Inspection on 21/06/05 for Eaves Hall

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Eaves Hall 08/02/07

Eaves Hall 18/01/06

Eaves Hall 16/12/04

Eaves Hall 30/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Eaves Hall Kiddrow Lane Burnley Lancs BB12 6LH Lead Inspector Pat White Announced 21 June 2005 9.30 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 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. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Eaves Hall Address Kiddrow Lane Burnley Lancs BB12 6LH 01282 772413 01282 771149 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Srebrenka Macintosh & Mr Ian Keith Macintosh Mrs Lynn Elizabeth Kendall Care Home 15 Category(ies) of Old Age OP 14 registration, with number Mental Disorder, excluding learning disability or of places dementia over 65 years of age MD(E) 1 Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. A maximum of 14 service users who fall into the category of OP (Older People) 3. One named service user who falls into the category MD(E). When this person no longer resides in the home, the registered person will notify the Commssion so that the registration can revert back to 15 OP Date of last inspection 16 December 2005 Brief Description of the Service: Eaves Hall was registered to provide care and accommodation for 15 people of either sex over the age of 65, and one named person over the age of 65 with a mental disorder within the overall registration number. The building is of an older type on the outskirts of Burnley town centre. It is situated in its own private grounds that provide a pleasant area for service users to walk and sit. The home consists of two floors linked by a chair lift. There were 9 single rooms, 7 of which were under 10 sq ms, and 3 shared rooms, one of which was slightly under 16 sq ms. The home was furnished and decorated to a high standard. Mrs Lynn Kendall, the care manager, was an experienced manager and had been the registered manager for 12 years. The home’s fees were “all inclusive”, with a supplement added on top of the standard fees, to cover all items of need, such as toiletries, papers, hairdressing and entertainment. Activities provided included games, videos, aromatherapy, singers and other entertainers. Residents’ birthdays were usually celebrated with a party. A range of policies, procedures and documentation had been developed to meet the requirements of the Care Standards Act 2000 and the National Minimum Standards. Investors in People was re awarded to Eaves Hall in 2004. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an announced inspection, the purpose of which was to assess important areas of life in the home that should be inspected over a 12 month period, check the progress of previous legal requirements and good practice recommendations, and check other matters in the home which came to the inspector’s notice. The inspection took 8 hours, 45 minutes and comprised of, talking to residents, a partial tour of the premises, looking at resident’s care records and other documents, and discussion with the manager, the owner and the administrator. A member of staff was interviewed. Ten residents were spoken with and others were observed in their routine daily activities. Three relatives were spoken with. Eleven residents and ten relatives completed comment cards. Four general practitioners and a district nurse team leader also completed comment cards What the service does well: Residents are well cared for in the home. All residents spoken with, and who completed comment cards, stated that they were well cared for, that staff were caring and patient. One general practitioners and the district nurse team leader stated that Eaves Hall was an “excellent” home in terms of the health care of their patients. The food served has been consistently praised by the residents, and at this inspection comments such as “they do very well with the food” and the “food is very good” were made. Eaves Hall has always been well – maintained and well decorated with good quality furnishings. There is a high standard of cleanliness in the home. The staff team are well supported and guided by the manager who demonstrates a high level of commitment to the home. The home is a safe place for residents and staff, with staff having appropriate health and safety training, and the environment having appropriate safeguards such as guards on radiators and window restrictors. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4 & 5. Standard 6 was not applicable The home’s admission procedures, including pre admission assessments in the place of residence and prior visits by prospective residents and relatives to the home, helped to determine whether or not the home could meet people’s needs. Residents needs were being met in the home. EVIDENCE: The Statement of Purpose and the Service User Guide were not assessed at this inspection but the registered person must ensure that these documents have been reviewed and that they comply with Regulations 4 (schedule 1) & 5 and standard 1. Up to date copies must be sent to the CSCI. The viewing of residents’ records confirmed that residents had “Service Agreements” from the Social Services, if applicable, and the home’s “Terms and Conditions”. Records also showed that an in house assessment was carried out prior to admission for all those people recently admitted, including a resident admitted for respite care the day before the inspection. Copies of the social worker assessment had been obtained for those residents admitted through “care management” arrangements. After admission a more detailed assessment was carried out and a care plan was generated. The registered person confirmed in writing to prospective residents that the home could meet their needs and Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 9 residents spoken with indicated that their needs were met. Residents spoken with and who completed comment cards stated that their needs were met at Eaves Hall and that they were well cared for. Residents were given the opportunity of visiting the home prior to making a decision. Most residents stated that their relatives had visited the home and that the manager had visited them in their place of residence. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 The care plans had improved and contained useful information about the residents’ health, personal and social care needs. Residents’ health care needs were promoted and maintained. Medication procedures and systems had been developed to ensure the safe handling, storage and administration of medication. Residents and visitors felt that residents’ rights to privacy and dignity in the home were upheld. EVIDENCE: All residents had a written care plan and the documentation used for this had been improved since the previous inspection. These contained appropriate risk assessments, including one for the prevention of falls. There was a useful section on people’s preferred routine. Information on psychological issues and pressure area care was recorded on the care plans. The care plans were being reviewed every few months and there was evidence that residents were involved in the compilation of their care plans. A key worker system had been established to make the system of reviews and the day - to - day care of the residents more efficient. The residents’ health care, including psychological health, was promoted and residents had access to all the necessary health care services. One resident Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 11 was on the “Care Programme Approach” and having all relevant support from the mental health services. Pressure area care was managed appropriately in the home, with advice and support from the district nurse as required. There were good nutrition assessments and residents’ weights were monitored and recorded. However the care plans need to include procedures for the management of MRSA, the promotion of continence and risk assessments on the use of the stair lift without staff assistance. The 4 GPs and the district nurse team leader who completed comment cards stated that their patient’s health care was well managed by the home. All stated that there was good communication between the surgery and the care staff, that staff demonstrated good understanding of their patients’ needs and made appropriate decisions. The district nurse team leader stated that the standard of care at Eaves Hall was “excellent”. Residents’ medication was satisfactorily and safely managed in the home. Some procedures and systems had improved over the last year such as: the policies and procedures had been developed according to the Royal Pharmaceutical Guidelines, the home was checking the prescriptions prior to dispensing, records were being kept of all medication being returned to the pharmacist and staff administering medication were undertaking accredited training. However further improvements need to be made and the following requirements must be met with priority: The medication of residents admitted to the home must be verified by the GP, all forms of secondary dispensing must cease and the temperature of the medicine storage areas must be monitored regularly. Some other requirements, and some good practice recommendations, have also been made. Residents stated that their right to privacy was respected, and that staff treated them appropriately when giving assistance. Visitors and general practitioners who completed comment cards stated that they could see residents in private. The member of staff spoken with demonstrated a good understanding of the importance of privacy and dignity to residents. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 15 Routines were flexible enough to suit individual preferences. There were some activities appreciated by the residents, and the visiting arrangements encouraged and enabled residents to maintain contact with family and friends. The food served was appetising, wholesome, enjoyed by most residents and afforded them choices. EVIDENCE: Routines appeared flexible enough to suit individual needs and preferences. “Preferred routines” were recorded on the care plans. Residents had choices in rising and retiring times and were asked about what meals they would. Some residents would like to use the stair lift independently and so increase their choice of moving to and from their bedrooms (see standards 7 & 22). Residents’ interests and hobbies were recorded on the care plans, and some spoken with appreciated the parties that were held to celebrate residents’ birthdays and to which “entertainers” were invited. Some residents said they played games with staff and watched films. Eight out of 11 residents who completed comment cards stated that the home organised suitable activities. However 3 residents stated that the home did not, and some residents spoken with stated that there was “not much going on”. There had been no organised trips out. Residents and relatives spoken with, and those relatives who completed comment cards confirmed that visitors were made welcome in the home at any Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 13 reasonable time. Some residents were having aromatherapy at the time of the inspection. The meals served appeared wholesome and appetising and suited residents’ tastes. Appropriate assistance was given to those who needed it. Those spoken with praised the food and 10 of those who completed comment cards stated they liked the food. One said they “sometimes” liked it. The menus supplied indicated that wholesome and nutritious food was served. Appropriate alternatives were served to those with diabetes. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 There was a simple and clear complaints procedure accessible to residents and relatives in the information pack given to people on admission. Residents and relatives knew how to make a complaint. The home had appropriate policies and procedures to protect the residents from abuse. EVIDENCE: The home had a suitable complaints procedure, of which all the visitors who completed comment cards stated they were aware. All the residents who were able stated on comment cards that they knew who to talk to if they were unhappy about their care. Residents spoken with stated that they had no complaints, and comments such as “it’s very nice here” were made. One new resident stated “Why should he have any complaints about such a home”. Relatives and the general practitioners who completed comment cards stated that they had never had cause to make a complaint. One resident who had just been admitted for a period of respite care expressed favourable first impressions. There were no recorded complaints in the home. The home had appropriate policies and procedures to assist in the protection of residents from abuse, and guidelines to protect staff from aggression from residents. There had been no recent allegations or suspicion of abuse. Residents who were spoken with and those who completed comment cards stated that they felt safe living in the home. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 & 22 Eaves Hall provided safe, well – maintained, well - furnished and comfortable accommodation for the residents. There were ample gardens that were accessible to the residents. High standards of cleanliness were maintained. EVIDENCE: The areas of the home viewed were well – maintained, decorated to a high standard and provided safe and pleasant accommodation. Furnishings and carpets were of a good quality, comfortable and homely. Audits of the property were carried out regularly to ensure that renewals and repairs were carried out rapidly. A new shower had been installed and some new bedroom furniture had been purchased. Key workers were responsible for checking the contents of the bedrooms and the beds and bed linen. The grounds were accessible to residents in wheelchairs and were a pleasant area for residents to sit and walk in. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 16 Communal space consisted of 2 lounge / dining areas and a sitting area between the two. This allowed each service user approximately 4.0 sq m of communal space, which for a home registered before April 1st 2002, complies with standard 20.4. The home was bright, and lighting in the communal areas facilitated reading and other activities. The bedrooms were not viewed at this inspection but the residents spoken with stated that they were satisfied with their private accommodation. The registered person had completed an audit of the premises with respect to disability equipment and adaptations. This information needs to be used to assess whether or not further equipment and adaptations are necessary, including a hoist. Individuals had equipment for walking and mobility, and there was one assisted bath and one assisted shower in the home. The registered person must carry out risk assessments to determine whether or not residents can use the stair lift without staff assistance, and so increase their choice and independence with respect to moving to and from their bedrooms (see standard 14) The parts of the home seen were clean and fresh with no offensive odours. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The home had sufficient staff on duty to meet the needs of the residents. The staff training programme was being improved and developed according to the needs of the residents and staff. The home’s staff recruitment policies and procedures were thorough, met statutory requirements, and therefore assisted in the protection of residents from unsuitable staff. EVIDENCE: At the time of the inspection, and according to the rotas supplied, the numbers of staff in the home were sufficient for meeting the needs of the residents. Since the previous inspection a designated cleaner had been appointed in the home. The care staff were responsible for the cooking and meals preparation. Residents and relatives who spoke to the inspector, and all those who completed comment cards, indicated that they thought there were enough staff on duty, and that in general members of staff were kind and caring. One service user stated that the “staff are very kind”; another said that “some were nicer than others”. The inspector was informed that in the near future, 70 of care staff will be trained to at least NVQ level 2. Staff records showed that the home’s recruitment procedures were fully in accordance with the Care Homes Regulations, and supported the protection of residents from the appointment of unsuitable staff. The staff training programme was being developed in accordance with the needs of the staff and the residents. Records showed that staff had completed Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 18 courses in dementia, challenging behaviour, palliative care, diabetes, medications management and abuse of vulnerable adults. The home’s in house Induction training programme was being developed according to the Skills for Care (the former TOPSS) specifications. The member of staff spoken with confirmed the training opportunities offered by the home and demonstrated commitment and enthusiasm for her work. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 & 38 The manager was competent and fit to run the home. She demonstrated strong leadership, and support for residents and staff. Quality monitoring systems, involving residents and relatives, had been developed. Residents’ monies were managed appropriately and therefore safeguarded. Staff training and the home’s procedures ensured a safe environment, and the promotion of the health and safety of both residents and staff. EVIDENCE: Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 20 The current registered manager of Eaves Hall, Mrs Lynn Kendall, is experienced and competent to run the home, with about 12 years experience in managing a care home. She demonstrated a clear commitment to Eaves Hall and that she had knowledge and skills for the resident group. Mrs Kendall had finished the NVQ level 4 in “Management” and will complete NVQ level 4 in “Care” before the end of 2005. She had attended numerous other courses relevant to her post. There appeared to be clear lines of accountability within the home and also with the registered provider and responsible individual, Mr Macintosh, who visits the home on a regular basis. Mrs Kendall worked along side the care staff and was described as being approachable, supportive and committed to her job. She communicated a clear sense of direction and leadership. A quality monitoring survey had been conducted a few weeks prior to the inspection and the results were sent to the CSCI. These results showed a high level of satisfaction with life at Eaves Hall. The results will be discussed at the next residents’ meeting. A negative view expressed by one resident had been addressed. Relatives and visiting professionals had been consulted about the service. The home’s fees were “all inclusive” and a supplement is paid for this, which is stated in the home’s terms and conditions. As a result residents are not charged individually for such things as hairdressing and newspapers. Financial procedures appeared to safeguard residents’ finances and records inspected showed that the accounts of residents’ fees paid were well maintained and accurately recorded. Since the previous inspection the manager had begun to undertake one to one formal supervision with care staff, and annual appraisals were included in this. It is recommended that the manager use her work along side the care staff as an opportunity for formal supervision sessions. The registered person ensured the health and safety of both residents and staff. Appropriate staff training in health and safety and safe working practices was undertaken. There was a rolling programme of moving and handling training and there was a person competent in first aid on every shift. The home’s fire precautions were in accordance with the Regulations and the home’s electrical and gas appliances had been tested appropriately. Accidents were recorded appropriately and the CSCI notified accordingly. The registered person must confirm to the CSCI that the home’s water system does not pose a threat of the spread of Legionella. Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x 2 x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 2 x 2 Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last 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 1 Regulation 4 (schedule 1), 5 & 6 Requirement The registered person must ensure that the Statement of Purpose and Service User Guide have been reviewed and that they comply with Regulations 4 (schedule 1) & 5. Up to date copies must be sent to the CSCI The care plans must set out in detail all aspects of the health, personal and social care needs of the residents, including the procedures required for MRSA management and the promotion of continence. The registered person must ensure that records made of medication entering and leaving the home are dated The step by step medication procedures followed must be detailed in the written procedures, for example the administration and recording of homely remedies. The criteria for PRN and variable dose medication should be clearly defined and recorded on or with the MAR sheets A Policy and procedure must be developed for the administartion of covert medication. Timescale for action 31 August 2005 2. 7 15 (1) 31 July 2005 3. 9 13 (2) 4. 9 13 (2) Immediate from the receipt of the report 31 July 2005 5. 9 13 (2) 31 July 2005 31 July 2005 Page 23 6. 9 13 (2) Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 7. 9 13 (2) The medication of residents must be verifiedb the GP on admission All forms of secondary dispensing must cease, including the that put into a compliance aid. The temperature of the medicine storage areas must be monitored regularly. Oxygen cylinders must be stored securely either on a trolley or link chained to the wall. When eye drops are being administered there must be a separate supply for each eye to prevent cross infection. The registered person must carry out risk assessments to determine whether or not residents can use the stair lift without staff assistance, with a view to increasing their choice and independence with respect to moving to and from bedrooms. The registered person must confirm that the homes water supply does not pose a threat of the spread of Legionella. 8. 9 13 (2) Immediate from the time of the inspection From the time of the inspection From the time of the inspection 31 July 2005 31 July 2005 31 August 2005 9. 10. 11. 9 9 9 13 (2) 13 (2) 13 (2) 12. 22 12 (2) & (3) 13. 38 13(3) & (4)(a)&(c) 31 August 2005 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. Refer to Standard 9 12 22 Good Practice Recommendations It is recommended that residents if possible, not the relatives, give and sign their consent for the staff at Eaves Hall to manage their medication. The registered person should review the leisure activities with residents and particularly to give consideration to organised trips. The registered person needs to ensure that the audit of F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 24 Eaves Hall 4. 36 disability equipment is used to assess whether or not further equipment / adaptations are needed in the home. It is recommended that the registered person ensures that staff supervision is carried out at least 6 times per year Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Unit 4 Petre Road Clayton-le-Moors Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Eaves Hall F57 F07 S9495 Eaves Hall V224212 21605 Stage 4.doc Version 1.30 Page 26 - 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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