Inspection on 06/05/08 for Eastwood House

This inspection was carried out on 6th May 2008.

CSCI found this care home to be providing an Adequate service.

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

Eastwood House 15/04/09

Extracts from inspection reports are licensed from CQC, this page was updated on 16/12/2008.

CARE HOMES FOR OLDER PEOPLE Eastwood House Doncaster Road Rotherham South Yorkshire S65 2BL Lead Inspector Valerie Hoyle Key Unannounced Inspection 6th May 2008 08:30 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 DS0000070909.V363613.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. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastwood House Address Doncaster Road Rotherham South Yorkshire S65 2BL 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) 01709 363 093 01709 837 788 None Nightingale Premier Care Homes Ltd Mrs Rosaleen McCafferty Care Home 37 Category(ies) of Dementia (37), Old age, not falling within any registration, with number other category (37) of places Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC; to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - code OP; Dementia - Code DE. The maximum number of service users who can be accommodated is: 37 This is the first inspection under the new providers Nightingale Premier Care Homes Ltd 2. Date of last inspection Brief Description of the Service: Eastwood House is a large converted and extended Victorian house situated close to the centre of Rotherham. It is set back from the main road into Rotherham and it close to the local park. The home is situated near to bus routes. It is a care home, registered to provide care and accommodation for 25 older people and a twelve bedded unit for people who have dementia. The home offers single room accommodation, all of the rooms benefiting from ensuite facilities with the exception of two rooms on the first floor. There is a lift, which give access to the first floor. There are a variety of communal areas and two dining rooms. The dementia unit is on the first floor. The facilities are: two lounges, dining room, snack kitchen toilets and bathrooms. There is a secure garden for these People who use the service. The home is maintained to a high standard. There are attractive gardens to the front, rear and side of the property and outdoor seating and patio areas. The gardens are well stocked with various plants, shrubs along with tubs and hanging baskets. The walkways around the home are designed to enable the residents to access all parts of the garden Fees for Dementia Care are £397 and residential £353 as at 1st April 2008 and additional charges are made for hairdressing from £5:50, Chiropody from £18:00, Optical, Dental services, specialised toiletries and magazines, dry cleaning etc at cost. Service User Guides and Statement of Purpose is available on request from the manager. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 5 Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This first key unannounced inspection of this service took place over 7.5 hours starting at 8:30 to 16:00, this included a partial inspection of the home. Eight people who use the service, two relatives and six staff were spoken to during the visit; their views are included throughout the report. Occupancy at the home remains high with 35 of the 37 beds occupied. Four peoples care plans were looked at and policies relating to medication, complaints, protection of vulnerable adults and handling of people’s monies were looked at. Three staff recruitment and training records were examined to assess how people were protected. As part of this visit we looked in detail at how people were protected from harm. Five CSCI service users and relative’s questionnaires were sent to the home, although at the time of writing this report none had been returned. The registered manager Rosaleen McCafferty has been in post for a good length of time, and continues to develop her own knowledge and experience. She was sent the AQAA, this was returned to us on time which demonstrates responsiveness and cooperation. An annual quality assurance assessment (AQAA) is a self-assessment and a dataset that is filled in once a year by all providers whatever their quality rating. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their service. The AQAA also provides us with statistical information about the individual service and trends and patterns in social care. The inspector would like to thank everyone who agreed to being interviewed as part of the inspection process, and the friendliness of staff. What the service does well: Activities were well organised and people made positive comments about living at the home. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 7 People said, “staff are kind and I like living here, it’s close to my family and that is very important to me”. “Food is very good, with lots of variety”. “I like my room, I spend a lot of time watching TV”. “We like to have a game of dominoes it helps to pass the time. We also join in games of bingo for small prizes”. Visitors to the home said “staff always make me feel welcome, I have recommended the home to a number of people. I am very satisfied with the care, they inform me straight away if there is a problem”. The new providers have made a commitment to continue with the refurbishment of the home. The dining area has recently been decorated and there are plans to replace the carpet and dining furniture. Staff was commended for there efforts to ensure people live in a clean and safe environment. People said, “the home was always kept clean and fresh, staff work very hard”. There is a stable staff team who have shown commitment to there own learning, they were commended for their NVQ achievements. What has improved since the last inspection? What they could do better: The information provided to new people and their representative should be kept up to date, including information about the new registered providers and contact details of CSCI. Care plans could contain more detail to ensure staff have the correct information to deliver the care people need. Some people could be at risk as staff do not move and handle people safely. The registered provider must ensure that there is sufficient and appropriate equipment to enable staff to move people safely. Nutritional assessments must be kept up to date to ensure people have the correct diet. Medication procedures were generally followed although care should be taken to make sure people do not run out of medication, and that medication stocks can be easily audited. Safeguarding, and restraint procedures must be updated to ensure people are safe and protected. Some staff including the manager must attend formal Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 8 training so that they understand how to keep people safe without the use of restraint. The staffing numbers and skill mix was sufficient, although the deployment of staff could be improved to ensure vulnerable people on the dementia unit are not left unsupervised. Night staffing levels must be maintained to ensure the safety of people who use the service. Recruitment procedures were generally followed, although the manager must ensure that a new CRB (Criminal Record Bureau) check is obtained for all new staff. The new registered providers provide support to the manager, although they have not completed the monthly audit as required by regulation 26 of the Care Homes Regulations 2001. 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 DS0000070909.V363613.R01.S.doc Version 5.2 Page 9 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 DS0000070909.V363613.R01.S.doc Version 5.2 Page 10 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, 4, 5, 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service and their representatives were provided with information they needed to choose a home that can meet their assessed needs. Intermediate Care is not provided at the home. EVIDENCE: People who use the service were provided with sufficient information about the services provided at the home. The Service User Guide needs updating to reflect the changes of ownership. The Commission For Social Care Inspection (CSCI) details should be changed to include the Newcastle address and customer care telephone number. This will enable people to contact CSCI if they were unhappy at the way complaints were handled. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 11 New people were provided with a statement of terms and conditions or a contract. The AQAA confirmed the number of people who pay their fees privately, and they receive a different contract to those funded by the local authority. This sets out in detail what was included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. All new people received a full comprehensive needs assessment before admission; this was carried out by the manager who had the required skills and competencies. The service was efficient in obtaining a summary of any assessment undertaken by the placing authority, and insists on receiving a copy of the care plan before admission. A visitor said that she was involved in the admission of her relative, and people who had used the service previously recommended the home to her. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 12 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, 11 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans generally provided adequate information to protect people who use the service. Medication policies and procedures were generally well managed, however some improvements would make administering medication safer. EVIDENCE: Four care plans were looked at; these were generally well constructed, although some essential details were not fully completed. Very basic nutritional assessments had been completed, although they were dated 2006. One person’s assessment stated that the person was able to go out independently, although the person’s actual needs had changed greatly. One person’s assessment identified that they were at risk from chocking, and could only have liquidised meals. The daily food intake record showed that the person regularly had marmalade sandwiches for breakfast and salmon sandwiches for tea. The inconsistent approach means people’s nutritional needs were not always met, and could have serious consequences to the health and wellbeing. There was no evidence to confirm that people identified as a choke risk, had been referred to a dietician, for advice. The manager could not confirm why Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 13 referrals had not been made. People may be put at significant risk, as they may not receive the most appropriate care they need to stay healthy. One care plan looked at had not been updated to reflect changes to the person’s care following a fall. The accident had taken place three days earlier, and resulted in significant changes to the person’s independence. Three people were observed in the lounge area, one person was sat in the wheelchair, which had no footplates. Staff did not consider that the person’s feet were unsupported, which could cause considerable discomfort if left for long periods of time. Staff did provide a footstool to ease any discomfort, but only after the inspector had requested it. Two other people sat in wheelchairs were secured by the use of a lap Strap. Although the care plan stated the people were a fall risk there appeared to be little or no consultation to manage the risk, other than to use restraint. There was no evidence to support why the decision to leave the people in the wheelchairs had been made, or that relatives had been consulted, and other options explored. There was no evidence to confirm accidents had occurred or that the risk assessments had been reviewed. The date on the risk assessment was 2006. The registered manager must review the way risks are managed to prevent institutional practise on the dementia unit, and to prevent people being restrained. Care plans looked at indicated that people needed assistance with mobilising and transfers, although there were no clear instructions to direct staff to move and handle people safely. Staff said that they lifted people from bed to wheelchair etc, which is extremely unsafe for both the person and the member of staff. There was no moving and handling equipment sited on the dementia unit, staff said they had to bring the hoist from downstairs if they needed to use the hoist. Medication procedures were generally well managed, however one persons medication had not been booked in correctly, so it was difficult to audit the stock. One item had run out, therefore the person had gone three days before a new supply had been gained. Another medication looked at had been written, and signed for on the MAR (medication administration record) as being taken twice daily, although the dispensing label said one daily. This means that the person had not received their medication as prescribed. There was two brown bottles with hand written labels. The member of staff said the bottles contained olive oil. Household remedies should be dispensed from the original bottles to ensure it is administered safely and correctly. There was clear evidence that people were treated with respect and their dignity was maintained. A visiting district nurse said people were always seen in the privacy of their bedrooms and staff always showed respect when giving assistance. People were spoken to in and appropriate manner and people said staff always called them by their first name and that was what they wanted. Eastwood House DS0000070909.V363613.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, 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to socialise with family and friends and mealtimes were well managed. EVIDENCE: People were able to join in activities, which were provided by the care staff. People were observed joining in games of dominoes and skittles, while on the dementia unit people could join in a game with balloons and watching old time musicals on video. The manager said the activities co-ordinator had left, and they intended to advertise for a replacement. Entertainment from outside was also brought into the home on a regular basis, and funds were raised to pay for that. People were able to purchase newspapers at their own cost and the hairdresser visits weekly. Visitors said that staff always made them feel welcome, and they could visit anytime. People said they enjoyed family and friends visiting, one person said they looked forward to trips to their relative who lived locally. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 15 People were able to make choices about where and how they spend there time. Many people said they liked to spend time in their bedrooms watching TV and listening to music. They said they had brought in lots of their belongings, which helped them feel at home. Mealtimes were well managed and the food nicely presented. People said they enjoyed all of the meals provided, as the cooks were very good. Staff were available to give assistance where needed and meals provided to people in their rooms were nicely presented. Visitors were provided with drinks and they said they were able to join their relative for a meal if they wanted to. Eastwood House DS0000070909.V363613.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): 16,17,18 People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns, and have access to an effective complaints procedure. However policies and procedures to protect from abuse, need to be reviewed to safeguard adults. EVIDENCE: There was a complaints procedure that was available to people who use the service and visitors. The procedure was also referred to in the service users guide, identifying the stages to follow; this included the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection was included in the procedure, although it needs amending to reflect the Newcastle address. Examination of the complaints records showed that there were no complaints recorded since the last visit to the home; the AQAA also confirmed that no complaints had been received. People confirmed that they were aware of the complaints procedure and who they would contact if they wanted to raise concerns. The AQAA stated that policies regarding Restraint and safeguarding adults had been reviewed in October 2007, although examination of the policies showed that they had not been reviewed since 2002. The manager had not acquired the new Safeguarding Adults procedure and seemed unaware that new procedures were in place. The manager had not attended any of the launches Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 17 of the new procedures, and did not appear to know who to contact to arrange training for herself. The manager stated that staff received instruction on safeguarding during supervision, although 2 of the 3 staff interviewed said they had not had any training on abuse. One member of staff said she had attended training at her previous employment. Training records looked at confirmed a number of staff had not received safeguarding training. One staff member interviewed said she was not familiar with the whistleblowing procedure but could answer questions when prompted. The home had policies and procedures for the use of restraint, although it mainly covered restraining people who were displaying aggressive behaviour. It lacked detail with regard to the strategies which should be considered, before the use of restraint in preventing harm to individuals. Eastwood House DS0000070909.V363613.R01.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, 20, 21, 22, 23, 24, 25, 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with a clean, comfortable environment and there were sufficient staff to maintain good hygiene standards. EVIDENCE: Eastwood House is a long established residential home, which has had extensions, added. The home meets the requirements of the Disability Act and the layout is suitable to meet the needs of the all the people of Eastwood House. In April 2006 an application was approved to have a dementia unit upstairs. The unit has two lounges, dining room and snack kitchen and has an enclosed garden for the use of these people. At Eastwood House all bedrooms are single occupancy and there was evidence that many of the people had personalised their bedrooms. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 19 There is a selection of communal areas throughout the home. There is a redecorating programme in place for all areas of the home. The downstairs dining area had recently been redecorated and there are plans for new carpets to be laid in that area. The domestic and care staff work extremely hard to ensure a clean and hygienic environment without offensive odours. There is a choice of bathing facilities for example, assisted baths and shower room with a number of toilets placed around the home. The home provides a hoist to assist people with moving and handling needs, however there is no such facility on the dementia unit. The water temperature in people’s bedrooms was randomly checked. The temperature was above the required 43 degrees. The manager took immediate action to rectify the problem. Regular monitoring checks should be undertaken to ensure the problem does not reoccur. The grounds are well kept with patio areas at side and rear of the home, which are used for people who receive care on the residential unit with a separate area for the people in the dementia unit. Eastwood House DS0000070909.V363613.R01.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff had the skills and knowledge to fulfil their roles within the home, and there was a stable staff group. Recruitment policies are generally followed ensuring the safety and protection of people who live at the home. EVIDENCE: Staff rotas were looked at and they showed that overall there were sufficient staff to meet the needs of people who use the service. The dementia unit is staffed by two staff, which is not sufficient, as a number of personal care tasks require the assistance of both staff. The manager said when these occasions arise assistance is called for from staff on the residential unit. Staff rotas looked at for night care arrangements showed that only two staff instead of the required three members of staff had covered three nights. The manager said when staffing level were reduced a senior or herself slept on the premises. Levels must be maintained to ensure the health and safety of people who use the service. Three staff recruitment files were examined; two files contained all the required employment checks, however one file only had one written reference and a CRB (Criminal Record Bureau) check from a previous employer. None of the files examined had a POVA 1st check, although the manager said these were carried out and held centrally. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 21 The manager should check the date on the CRB as good practise suggests that a new CRB check should be carried out every three years, to ensure the information is up to date. Staff training and development plan was looked at; it identified staff training needs, courses completed and courses being undertaken. Staff interviewed, confirmed that most had undertaken training on the protection of vulnerable adults and dementia care, although some newer staff still required training on the protection of vulnerable adults. They were also involved in National Vocational Qualification (NVQ) training. The numbers of staff trained to level 2 NVQ in care exceeded the minimum 50 required. Eastwood House DS0000070909.V363613.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, 32, 33, 34, 35, 36, 37, 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were protected by sound management practises, and their views were actively sought to improve the service. The financial interests of people were safeguarded, and good health and safety procedures ensured they are protected. EVIDENCE: The manager has worked at the home for a number of years. She continues to work towards attaining the NVQ level 4 qualifications and also undertakes other statutory training to maintain her care competencies. The manager has responsibility for providing supervision to all staff, and staff said they feel supported by the senior team. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 23 The new registered providers provide support to the manager, although they have not completed the monthly audit as required by regulation 26 of the Care Homes Regulations 2001. Quality assurance systems have been developed using a survey to gain the views of residents. Residents meetings are also used to ensure they play an active part in making decisions about how the home is run. People who use the service are able to manage their own finances, although most prefer the manager to assist with dealing with their personal allowances. Records and monies were examined and these were accurate. The home was well maintained; the employment of a handyman has helped to maintain a safe environment for people who use the service. Eastwood House DS0000070909.V363613.R01.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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 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 3 18 2 3 3 3 2 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 2 3 Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? First Inspection 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 13, 15 Requirement Peoples care needs must clearly state how staff are to deliver care safely. This must include risk assessments on how to move and handle people, and the methods and strategies used to prevent falls. Nutritional assessments must be regularly monitored and reviewed, to ensure they receive appropriate care, and where risks have been identified people must be referred to a dietician. Timescale for action 01/08/08 2. OP8 14 01/08/08 3. OP9 13 A record of all medication 01/07/08 received must be made to ensure an audit can be undertaken. Care must be taken when recording how the medication is to be administered. This will ensure people receive their medication as prescribed. Sufficient moving and handling equipment must be provided on the dementia unit, to ensure people are moved safely. 01/11/08 4. OP22 13(5) Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 26 5. OP29 19 A new CRB must be obtained for all new staff employed at the home. Two written references and a POVA 1st check must also be obtained to ensure the right staff are employed. All staff including the manager must attend formal safeguarding adults training. Monthly audits must be undertaken, as required by regulation 26 of the Care Homes Regulations 2001. 01/08/08 6. OP30 OP18 18 01/08/08 7. OP37 26 01/07/08 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 OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be updated to ensure people are provided with accurate details of the new registered providers and CSCI change of address and customer care telephone number. Household remedies should be dispensed from there original packaging. The new Safeguarding Adults procedures should be acquired and implemented. The risk and restraint policy should be reviewed, to give clear guidance to staff when assessing people who use the service. Water temperatures in people’s bedrooms should be regularly checked and recorded to ensure they are no higher than 43 degrees. Staffing levels should be reviewed to ensure there are sufficient numbers and skills mix to meet the needs of DS0000070909.V363613.R01.S.doc Version 5.2 Page 27 2. 3. OP9 OP18 4. OP25 5. OP27 Eastwood House 6. OP29 people who use the service. The manager should check the date on the CRB as good practise suggests that a new CRB check should be carried out every three years, to ensure the information is up to date. Eastwood House DS0000070909.V363613.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 DS0000070909.V363613.R01.S.doc Version 5.2 Page 29 - 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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