Inspection on 14/08/06 for Esther House

This inspection was carried out on 14th August 2006.

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

Esther House 21/11/07

Esther House 01/11/05

Esther House 28/06/05

Esther House 14/12/04

Esther House 30/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Esther House 34 Mauldeth Road Heaton Mersey Stockport Cheshire SK4 3ND Lead Inspector Kath Oldham Unannounced Inspection 14th August 2006 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 Esther House DS0000008554.V306856.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. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Esther House Address 34 Mauldeth Road Heaton Mersey Stockport Cheshire SK4 3ND 0161-432 0826 0161 947 9439 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) Mr. Paul James Kelly Cheryl Owen Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 15 service users to include: *up to 15 service users in the category of OP (Old age not falling within any other category). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The manager must obtain NVQ 4 in Management and Care by December 2006. 1st November 2005 Date of last inspection Brief Description of the Service: Esther House is a small home situated in the Heaton Mersey area of Stockport, close to local shops and amenities. It is a large detached house set in its own grounds. Esther House is registered to take people whose primary need for care is due to old age. At any one time, a minority of service users may suffer from short-term memory loss. The majority of service users have care needs which are relatively uncomplicated, i.e., help with washing, dressing/ undressing, assistance with toilet, administration of medication, acquisition of medical treatment, as and when necessary. A member of staff is employed to co-ordinate an activities programme for service users. Eight bedrooms have en-suite toilets. The home has a statement of purpose and service user guide which were reported to be given to prospective service users or their families when they visit the home to look round. The fees for staying at the home were reported to be between £328 and £339. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection which included a site visit undertaken on 24th August 2006, commencing shortly after 8:00am. The manager is registered with the Commission for Social Care Inspection and was present during the inspection. Time was spent talking to the manager, residents and staff and observing routines within the home. The visit was used to monitor the requirements and recommendations of past inspections, examine records and to spend time in conversation with service users. Comment cards were given out for service users, relatives, visitors and staff. Comments received on the inspection and in comment cards are contained within this report. The case files of three service users were looked at in detail, looking at their experiences in the home from their time of admission to the present day. Lunch was taken at the home with service users and a partial inspection of the premises was undertaken. The inspector spoke with service users and several members of staff who were on duty. Verbal feedback of the findings from the inspection was given to the manager at the end of the inspection. What the service does well: The home encourages and promotes service users’ abilities and preferences, ensuring that their individual needs and aspirations are achievable. About four or five of the service users continue with their knitting which is sent to children in need. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 6 One of the service users spends time in the garden tending the flowers and plants. A further service user goes to the local shops to purchase specific food which she likes to eat, which is used by her at the home. The service user said staff would go to the shop for her but she preferred to go herself, as she had always been independent. Two service users go for a short walk most days with one service user helping the other. When they get up each day, a service user takes time and attention in tidying the chairs in the lounge, making sure the cushions are plumped up in readiness for other service users coming down. Service users said they enjoyed their routines and helping out where they can which gives them a feeling of self-worth. A service user sets the tables each day and wipes down the mats after meals. A number of service users enjoy watching television and chatting with others. Staff said whatever anyone wants to do, they will help in any way they can. Service users get up when they want; a couple have breakfast in their bedroom, others go to the dining room. One service user said whatever time you get up, breakfast is only a minute away. Service users said they get up when they are ready, some staying in bed a little longer some mornings. The manager said service users have their own routines in the morning and come down for breakfast at different times to suit themselves. Choices are available at breakfast, most choosing to have cereal and toast with just two service users having a hot breakfast at the moment. One service user said they don’t like to have too much to eat in the morning and look forward to their lunch. Service users said they live as they wish, there’s always something to do if you fancy or you can sit and do nothing if that’s what you want. What has improved since the last inspection? The acting manager has been proposed to CSCI for registration and this has been confirmed. The manager has obtained NVQ level 4 in management and is currently making enquiries about obtaining the Registered Manager’s award. This will further enhance her skills as a manager of a care home. Funding has been secured for additional staff to study towards obtaining NVQ level 2 qualifications. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 7 Two senior staff have left in recent months and a member of the staff team is working towards becoming a member of the senior team. The staff member is hoping to do the NVQ level 3 qualification in forthcoming months. A residents’ meeting had taken place and service users felt empowered to discuss developments in the home. They said they didn’t want a meeting every week but once every couple of months would suit them. This is to be arranged by the manager. A number of the requirements issued on the last inspection, in relation to medication, have been complied with in full; others need attention in a timely manner. 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. Esther House DS0000008554.V306856.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 Esther House DS0000008554.V306856.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Standard 6 was not applicable Quality in this outcome area is good. Service users’ needs are assessed before they move into the home. The home can confirm they can meet the needs of the service user on admission. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The service user guide and statement of purpose are provided to service users and visitors. The terms and conditions of residency need to be developed to ensure service users are aware of the conditions of their stay. Three care files were seen; two of which were for the most recently admitted service users and one service user who had been at the home for a number of years. Each file had a community care assessment, which detailed clearly the specific care needs of the resident. This was supported by the home’s own assessment. The manager said she did go out and assess prospective new service users before admission to the home. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 10 The manager has ensured that staff training is a priority. New staff receive induction training. Mandatory training has been provided to most staff and NVQ training is established. Esther House DS0000008554.V306856.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. Service users felt well looked after, with staff supportive of their wishes. In the main, medication records were satisfactory, although more rigour with record keeping will keep service user safe. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Care planning documentation was seen. Two of the three files seen had detailed care plans. Discussion with care staff identified that staff were providing individualised care to the service users but the level of support provided was not reflected in all the care plans seen. Records were available of the community health and medical services used by the home for service users. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 12 Service users said staff were very efficient and able at meeting their health needs through ensuring that routine and specialist health input was arranged or following the instruction provided by health care professionals. Staff said, “Service users always come first”. One service user said, “if they think anything is wrong, they will do anything to get you right again”. Service users’ weights are recorded to ensure they are not losing weight. Staff stated how they promote residents’ privacy and dignity when carrying out personal care and when speaking about personal matters. Staff practice was observed and staff when undertaking personal care tasks took time discreetly. Good relationships appear to have been formed; laughter and conversation were in evidence. Service users said they felt “well looked after”. Examination of the medication administration records identified that where a variable dose of medication was prescribed, the actual dose administered was not always recorded. The home is therefore not maintaining accurate records of medication administration. Medication administration details had, on occasions, been handwritten which had not been signed or dated or validated by an additional member of staff. This should be carried out to ensure the detail has been transcribed accurately and service users get the medication they are prescribed. Examination of medication records identified a number of duplicate dispensing labels, which were attached to the medication records. This must not be continued as labels may be placed over previously printed directions, thus obliterating the record of the medicine or they may be removed at a later date. Appropriate risk assessments had not been completed for service users who self-administer medication. The containers of eye drops or eye ointment had not been labelled with the date of opening. This medication has a limited shelf life and needs to indicate the date of opening to safeguard service users. Staff who have received basic training in the handling and administration of medication give out medication. This training had been updated recently. Not all staff had undertaken this essential training. The training is not followed-up with a formal assessment of carer competency. The manager stated that she is currently looking for someone to undertake this training. Esther House DS0000008554.V306856.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. Service users live in a home with flexible routines, providing an interesting lifestyle that promotes social, spiritual and physical development. Meals and mealtimes in the home are varied and wholesome, ensuring that service users enjoy their meals and are well nourished. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home employs an activities co-ordinator who works three days each week. Care files seen contained little reference to the social aspects of the service. Discussion with the manager identified that she was aware of this area of development and she is to update this aspect of the care plan from the information they have obtained from service users and relatives. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 14 Staff were polite and supportive to service users and they responded positively to staff. Routines in the home enabled service users to make some choices, such as rest and retiring times. Service users said they could do what they wanted when they wanted. Visitors said they had peace of mind that their cared for relative was well looked after. Service users said that their visitors come when they want Other activities take place at the home, which include darts, quizzes, bingo, craft sessions and manicures. Service users said they chose what they want to do and that they watch specific television programmes. A recent residents’ meeting reported that service users said they were happy with a few days of organised activities, as on other days they can continue with their knitting, do colouring and painting and chat amongst themselves. Service users commented on the recent entertainer who came to the home and reminisced about a barge trip some of the service users went on. Staff stated that they are encouraged to support service users to go out individually. A number of service users visit church weekly and attend meetings outside the home. Menus seen offered a variety of meals, which included a cooked breakfast, traditional meals, lighter meals and a variety of desserts and puddings. Lunch was taken with service users. The meal was tasty and nutritious. Meals were served in a pleasant and comfortable dining room. Hot and cold drinks and snacks, such as biscuits and fruit, were offered to service users throughout the day. Service users commented that, “the food was good, you get plenty to eat and if you don’t fancy something, the cook will make something else for you”. Staff were observed supporting service user who required assistance with meals in a caring, patient and dignified manner. The meal was a social occasion with the service users chatting to one another and with staff. Several service users commented on their enjoyment of the meal and thanked the staff. Esther House DS0000008554.V306856.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home’s complaints procedure is comprehensive and detailed, informing all concerned of how a complaint could be made and the expected response. Service users said all staff were very approachable any issues were dealt with quickly. One service user said, “you just have to tell them and they sort it”. Examination of the complaints record identified comments and complaints and the outcome of the investigation. The manager said she encourages comments from service users, relatives and staff that help to improve the service provided at the home. Staff said “we have a good team and range of services and also a good complaints, comments and compliments book where everybody’s, service users and staff, views, opinions and ideas are taken into account”. The recent introduction of residents’ meetings also provides service users with an opportunity to comment on the service they receive and may identify any concerns or areas of improvement that can be dealt with right away. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 16 Protection of vulnerable adults training has been arranged through Stockport Social Services for some staff. It is understood that all carers who have achieved the National Vocational Qualification (NVQ) at level 2 have also received training in abuse awareness. The remaining staff need to attend this training so that they are aware of what constitutes abuse and how to identify any signs of potential abuse. Esther House DS0000008554.V306856.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. Esther House provides service users with a warm, comfortable, homely and clean place to live. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: On entering the building the atmosphere was warm, comfortable and free from unpleasant odours. A service user invited the inspector into their room. The room had been personalised and the service user was very proud of it. The service user said they had enjoyed putting the room together and introducing all their ornaments and furnishings. Staff described the room as “a little palace”. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 18 The gardens were accessible and well maintained, allowing easy access for service users. One service user tends the garden and has planted shrubs and plants. The garden is to receive additional attention to improve its appearance. Two service users were sat outside, one service user said they only need to see a bit of sun and they sit out. There is ramped access to the home and gardens, so service users are able to independently leave the house if safe to do so. One service user said staff have told her to let them know if she wants some help to get about the house and that they ask her periodically. There are two lounges and a dining room. The smaller of the two lounges is used for service users who want “to have some peace and quiet”. Some visitors spend time in this lounge with their cared for service user. The seating and flooring in the lounges was clean and free from stains and odours. The home was very clean and tidy. Service users said it was always this way. The dining room tables were set with crockery; tablecloths and flowers, which provide a welcoming feel to the room. One of the service users routinely wipes the tablemats after each meal and sets the tables. A further service user tidies the lounge chairs in the morning when they get up and sprays round each morning. The service user said it kept them busy and is just what they used to do at home. Examination of records identified that electrical and gas service checks were carried out to maintain the equipment in the home safely. Esther House DS0000008554.V306856.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. The home employs staff in numbers to meet the assessed needs of service users. Staff were well informed and clear about their responsibilities concerning all aspects of working in a residential home. The procedures for the recruitment and training of staff provide protection to service users. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: This is a stable workforce, which provides service users with continuity of care. Observation of staff identified them to be attentive and responded to service users in a respectful manner. Two care staff and the manager were on duty, supporting 15 service users; a part-time cook was also on duty. Staff said, “Esther House is a well maintained and pleasant place to work and staff are all well settled”. The staff rota also indicated that there were experienced care staff on duty in sufficient numbers during the morning and other busy times. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 20 Certification confirmed that some staff have completed National Vocational Qualification (NVQ) level 2 award in care. The manager is actively involved with the training consortium as a means of accessing up-to-date and relevant courses for staff. Staff who cook at the home have all completed intermediate food hygiene training, other staff have the basic food hygiene training. Examination of a sample of staff files identified that staff had completed a job application form and Criminal Record Bureau checks had been undertaken. Two written references were also on file. The two most recently appointed staff had commenced induction training inhouse. The manager said she is to further research external training in this area. The two most recently appointed staff have not received moving and handling training. This must be arranged to safeguard service users and staff. Three staff have been successful in obtaining NVQ level 2 training and two staff are awaiting a start date. A further member of staff is to commence NVQ level 3. Esther House DS0000008554.V306856.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. The home is well managed and is run in the best interests of service users. Health and safety is taken seriously and whilst there are some shortfalls, overall, the home provides a safe place for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the manager has obtained NVQ level 4 qualifications and is to apply for the Registered Manager’s award. One staff member said “the manager is an excellent manager who takes everybody’s needs into consideration”. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 22 Staff meetings are arranged at the home, the most recent being in July 2005. Notes are made of the meetings, which provide staff with an opportunity to discuss areas of development within the home and to influence practice and routines. Currently, the meeting is predominantly used for management to tell staff what should and shouldn’t be done. A record is maintained of any accidents, incidents or occurrences experienced by service users. Examination of the accident records identified their completion in line with Data Protection legislation. The home does not carry out an audit of accidents, which would identify any patterns to the accidents experienced by service users. Fire safety records identified the means of escape and emergency lighting to be recorded as having been checked regularly to safeguard service users and staff. The fire alarm checks were not recorded as having been undertaken since June 2006. Fire drill training and practice records did not detail all staff as having received training in the previous six months. Of 15 staff, four were identified as needing this training. This needs to be addressed by the home to ensure that all staff are aware of what to do in an emergency situation A service user meeting had been arranged and the majority of service users attended and contributed to the meeting sharing their views and opinions. At the request of service users, these will be held regularly. A record is made of the maintenance jobs within the home. Staff detail all jobs that need attention and when the job is completed, it is signed as such. The home appeared well maintained and records supported that equipment was regularly serviced. The owners visit the home regularly and spend time in conversation with service users to see if the care that they receive is what they need. The reports of these visits are kept. The regulations indicate that CSCI must be notified of any events affecting the health and welfare of service users. These events are defined within the regulations and standards. One service user has been treated for a pressure sore. This fact was not notified to CSCI as required. Formal supervision was not being provided for all staff. This should be developed, as it would assist in staff’s individual development and inform the manager of their training needs. Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 23 Procedures for handling money for service users were satisfactory. Service users said staff purchased toiletries and such like on their behalf and obtained receipts. Esther House DS0000008554.V306856.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 3 2 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 2 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure that all service users have an up to date individual care plan that includes all areas of care and support. The registered person must ensure that if the prescriber amends the dosage of medication, the current record is discontinued and a new record is commenced. (Timescale of 7/11/05 not met). The registered person must ensure that residents who wish to manage their own medication are assessed as to their ability to do so, before medication is provided to them. Assessments must then be repeated on a regular basis. (Timescale of 5/12/05 not met). The registered person must arrange for all staff to attend adult protection training. Timescale for action 31/10/06 2 OP9 13(2) 17(1) 25/09/06 3 OP9 13(2) 13(4)(c) 25/09/06 4 OP18 13 31/10/06 Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 26 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. 5 Standard OP30 Regulation 13(5) Requirement The registered person must ensure that all staff receive updates to the moving and handling training annually. (Timescale of 28/06/06 not met). The registered person must ensure that the checks to the fire alarm system are carried out as prescribed by the fire authority and these checks are recorded in the fire safety records. The registered person must ensure that all staff receive fire drill training and practice at a minimum of twice yearly. (Timescale of 28/06/05 not met). The registered person must arrange for a report of the visits to the home to be forwarded to CSCI monthly. The registered person must ensure that CSCI are routinely notified of events that affect the health and safety of service users. Timescale for action 31/10/06 6 OP38 23 23/08/06 7 OP38 23(4) 30/09/06 8 OP38 26 30/09/06 9 OP38 37 30/09/06 Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 27 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 OP2 Good Practice Recommendations The registered person should amend the present contract to contain information regarding which room is to be occupied and charges applicable should a service user be admitted to hospital. The registered person should ensure that on occasions where a variable dose of medication is prescribed, for example, one or two tablets to be taken, an accurate record is made of the actual dosage of each medication administered. The registered person should ensure that handwritten medication details on the medication administration records are signed and dated and the details are validated by an additional member of staff. The registered person should ensure that duplicate labels are not requested from the supplying pharmacy for the purpose of affixing to the medication administration record chart. The registered person should liaise with the supplying pharmacist to ensure that all medication received by the home is labelled on both the inner container and the outer box. The registered person should ensure that all eye drops and eye ointments are labelled with the date of opening of the container, and discarded 28 days after this date. The registered person should ensure that all carers with responsibility for medication administration receive appropriate updated training and that their competence is assessed regularly on a formal basis. The registered person should enable the staff to bring items to staff meetings to assist in the development of the home and the care and services provided. 2 OP9 3 OP9 4 OP9 5 OP9 6 7 OP9 OP9 8 OP27 Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 9 Refer to Standard OP24 Good Practice Recommendations The registered person should provide, in all service users bedrooms, lockable storage space for medication, money and valuables and provide a key, which can be retained by the service user. (This recommendation was not assessed at this inspection). The registered person should produce a staff training and development programme. The registered person should arrange for fifty per cent of staff to sign up to obtain NVQ 2 qualifications. The registered person should arrange for all staff to receive development supervision at a minimum of six times each year and these sessions are recorded. 10 11 12 OP30 OP30 OP36 Esther House DS0000008554.V306856.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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. 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