CARE HOMES FOR OLDER PEOPLE
Falcon House Care Home 2 Middle Street Beeston Nottingham NG9 1FX Lead Inspector
Chris Wroe Unannounced Inspection 13th November 2007 9:50 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 Falcon House Care Home DS0000008673.V354123.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. Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Falcon House Care Home Address 2 Middle Street Beeston Nottingham NG9 1FX 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) 0115 922 8151 0115 922 3759 Minster Care Management Limited Mrs Jacqueline Gamble Care Home 40 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40) of places Falcon House Care Home DS0000008673.V354123.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 - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is 40. 22nd May 2006 2. Date of last inspection Brief Description of the Service: Falcon house is a purpose-built modern home providing accommodation for up to 40 people. The care home provides personal care for people who have needs due to older age and/or dementia. There are bedrooms, bathrooms, lounges and dining rooms on ground and first floor levels. The first floor can be accessed via a shaft lift or stairs. There are four shared bedrooms; all the remainder are single rooms. Individual and shared bedrooms have ensuite toilets. The home is in the centre of Beeston near to local shops and amenities. There is a car park to the rear of the home. Bus routes operate along the road outside the home. The range of fees are from £290.00 to £344.00 for local authority funded residents and £450.00 to £475.00 per week for privately funded residents. Charges vary according to the levels of dependency of residents. Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection included a visit to the service. The inspector visited the home on 13th November 2007, together with one of our ‘Experts by Experience’ – a person with particular firsthand knowledge of the needs of older people, who assists us in inspections. The registered manager, Jacqueline Gamble, and staff helped us during the visit. The visit started at 9.50am and lasted for eight hours. We spoke with a number of residents and relatives during the inspection, and their views are given in the report. During our visit we gave some comment cards to residents, relatives and staff and asked for them to send us their views about the home. The main method of inspection used was ‘case tracking’. This means looking at the care given to service users in different ways. The ways this was done are: • talking to the service users • talking to staff and the manager • watching how service users are given support • looking at written records. We also looked at the provider (owner’s) own assessment of the services they provide, which they sent to us. All the residents who spoke to us were happy about the care given by staff. They felt they were well looked after. They felt the home was comfortable. Some people felt they would like a little more to do. All the key standards were checked during this inspection. The information below is based only on those aspects checked in this inspection. Details about individual people have been kept out of the report, to make sure it is kept confidential. What the service does well:
Written information about the home is detailed and gives a good picture to potential residents. The manager carries out an assessment for people who wish to move into the home, and residents may come for a trial period to see if they are happy with the home. Staff keep care records for all residents, detailing their needs, so that staff can give them the right support. These include risk assessments so that people can be kept as safe as possible. Attention is paid to health care needs, and trained staff give out medication, with policies and safe working practices in place.
Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 6 Staff offer a range of daily and weekly activities to residents, like bingo, quizzes, and skittles. Bigger events are sometimes organised, and lounges are set out to enable residents to mix with each other or to have quieter time alone if they prefer. Staff present meals well and in a welcoming environment, where residents are not rushed. Residents told us that they enjoy their meals in the home. The manager ensures that complaints are investigated promptly and action is taken to make any necessary changes. Staff receive training to ensure they are aware of keeping residents safe from harm. The home is generally clean, tidy and well-maintained. Residents may have their own possessions in their bedrooms. Laundry is carried out efficiently. Training is provided to staff in a range of areas, to ensure they are equipped to carry out their work. The manager carries out required checks on potential staff to ensure that they have the right attributes for the work and are safe to work with vulnerable people. A new registered manager is running the home. The manager is open to ideas and consults with residents and staff for their views on how the home is run. She ensures that safety checks are carried out in the home and that there are safe working practices. What has improved since the last inspection? What they could do better:
Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 7 Some of the information in the statement of purpose/service user guide is not completely clear, in relation to the amount of fees charged, and whether and when any top-up fee would have to be paid. The provider (owner) must make sure that information about fees is clear, so that residents/potential residents are able to make an informed choice about the home. There were some gaps in care plans relating to the specific needs of residents, for example in relation to dementia and challenging behaviour, and in relation to cultural and religious needs. Staff were not always carrying out the most appropriate care practices to meet these needs. The home must make sure that care plans have details about individual needs and how these should be met, and that staff meet the individual care needs of residents. There are some ways in which administration of medication did not comply with the home’s policy, and could lead to potential risks to residents’ safety. The provider must ensure that safe practices are in place for giving out medication. There were some inconsistencies in the way staff managed challenging behaviours, and the provider must make sure that staff are properly trained and support people who have dementia sensitively. Some residents said that they would still like more activities, and would like to go out more, so it would be good if the manager could make sure that time is spent with each individual to work out what they would like, and how the staff might be able to meet their needs/choices. Some of the flooring in parts of the home is worn and it would be good if it was replaced, so that it does not cause a hazard to residents. One member of staff working in the home did not have the correct Criminal Records Bureau check. The provider must make sure that no one is employed in the home without relevant clearance from the Criminal Records Bureau. 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. Falcon House Care Home DS0000008673.V354123.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 Falcon House Care Home DS0000008673.V354123.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, 2, 3 (6 not applicable at this time) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a mainly good admissions process to the home. EVIDENCE: We saw the home’s Statement of Purpose, which gives information about the home and staff. We also saw information that the manager gives to people who want to come and live in the home. There is good information for people about the process of moving into the home, including details of trial periods of stay, to see whether the home is right for them. This information is kept in the foyer of the home, available to residents and visitors to read. The manager has tried to make written information more accessible for residents, by using pictures to help orientate them. Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 10 We saw written assessments, which had been recorded when people came to live in the home. The manager carries out assessments for people who might like to come and live in the home, to find out about their care needs and whether the staff will be able to support them. The manager tries to get a picture of people’s lives before they come into the home, and to convey that the home is welcoming to people from a range of backgrounds/lifestyles. We saw training records and talked to staff. Staff have training to enable them to meet the needs of people living in the home, such as dementia training and training in moving and handling so they can safely assist people with reduced mobility.. We saw that signed terms and conditions were in place for residents. The written information for residents gives detail about the range of fees charged. It states that a £10 top-up fee may be charged. The manager says that this is at the discretion of the owner and is not often charged. This information, and the criteria for charges should be clearer for people who may come in to live in the home and relatives. Falcon House Care Home DS0000008673.V354123.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, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit to an extent from having their health and personal care needs looked after, but there are some issues, which could lead to gaps in proper care for residents. EVIDENCE: We saw a sample of care records for those people whose care we were tracking. Staff write care plans about people who live in the home, which give information about their needs. Staff review these to make sure they are kept up to date. One member of staff we spoke to showed a good understanding of the different needs of people who live in the home. We spoke to ten residents who told us that they felt very well cared for. Two relatives we spoke to also said that they felt the staff cared for residents very well. The manager is developing ‘person-centred care plans’ for residents, which give more detail about their individual lifestyle and choices.
Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 12 All residents we spoke said they felt they were treated with respect by the staff. They were happy with their bathing arrangements and felt well supported with their hygiene. We had some concerns about the care we observed being given to one resident who has dementia. Their care plan did not include all their needs, nor how the staff should best support them. In particular, there were some issues about how the staff managed some behaviours the person was displaying (due to their dementia). While most staff have had some training in dementia, and in managing challenging behaviour, not all staff handled this individual’s behaviour with full sensitivity and understanding. The care plans and risk assessments did not give full enough details to make sure that all staff could be aware of the person’s needs, and to ensure a consistently supportive approach. We saw that the intentions and attitudes of staff were caring, but that some more training and awareness about how to deal with some of the more difficult aspects of dementia should be put in place, to protect residents and staff. We found that care records did not in all cases give enough detail about the cultural needs of residents, and how staff could support people to meet their needs. This meant that the care staff gave was not always completely appropriate. Care plans contain details about risks to residents, to make sure that staff keep residents safe in the home. In some cases, these tie in with the care plans to tell staff how to make sure people are well supported, for example how to help people to move around the home safely. We saw that for some residents, there could be more detail in risk assessments, such as the risks relating to mobility or to personal care, when someone had dementia and is showing challenging behaviour, or the risks relating to mobility in relation to restricted vision and how someone can be best supported. We found that the manager had signed some risk assessments/authorisations on behalf of residents in some cases – to protect everyone involved it would be better to get someone independent to sign/countersign, like a relative, advocate or social worker. We looked at other records in the home, which the manager and staff keep to make sure they keep residents safe, like daily records about how residents are, and records of accidents. The manager monitors accidents/falls, but at this time does not have links with the health authority falls co-ordinator about work that can be done to prevent falls. Residents who spoke with us on the day of our visit said that they felt well looked after regarding their health and medication. Staff who give out medication in the home, have had training in safe handling of medicines. There is a medication policy in the home to tell staff how to give out medicines
Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 13 safely. We checked a sample of medication records and stocks, and observed how medication was given out. Members of staff were careful in how they gave out medicines, and made sure the cabinet was locked when they left it. We saw staff training in progress, as one senior member of staff supported a carer in learning how to give out medication properly. We did see that there were some issues in how medication was administered, which could create some risks: • One member of staff signed for medication before giving it out and watching the person take the medication. This could potentially lead to the risk that the medicine was not taken but had been recorded wrongly. • One person did not wish to take their medication until after lunch – they then left it on the table, unobserved, leaving open the risk it could have been taken by another person without the staff noticing. • Staff had written extra labels on medication to make them more noticeable and easier to handle – whilst this seems helpful and was done with the right intention, it can lead to risk of mislabelling. • Medication records showed that for two people, they had missed a number of doses of medication over several evenings, because they had been asleep. These were medicines, which the GP had prescribed to be taken at regular times on a daily basis. Not taking the medication could therefore be potentially risky to those residents. The manager and staff had not checked with the GP as to the safety of each person missing medication or what action they should take. (The staff made efforts to correct this during the inspection). Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are mostly enabled to have a good lifestyle in the home, although there are some aspects, which could be improved to enable full participation. EVIDENCE: We saw information in the home about different activities that are available for residents to take part in, which the manager has put into picture format to make them more accessible, since some people experience confusion and memory loss. The manager told us about different daily and weekly activities, such as bingo and quizzes, choir singers coming into the home and people who help residents do music and movement activities. The home recently held a bonfire event. Some residents told us that they would like more to do, and would like to go out of the home into the local neighbourhood a little more (there is no garden in the home, just a small central courtyard). During the morning, we did observe a lot of residents sitting for long periods of time, some sleeping. In the afternoon, staff played skittles with residents, which
Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 15 was an enjoyable social event for some. A number of residents chat with each other, but some spend more time on their own. There are several lounges in the home, and so there is sufficient space in the home for people to gather together or to have quieter time, and people are able to spend time in their bedrooms, which they are able to furnish with their own possessions. Chairs are comfortably set out in groups so that people may watch out of the window, or watch the television, or choose not to. One member of staff told us that they do more activities in the afternoon with groups of residents and spend more time individually in the evenings. The manager has put some photos in the home of old Nottingham for residents to look at and to use for reminiscence. The manager told us that a vicar used to come in to the home but no longer does so. She would like to set up a similar arrangement again. At present, no one goes out to church and there are no services in the home, although the manager said that there are some people who have religious beliefs. The clients’ guide to the home says that someone comes in to lead religious worship – so this is not consistent at the moment with what actually happens. The manager said that she has introduced more activities in the home after consulting with residents, and that they do intend to look at how to give more opportunities for activities. We saw that relatives and other visitors were made welcome in the home. Relatives who spoke to us said that they felt happy with the care the residents were receiving. Residents eat meals in one of two dining rooms – one of which is on the ground floor and one on the first floor. We saw that meals were well presented, and that residents had choice. Mealtimes were calm and unhurried. People who spoke to us told us they enjoyed the meals in the home. We saw that care plans contain details of individual dietary needs. Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by procedures regarding complaints and safeguarding from harm. EVIDENCE: We saw complaints records in the home and spoke with the manager about complaints. There is a complaints procedure and when complaints are received they are looked into promptly. We have received three complaints at the Commission for Social Care Inspection in the eighteen months since the last inspection. These were passed to the home for the manager/owner to look into. We saw from records that the manager has taken action to make changes and improvements where complaints have shown these were needed. People who live in the home told us that they feel able to raise any concerns they have with staff, and feel they will be listened to. We saw staff records and spoke with staff about training. Staff have received training relating to safeguarding residents from harm or abuse. By law, the home should report all serious incidents affecting the health or well-being of residents to the Commission for Social Care Inspection, so that we can
Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 17 maintain an overview - the manager has made sure that we have been kept informed. Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a mainly comfortable, clean and well-maintained living environment. EVIDENCE: During the visit, we looked around at some parts of the home. We looked at a sample of bedrooms, bathrooms and toilets, and lounges/dining rooms. We found all areas were clean and tidy and generally well-maintained. Residents are able to have their own possessions in their bedrooms. Residents told us that they felt comfortable in the home and had what they needed in their own bedrooms. There are some shared bedrooms in the home – the manager told us that some residents would prefer to have their own bedrooms,
Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 19 and the owner is looking at ways to enable all residents to have single bedrooms in the future if they want to. The manager makes sure that safety precautions and checks are carried out in the home. There is a fire risk assessment in place in the home, to make sure residents are kept as safe as possible from any risk of fire. There are systems in place for making sure laundry is done efficiently. There are industrial washing machines and dryers in the home, which are suitable for purpose. Staff are employed to carry out washing and ironing for residents. There have been some improvements carried out to the home: a number of areas have been re-decorated. Toilet and bathroom doors have been painted in one colour to enable residents, who may have confusion, to orientate themselves. Pictures and symbols have been put up in the home. The lounge/dining areas are bright and airy. There is a hairdressing salon in the home. Corridors are clear and bright. When a maintenance issue was identified by a member of staff during the inspection, it was repaired speedily and without delay. Areas of the home were cleaned throughout the day. We did note that some of the linoleum flooring in the en suite toilets and in the hairdressing room is very worn and in some cases stained. This means that it is harder to get fully clean and can retain odours. This could create some potential risk for contamination. Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the home having a trained staff team in place and mostly safe and positive recruitment processes, although a gap in checking and supervision could create a potential risk for residents. EVIDENCE: We saw that the numbers of staff on duty on the day of inspection was consistent with the staff rota. The manager said that five members of staff generally work during the day, although she is hoping to increase that to six, to enable the home to fully meet the needs of residents. Staff accompany people for hospital appointments and similar visits when needed. We saw records of training and recruitment. Staff have ongoing training in relevant aspects to help them to work well. Areas of training include moving and handling, first aid, dementia training, infection control. Staff who spoke to us confirmed that they feel supported in their work. As we discussed under section 2, there are some issues about how dementia/challenging behaviour training is put into practice, which the manager needs to address.
Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 21 The manager mostly makes sure that recruitment practices are safe and that relevant checks are carried out on people who wish to work in the home, including collecting references and making Criminal Record Bureau (CRB) checks - although we noted that for one member of staff, proper arrangements for supervised working were not in place before the manager received clearance from the CRB. Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a well managed home. EVIDENCE: Since the last inspection, a new registered manager has come to work in the home. The manager has completed the Registered Managers Award. We saw that the manager welcomed relatives to talk with her if they wished to. Staff said they felt the manager to be supportive. There are different ways in which the manager tries to get people’s views about how the home is run. Residents fill in surveys about their views of the home, and the manager prepares a report of the results. Residents’ meetings are held regularly. The manager also sends questionnaires to relatives and
Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 23 professionals to get their views about the home. We saw a comments book in the home, in which some relatives had written some positive comments. Staff meetings are held regularly to make sure that staff are aware of working practices and procedures, and to get their views. Staff told us they felt able to contribute their ideas. Relatives or other advocates mainly handle the financial affairs of residents. There are facilities for residents to keep money safely in the home. The manager invoices residents or their families or advocates regarding charges for chiropody, hairdressing and similar. Staff have training in safety aspects, such as infection control and first aid. There are procedures in the home to make sure that staff work safely. Safety checks of equipment are regularly carried out. Falcon House Care Home DS0000008673.V354123.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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 3 X 3 X X 3 Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP2 Regulation 5(1)(b) Requirement The provider must ensure that information about the amount and range of fees charged to residents is clear and detailed. The provider must ensure that the service user plan (care plan) prepared for each resident describes how that particular person’s needs in respect of their health and welfare shall be met (in particular in relation to dementia and in relation to cultural issues). The provider must ensure that measures are put in place to identify and prevent any risks to residents, in particular in relation to dementia and related behaviours. The provider must ensure that safe practices are in place for administration of medication, in particular that: • Care staff work in accordance with the medication policy and best practice The provider must ensure that safe practices are in place for
DS0000008673.V354123.R01.S.doc Timescale for action 31/12/07 2. OP7 15(1) 31/12/07 3. OP7 13(4)(c) 31/12/07 4. OP9 13(2) 31/12/07 5. OP9 13(2) 31/12/07 Falcon House Care Home Version 5.2 Page 26 6. OP9 13(2) 7. OP10 13(6) 8. 9. OP12 OP29 12(4)(b) 19(1)(b) administration of medication, in particular that: • Care staff observe people who use the service taking medication before they sign administration records. The provider must ensure that safe practices are in place for administration of medication, in particular that: • Care staff take appropriate action following missed doses of medication, to ensure that residents’ health is maintained. The provider must ensure that all staff receive consistent training and direction to enable them to properly support people who have dementia and protect them from harm. The provider must ensure that the religious and cultural needs of residents are met. The provider must not employ anyone to work in the care home without relevant clearance from the Criminal Records Bureau. 31/12/07 31/01/08 31/01/08 31/12/07 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 It is recommended that the provider considers further with each resident individually what sort of activities they may wish to take part in, including outings outside the home, and how staff may be able to meet these wishes. It is recommended that, as part of the ongoing maintenance plans, the flooring in en suite bathrooms and
DS0000008673.V354123.R01.S.doc Version 5.2 Page 27 2. OP19 Falcon House Care Home other areas where there are stains is replaced, to ensure the ongoing health and safety of residents. Falcon House Care Home DS0000008673.V354123.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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
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