there are at all times sufficient foods or funds provided to ensure that people’s dietary needs are met. The registered person must make sure that the systems in the home meet the requirements of the Environmental health Officer. Fridge and freezer temperature recording must take place. The registered person must DS0000067250.V356134.R02.S.doc 06/02/08 06/01/08 06/01/08 06/02/08 06/02/08 31/12/07 07/12/07 31/12/07 06/02/08 Page 27 Eastwood House Version 5.2 17 OP19 23 18 OP19 13 19 OP19 13 & 23 20 OP21 23 21 OP24 16, 23 22 OP27 18 23 OP27 18 24 OP28 18 make sure that complaints including the outcomes are recorded. The registered person must make sure that radiator covers are in good working order and do not pose a risk of harm to the people in the home. The registered person must make risk assessments are completed regarding the risk to people of unrestricted windows and where necessary restrictors are in place. The registered person must make sure that doors are held open by authorised means only and do not pose a risk of harm to the people in the home in the event of a fire. The registered person must make sure that the water supply to people’s rooms is sufficient and safe in the meeting of people’s needs. The registered person must make sure that locks are fitted to people’s bedroom doors; keys should only be restricted for people following a thorough risk assessment. The previous timescale of 01/02/07 was not met. The registered person must make sure that staff receive training specific to their roles and to the individual needs of the people in the home. The registered person must make sure that mandatory training is up dated within required time scales. The previous timescale of 01/03/07 was not met. The registered person must ensure that all staff receive an induction into the home which meets with the Skills for Care DS0000067250.V356134.R02.S.doc 31/12/07 31/12/07 07/12/07 06/01/08 06/01/08 06/03/08 06/03/08 06/02/08 Eastwood House Version 5.2 Page 28 25 OP29 19 26 OP29 19 27 OP29 18, 19 28 OP31 4, 12, 24, 26 29 OP33 4, 5, 6, 14, 15, 17, 21, 22, 24 30 OP38 26 31 OP38 37 32 OP38 13 & 23 requirements. The previous timescale of 01/03/07 was not met. The registered person must make sure that all staff have undertaken a CRB or POVA first check prior to commencing work in the home. The registered person must make sure that two written references are received for all staff prior to them commencing work in the home. The registered person must make sure that the staff files contain all the required information. The previous timescale of 01/02/07 was not met. The registered person must make sure that an application is submitted for the registration of the acting manager. The previous timescale of 01/12/06 was not met. The registered person must make sure that a quality assurance system is developed which includes consultation with all stakeholders. A report must be produced and made available to all interested parties. The previous timescale of 01/12/06 was not met. The registered person must undertake visits in accordance with regulation 26 of the Care Homes Regulations 2001. The previous timescale of 01/11/06 was not met. The registered person must make notifications in accordance with regulation 37 of the Care Homes regulations 2001. The previous timescale of 01/11/06 was not met. The registered person must make sure that the electrical DS0000067250.V356134.R02.S.doc 31/12/07 31/12/07 06/03/08 31/12/07 06/03/08 31/12/07 31/12/07 31/12/07 Page 29 Eastwood House Version 5.2 33 OP38 13 & 23 34 OP38 13 & 23 35 OP38 13 systems in the home are safe. Evidence of this must be forwarded to the local office of the CSCI. The registered person must makes sure that an up date risk assessment is completed in relation to the risk of fire in the home and that any actions required are taken to help keep people safe. The registered person must make sure that the fire systems are regularly checked and meet with the requirements of the local fire officer. The registered person must make sure that the emergency lighting is regularly maintained so that in time of need it would not pose or increase the risk of harm to the people in the home. 01/02/08 07/12/07 31/12/07 Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 6 7 8 Refer to Standard OP7 OP7 OP10 OP15 OP16 OP19 OP21 OP27 OP27 Good Practice Recommendations The registered person should make sure that staff are fully aware of the needs of people in the home. The registered person should make sure that care plans reflect the cultural needs of the individual. The registered person should make sure that confidentiality regarding personal appointments for people in the home is maintained. The registered person should make sure that people have choices over their diet. The registered person should make sure that there is only one policy for staff to follow should a concern or allegation of harm be raised. The registered person should make sure that the facilities in the home help to respect people’s privacy. The registered person should ensure that there are adequate bathrooms facilities to meet the needs of the people in the home. The registered person should make sure that50 of the care staff are trained to a National Vocational Qualification (NVQ) level 2 in care or equivalent. The registered person should make sure that staff are trained to meet any cultural needs of the people in the home. Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Eastwood House DS0000067250.V356134.R02.S.doc Version 5.2 Page 32 - 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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