Inspection on 18/12/07 for Egerton House Residential Home

This inspection was carried out on 18th December 2007.

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

Egerton House Residential Home 28/01/09

Egerton House Residential Home 16/01/07

Egerton House Residential Home 20/01/06

Egerton House Residential Home 28/06/05

Egerton House Residential Home 02/03/05

Egerton House Residential Home 13/10/04

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

CARE HOMES FOR OLDER PEOPLE Egerton House Residential Home 113 Hill Top Lane Kimberworth Rotherham South Yorkshire S61 2ER Lead Inspector Ramchand Samachetty Key Unannounced Inspection 18th December 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Egerton House Residential Home DS0000056460.V349791.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. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Egerton House Residential Home Address 113 Hill Top Lane Kimberworth Rotherham South Yorkshire S61 2ER 01709 559643 P/F 01709 559643 egertonhouse@aol.com None Mrs Parneet Virk Mr Sarbjit Singh Virk Miss Susan Lorraine Foster Care Home 21 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) Category(ies) of Old age, not falling within any other category registration, with number (21) of places Egerton House Residential Home DS0000056460.V349791.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 The maximum number of service users who can be accommodated is: 21 An action plan with timescales for the renewal of furniture and soft furnishings to be developed, agreed and provided to the NCSC within 3 months of this registration date. 16th January 2007 2. 3. Date of last inspection Brief Description of the Service: Egerton House is registered to provide care and accommodation for up to 21 older people. The home provides both long and short-term care for its client group. Mr and Mrs Virk are the registered provider. The home is situated in the Kimberworth area of Rotherham and is within easy reach of the town centre and other local amenities. Egerton House is a twostorey building, which has been extended to provide its current accommodation. There are 17 single and 2 double bedrooms. The communal areas consists of a dining room and two lounges. There is a small quiet room on the first floor for use by people living at the home and their relatives. Bathrooms and toilets are available on both floors. The kitchen and laundry are located on the ground floor. There is a call system in all rooms, which is available to all occupants. There is a passenger lift to facilitate access between the two floors. The Home has a garden and patio area and there is a car parking facility at the front of the building. The fees for care at the home at 18th December 2007 were £343.00 per week. Items not covered by the fee include hairdressing and personal toiletries. There is a statement of purpose and service user guide. These documents give more information about the home and its facilities. Further information can be obtained from the home. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out on 18 December 2007, starting at 10.00 hours and finishing at 18.30 hours. The service is registered to provide personal care for up to 21 older people. There were 20 people in occupancy at the time of this inspection. The registered manager, Mrs Sue Foster was present throughout the inspection. All the key national minimum standards for ‘Care Homes for Older People’ were assessed and compliance with the requirements made at the last inspection was checked. The inspection included a tour of the premises and examination of care documents and other records, which included staff rota, complaints, care records and staff files. We spoke to five people who live at the home and six relatives who were visiting on the day. We also spoke to four members of staff besides the manager. The care of two people who use the service was considered in some detail and we observed some aspects of care being provided. Feedback on the findings of the inspection was given to the manager. We would like to thank all the people living at the home, their relatives and staff who helped with this inspection. What the service does well: People who use the service and their relatives said that they were ‘very satisfied’ with the service being provided at the home. They described the place as being ‘homely and genuinely warm’. They told us that staff were ‘very caring and friendly’. They also praised staff’s attitude and approach to their work, which they felt contributed to the good and welcoming atmosphere of the home. There was a good staff team, which worked well together to ensure the continuing wellbeing of people living at the home. There was good communication between staff and people, who use the service and their relatives and this increased their confidence in the service. The meals provided were, according to people who live at the home, ‘good and tasty’. They were offered a good choice of meals, which included a cooked breakfast. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 6 A sufficient number of experienced staff was deployed on duty in order to meet the needs of the people who live at the home. Commendably, all the current care staff had achieved their ‘National Vocational Qualification’ (NVQ) level 2 in care. What has improved since the last inspection? What they could do better: Although a new care planning system has been introduced, there is a continuing need to improve the overall management of care. The recording of care provided must be improved to make sure that there is sufficient information to allow for its effective evaluation. Staff must also make sure that observations and care interventions are appropriately followed up and concluded, to ensure continuity of care for the individuals involved. Records of medicines that have been administered need to be appropriately maintained. Programmes of social and recreational activities should be developed, as part of care planning and in consultation with people who use the service and their representatives. This should take into consideration peoples’ capabilities and preferences and so allow them to benefit equally from these activities. A few items of repair and maintenance need to be carried out to continue keeping the environment safe and comfortable. There is a need to improve staff records to ensure that details of their applications for a post at the home, including their employment history and the relevant pre-employment checks are appropriately kept. Efforts should be made to achieve a more diverse staff team for the benefit of people who use the service. We have also recommended staff training on issues of ‘Equality and Diversity’. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 7 Although some internal quality assurance methods have been put in place at the home, there is a need to make sure that they are appropriately implemented and that their outcomes are used effectively to further improve the overall service. 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. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. 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 the service. People using the service and those who were interested to use it, were given sufficient information to help them with their choice. Assessments of needs were carried out before people were admitted to the home, in order to make sure that their needs could be met. EVIDENCE: The statement of purpose and service user guide were well publicised within the home. Staff confirmed that these documents were also given to people who were interested in obtaining a placement at the home. People using the service and their relatives said that they were given enough information to enable them to choose whether the home was right for them. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 10 The care files of three people who use the service were checked. They contained copies of their full assessments of needs undertaken before their admission to the home. The service was therefore able to confirm that the needs of the people it had admitted could, in general, be met. The assessments of needs also allowed staff to develop care plans for the individuals concerned. The home does not provide intermediate care. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. 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 the service. People living at the home were satisfied with the care and support they were receiving, which they felt was helping them to enjoy a good quality of life. However, the management and recording of care were not always satisfactorily carried out. EVIDENCE: People who use the service and their relatives told us that they were satisfied with the care that they were receiving. They said that ‘ staff were very caring and friendly’. People living at the home said that personal care was provided to them in the privacy of their own bedrooms and in bathrooms. They commented that staff always addressed them with respect. People living at the home were observed to be in good attire and this helped to maintain their dignity and self-confidence. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 12 We noted that a new care planning system was in use at the home. It was simple to use and it enabled information to be well organised and kept together. The care plans of two people using the service were checked. They were based on identified personal and health care needs of people and the risks that they faced in their daily activities. They also included information on social care needs and therefore staff were able to assist people in maintaining their preferred lifestyle. Actions to be taken to meet needs of individuals were set out in their care plans. However, records of care provided were often too generalised and lacked detail and this led to poor evaluation of care. Although, records indicated that care plans were reviewed every month, the evaluation of care was inadequately undertaken. In some instances, there was no evidence that important care observations and requests for care interventions had been followed through. This could lead to inadequate care being provided. In discussion, people who use the service and their relatives told us that they were satisfied that staff always made sure that prompt medical and other health care services were available as necessary. Records showed that people had good access to their GPs, chiropodists, opticians and to the district nursing service. There was a policy and procedures regarding the management of medicines at the home. None of the people at the home were self-administering their medicines. Staff who administered medicines had received accredited training in their safe handling. The storage, handling and administration of medicines were checked. The storage of medicines was satisfactory. However, the location of the medicines trolley caused some difficulty, in particular at meal times. Medicines administration records were checked. They showed that medicines received at the home were appropriately recorded. In a few instances, medicines administered were not signed for. The manager said that she undertook regular audit of medicines in order to ensure good practice. There was no record of the outcome of these audits and of action taken to improve the management of medicines at the home. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People using the service were satisfied with the daily routines and with the social stimulation that were available to them, in order to maintain a good quality of life. EVIDENCE: On the day of this inspection, people living at the home were observed to spend their time sitting in the lounge in between meals and care interventions. People who use the service and who could express themselves told us that the routines at the home were very flexible. They were helped to make various choices regarding their daily activities. They said that they were able for example, to choose what time to get up and to retire to bed and how to spend their time. Social and recreational activities were organised on a regular basis. These included indoor events like bingo games and events by professional entertainers. However, people who were frailer were not always able to benefit from these activities. During the inspection, some care staff were observed Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 14 sitting and talking to people individually. This helped people, in particular those who were less capable, to experience some social stimulation and benefit from the personal attention. One relative commented that although she was happy with the occasional events by staff and entertainers, she would like to see more planned activities taking place on a daily basis. A number of relatives told us that both their loved ones and themselves were very satisfied with the care and support that staff were providing. One relative said ‘ My mother has improved quite a lot here, she can now walk better and she is much happier in herself’. There were two married couples living at the home. They said that staff always respected their privacy and choice, which enabled them to continue enjoying their relationship. Relatives also told us that they were always welcomed at the home. There was good communication between themselves and the staff and this contributed to the wellbeing of their loved ones. People using the service said that the meals served at the home were ‘good and tasty’. They said that they had the choice of a cooked breakfast every morning and a number of them did make that choice. The manager stated that a new dishwasher had been installed in the kitchen. They had also worked closely with Rotherham Council to implement their food safety standard. The lunchtime meal was observed. It consisted of shepherd pie, chicken casserole, vegetables and gravy. A number of people confirmed that staff had helped them make their food choices for the day. The atmosphere within the dining room was relaxed. Care staff were observed assisting some people to eat their meals, in an appropriate and unhurried manner. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. 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 the service. Policies and procedures to handle concerns about the service and to protect people, who live at the home from harm, were in place and well publicised. This meant that people using the service were listened to and protected from harm. EVIDENCE: There was a complaints procedure in place and it gave information on how to make a complaint and who would deal with it. It also gave the timescale within which a complaint would be investigated and concluded. The complaints procedure was included in the statement of purpose and service user guide and a copy was displayed in the home. The home had not received any complaints since the last inspection. Relatives told us that they were aware of the complaints procedure and would use if they had reason to do so. They said that they usually talked to staff if they had any concerns and these would be dealt with promptly and to their satisfaction. There was also an adult protection policy in place to promote the safety and welfare of people living at the home. Staff were aware of this policy and had Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 16 received training on issues regarding the safeguarding of vulnerable adults. There had been no concerns about the safety and welfare of people using the service in the last twelve months. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 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 the service. People living at the home were satisfied with the standard of accommodation and its facilities, which together made the place comfortable and pleasant. EVIDENCE: People living at the home and their relatives were satisfied with the standard of accommodation provided. They described the atmosphere as ‘very homely and genuinely warm’. They commented that both the communal areas and the bedrooms were always clean, tidy and well decorated. We undertook a tour of the premises in the company of a senior member of staff. The main entrance was wheelchair accessible. One of the back doors had Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 18 a ramp, which also allowed access to wheelchair users. The laundry facilities were sited away from all food preparation and storage areas. We noted that the laundry equipment had been upgraded to include a sluicing facility, in order to assist in the prevention of infection. Hygiene in the kitchen was maintained to the Local Authority Standards. However, we noted that the location of the medicines trolley was affecting the use of that communal space and caused some difficulty to people, in particular visitors and staff. We checked a few bedrooms with the permission of people who lived in them. They were found clean and odour free. A few people had been able to personalise their bedrooms with their own items of memorabilia and this made their personal accommodation more pleasant. We noted that one bedroom had no supply of hot water and one had a slightly damaged doorframe. Otherwise, the home was well maintained, clean and in good decorative condition. A programme for decorating and refurbishment was in place and was being implemented. The surrounding grounds were also well maintained for the time of the year. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. 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 the service. People living at the home and their relatives were satisfied with the staff team, which they found to be very committed and conscientious. Sufficient trained staff were deployed to meet needs of people living at the home and this helped to maintain a good standard of care. EVIDENCE: The home was registered to care for up to 21 older people. At the time of this inspection, there were 20 people in residence, including two who were in hospital. There were three care staff during the day besides the manager, the kitchen and domestic staff. Two care staff were scheduled to work at night. The number of care hours provided was based on the dependency needs of people who live at the home. Staff rotas showed that the number of care staff deployed was sufficient to meet needs of people being cared for. People who use the service and their relatives told us that in their opinion, there was always enough staff on duty. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 20 In discussion, staff told us that they were satisfied with the training they had received. Commendably, they had all achieved their ‘National Vocational Qualification’ (NVQ) level 2 in Care. (100 ). Training records showed that staff had received training on various topics. These included moving and handling, first-aid, fire safety, food hygiene, adult protection and the safe handling of medicines. However, we noted that none of the staff had received any specific training on issues concerning ‘Equality and Diversity’. The home had a recruitment and selection policy and procedures in place. It included the practice of equal opportunities. However, we noted that there were no males in the current staff team. This may affect the way care is delivered to people of the male gender. Staff records were checked. In one instance, there was no application form for a member of staff and therefore the employment history could not be checked. Two written references and appropriate disclosures were usually sought and obtained before staff started working at the home. The manager stated that new employees were usually provided with appropriate induction. However, staff records seen at the inspection were incomplete and inappropriately kept. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. 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 the service. Adequate management arrangements were in place and people who use the service and their relatives were satisfied with them. However, there were shortfalls in the management of health and safety and of the internal quality monitoring system, both of which could put people at risk. EVIDENCE: The new manager has relevant experience in the care of the elderly in a residential setting .She has just completed her ‘Registered Manager’s Award. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 22 People who live at the home, their relatives and staff said that they were satisfied with the day- to- day running of the home. The manager explained that quality assurance questionnaires were periodically distributed to people who use the service and their relatives. Positive feedback was obtained from the last survey carried out in January 2007. People who use the service and their relatives found it to be highly satisfactory. Staff meetings were held frequently and this helped with maintaining good communication and good teamwork. Staff confirmed that they were receiving regular supervision and support from the manager. The manager said that she was receiving good support from the owner and that reports of their monthly visits to the home were completed. However, none was available for this inspection. The manager explained that other quality assurance methods used at the home, included medicines and care plans audits and regular health and safety checks, including water temperatures. However, during the inspection, we found that there was no hot water at outlets used by people living at the home. There were also omissions in the records of medicines. These shortfalls indicated that the quality monitoring tools were not being appropriately used. This failure to be proactive on quality assurance issues has affected the rating of this service. Arrangements were in place to support people living at the home with the management of their money, which was left for safekeeping by relatives. All financial transactions were appropriately recorded, witnessed and signed for and receipts were kept. Accounts checked were in balance. The manager stated that she carried out a monthly audit of these accounts and they had been satisfactory. Information regarding the maintenance of equipment and the major utilities in use at the home was provided in the home’s ‘Annual Quality Assurance Assessment’. Health and safety issues were discussed with the manager and records were checked. The latter included fire safety and service maintenance records. They were found to be satisfactory. Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Daily records must be more detailed to ensure that the health and wellbeing of the resident can be fully monitored. (Previous timescale 01/04/07) Care observations and requests for care interventions must be appropriately followed up and concluded. Accurate records of medication administered must be maintained. (Previous timescale 01/04/07) The medicines trolley must be located to another area to ensure the health and safety of people at the home. Hot water, at the appropriate temperature, must be made available in all bedrooms used by people who live at the home. The damaged doorframe, as identified, must be repaired and made good. Staff records must be appropriately kept and must include application forms, with DS0000056460.V349791.R01.S.doc Timescale for action 29/02/08 2. OP7 15 29/02/08 3. OP9 13 29/02/08 4 OP19 23 29/02/08 5. OP19 23 29/02/08 6. 7. OP19 OP29 23 19 29/02/08 29/02/08 Egerton House Residential Home Version 5.2 Page 25 8. OP33 26 9. OP33 24 relevant employment history and appropriate pre-employment checks. A written report of the providers’ monthly visit must be completed and retained on site for inspection. (Previous Timescale 01/04/07) The quality assurance methods must be more effectively used, in order to improve the overall service. 29/02/08 29/02/08 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 OP12 Good Practice Recommendations Programmes of social activities should be developed in consultation with people who use the service and their relatives or advocates, to ensure that they can all benefit from them. Training on issues of ‘Equality and Diversity’ should be provided to staff. Consideration should be given to the recruitment of male care staff for the benefit of people who use the service. 2 3 OP30 OP29 Egerton House Residential Home DS0000056460.V349791.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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