Inspection on 24/05/06 for Farriess Court

This inspection was carried out on 24th May 2006.

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

Farriess Court 02/09/08

Farriess Court 09/04/08

Farriess Court 23/05/07

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

CARE HOMES FOR OLDER PEOPLE Alvaston Manor Alvaston Manor 103 Boulton Lane Alvaston Derby Derbyshire DE24 0FF Lead Inspector Steve Smith Key Unannounced Inspection 24th May 2006 09:30 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 Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 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. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alvaston Manor Address Alvaston Manor 103 Boulton Lane Alvaston Derby Derbyshire DE24 0FF 01332 755555 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 Allen William Heath Susan Mary O`Kelly Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Provider must ensure that the Requirements set out in the site visit report dated 5 January 2006 are met within the timescales laid down. Date of last inspection Brief Description of the Service: Alvaston Manor Residential Care Home provides care for up to 26 Older People. The Home is situated within its own grounds, and comprises of an older building, with ground floor and first floor facilities that retains many of its original features, and a more modern ground floor extension that provides 5 single bedrooms. The Home has a communal dining room and two main sitting rooms. Residents are permitted to smoke, but only in the conservatory area. The Home is positioned between the areas of Alvaston and Allenton, and has access to several GP surgeries. The centre of Alvaston is within walking distance, where a small range of shops can be found. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just under 7 hours. Discussion was held with the two Residents, the Registered Provider, the Manager and one member of staff. Some of the Home’s records were seen, and the public areas of the Home and all bedrooms were examined. The fees for staying within the Home range from £303.00 to £320.00 a week, depending on the size of room required by the Resident. What the service does well: What has improved since the last inspection? Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 6 This was the first formal inspection following the purchase of the Home by the current Registered Providers. At the point of the new Registered Providers taking over the Home they were required to addresses certain Regulations relating to the physical environment of the Home, and approximately 50 of these had been addressed. However, the Registered Providers found that much more was needed than had been required of them, and many of these additional issues have also been addressed. This was a very positive approach provided by the new Registered Providers, and it is to be hoped that the issues not as yet addressed will be addressed within the time schedules provided in this report. 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. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 3. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. The Registered Providers statement of purpose and Residents Guide were appropriately completed, although some additional information was required, and all new Residents moving to the Home were appropriately assessed prior to their admission to ensure that Residents needs were fully met. EVIDENCE: This is the first inspection undertaken at this Home since the new Registered Providers had purchased the Home. The Registered Providers and Manager had provided a statement of purpose for the Home together with a Residents Guide. Both these documents had been appropriately completed, and included details of how to contact the Commission, the local Social Services Dept and the local Health Authority. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 9 All Residents had been provided with copies of the statement of terms and conditions of residency in the Home or a contract if purchasing their care privately. However, this document did not include information to Residents on their liability if there were a breach of contract. When new Residents were admitted to the Home, the Manager was provided with a summary of needs of each person, completed by the Social Services Dept Care Manager supporting each Resident. If the Resident was self-funding from the outset, the Manager said she would complete her own summary of needs. An examination of Residents file supported this. Standard 6 does not apply to this Home. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. Residents’ health and personal care needs were being well met, as demonstrated within care plans. Medication was also appropriately distributed to meet Residents needs. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of three Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined, although one Resident’s file did not state the Resident’s preferred name, or provide the name of the designated keyworker. Copies of the initial assessment, completed by the Social Services Care Manager that placed each Resident at the Home, were available, and the Manager had completed her own initial assessment of Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 11 needs for each of the three Residents. There were also copies of good ongoing care plans and risk assessments available in each file examined. However, the Manager was not able to provide copies of the Home’s contract or statement of term and conditions of residency signed by the Resident or their representative. The Manager had provided written details of each Resident’s possible limitations of choice, freedom or decision making abilities. The files showed that records of events affecting each Resident were kept by the Home. The Residents’ files, however, had not been shown to each Resident, or their representative, on either a monthly basis or six monthly basis, when formal reviews of care were undertaken. All of the files contained a confidential section, were easy to read, and were well organised. They were also regularly reviewed by the Manager and were kept to maintain confidentiality. Within the daily record of events, in one file, the Manager had asked staff to encourage a Resident to walk using her new Zimmer, but staff had not subsequently commented on the success or otherwise of this. Staff of the Home were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents were examined, and a good record was found. Two Residents were spoken to about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being. ‘Oh yes, (staff) will do anything for me.’ During the inspection of January 2006 the new Registered Providers were required to install a telephone for the use of Residents, but as yet this had not been provided. The Manager said that she did not ask Residents, or their relatives about their funeral plans shortly after moving to the Home. However, this had been a Requirement under the previous Registered Providers ownership. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. Residents preferred lifestyles were respected by the Home. They were able to receive visitors and to exercise choice and control over their lives. Residents were given a wholesome and appealing diet in pleasant surroundings, although a choice was needed to meet Residents varied needs. EVIDENCE: Two Residents was asked about the activities provided in the Home. They said that they did not take part in the Home events, but one of them said that she did her own washing, with occasional assistance from the staff. The Manager said that an Activity Coordinator calls at the Home twice each week for approximately 2 hours on each occasion. Residents said that they felt very safe living in the Home - ‘Oh yes, very safe’. Staff respected their confidences and all their needs were met with dignity, respect and choice. Staff will ‘…do anything for me’. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 13 Residents said that they could go to bed and get up at times of their own choosing. ‘I can do whatever I want to do.’ ‘I make the bed myself’. They also said that they could choose or change their bath times. ‘I can bath when I want to.’ ‘Staff will always help me with baths’. Residents also said that meals were always good. A choice was provided at breakfast time, but there was ‘…no choice at dinnertime, but if I wanted something special they would give it to me.’ Again, no real choice was offered at teatimes, being offered sandwiches and cake daily, although soup could be asked for as an alternative. Both Residents said were aware of whom their keyworker was and spoke highly of them. Both Residents said that Residents could go shopping in the local shops if they wished to do so, although relatives usually took them. Lay ministers of religion visited the Home regularly to provide communion and other services. Relatives and friends of Residents were able to visit at any time, and could always be seen in private. Both Residents very confidently said that staff always knocked upon their bedroom doors and waited to be invited in. They also that this was a ‘nonsmoking’ home, although Residents could smoke in the hallway by the front door if they wished. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. Complaints made to the Registered Providers and Manager were appropriately addressed to meet Residents needs. The protection policies and procedures provided by the Home meant that Residents were well protected. EVIDENCE: Both Residents spoken to said that they would raise a complaint with the Manager if something troubled them. The Commission has not received any notice of complaint since the new Registered Providers took over the Home in January 2006. Good procedures and satisfactory records were maintained of both verbal and written complaints. They showed that the Manager maintained a good system for Residents complaints and that both written and verbal complaints were recorded. The Home’s record also detailed that all complaints would be responded to by the Registered Providers within at least 28 days. The Manager had an Adult Protection procedure that included a ‘Whistle Blowing’ policy. She also had copies of the Public Interest Disclosure Act of 1998 and the Dept of Health’s policy called ‘No Secrets’. She was able to confirm that she would follow up all allegations and incidents of abuse promptly and that all actions taken would be recorded. The policies and Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 15 practices laid down by the Manager ensured that all staff understood physical and verbal aggression by Residents. She also said that there was a policy available to staff stating that they could not benefit from Residents wills. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 16 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): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome group is ‘Adequate’. This judgement has been made using available evidence including a visit to the Home. Generally, the Home was adequately maintained throughout, however, significant improvements were needed to ensure all Residents lived in a wellprovided and maintained environment. EVIDENCE: A tour was made of the entire Home, including all of the bedrooms of the Residents. The Home and bedrooms were well laid out with good space provided for each Resident. Appropriate furniture was provided in the bedrooms. However, the following items needed attention: The armchairs provided for Residents in the lounges were plastic upholstered. These have a tendency to cause the Resident to perspire Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 17 when using them and it is recommended that covers be put over the chair to improve Residents comfort. In bedroom 1 a light and light shade was needed in the ensuite bathroom. This bathroom was also dirty and unpleasant, with a number of items abandoned within the bathroom. The toilet in bathroom 23 is very badly stained. The staff call lines in toilets need to be re-sited so that Residents could reach them. Currently, they hang behind the Resident using the toilet and so could not be reached. The bramble found to be growing at the foot of the fire escape staircase needed to be removed to safeguard Residents legs should the fire escape need to be used. The general area at the foot of the staircase also needed to be regularly checked to ensure a safe escape should the need arise. Currently only one bathroom is operational, three other bathrooms are unused. These bathrooms needed to be made operational to ensure that Residents are able to bath as close as possible to their bedrooms. This will also maintain the ‘Regulation’ number of bathrooms for the Home A hearing loop system should be provided in both lounges and the dining room to enable Residents with hearing aids to take part in all activities etc. In all single bedrooms two double electric sockets, and in all double bedrooms four double electric sockets, needed to be provided where necessary. When the new Registered Providers took over the Home, in January 2006, the following Requirements were set for them to address, but the following Requirements were found to be still outstanding at the time of this inspection: In the toilet by the dining room the toilet cistern was found to be still loosely attached to the wall. In bedroom 15 the dysfunctional medic-bath needed to be removed and a shower installed. In bedrooms 5, 9 and 10 the sash cords for the windows were broken and needed repair. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 18 All Residents’ bedroom doors needed to be fitted with locks that could be operated by the Resident from both the inside and outside of the bedroom. Keys also needed to be provided to all necessary staff. Hot water for baths and showers needed to be stored at 600 centigrade, distributed at 500 centigrade and to leave the taps at 430 centigrade or – 2 degrees. All radiators needed to be risk assessed to prevent Residents from being scalded or burned. Covers were needed in Residents bedrooms and bathrooms to achieve this. Radiator controls were also needed in some bedrooms to allow the Resident to vary the temperature of the bedroom. A washing machine needed to be provided that could provide a washing sequence of at least 650 centigrade for at least 10 minutes. However, due to other matters that needed attention within the Home this had not been addressed. It needs to be noted that the new Registered Providers found many other tasks that needed urgent attention, and as a result of tackling those tasks have not as yet been able to address those listed above. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 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): Standards 27, 28, 29 & 30. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. More than sufficient care staff were provided within the Home to meet Residents needs. However, the training needs of care staff had not been met to ensure Residents ongoing well being. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the three weeks beginning 1 May and the 15 and 22 May 2006 the Home was providing up to 10 hours of care a week more than the minimum amount required for 18 Residents at the Medium Dependency level. These figures were calculated without the Manager’s working time included, as recommended by the Residential Forum. The Home did not have 50 of care staff holding an NVQ level 2 in Care at the time of this inspection. This was supposed to have been achieved by December 2005. However, the Manager said that staff were currently undertaking training to achieve this before 31 December 2006. The Registered Providers and Manager had not employed any addition staffing since taking over the Home. It was therefore considered inappropriate to Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 20 review their recruitment practices. However, the expectations set by the Commission and by law were discussed. Staff training was examined. This showed that at least 3 days training was provided for all staff each year and that all staff also had an individual training and development assessment and profile. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 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): Standards 31, 33, 35 & 38. The quality in this outcome group is ‘Adequate’. This judgement has been made using available evidence including a visit to the Home. The Manager was appropriately qualified, although the Registered Providers needed to provide written verification of their regularly monthly ‘inspections’ of the Home. The Registered Providers and Manager had also nopt addressed the Quality Assurance issues to ensure Residents’ care was maintained at a positive standard. EVIDENCE: The Manager was fully qualified to be in charge of the Home. She said that one of the Registered Providers visited Home at least once a week. During his visits he apparently interviews both Residents and staff and discussed the operation of the Home with the Manager. However, no record was made of Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 22 these visits, even though this was required by the Regulations covering the Home. It was found that the Registered Providers and Manager had not addressed the requirements listed within Regulation 24 and Standard 33, the Quality Assurance issues. The Manager was able to show the personal money of at least two Residents, randomly selected, was maintained satisfactorily. The training provided for staff was examined. This showed that Moving and Handling training, Fire training and First Aid training had been provided to all relevant staff and was up to date. Food Hygiene training was required by 3 staff, and Infection Control training was required by 6 staff. The Registered Providers and Manager were also recommended to provide a qualified First Aider to be on duty on all shifts in the Home, both day and night. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Manager said that the Home did not have information on the Management of Health and Safety at Work Regulations of 1999, or the Workplace (Health, Safety and Welfare) Regulations of 1992 or the Provision and Use of Work Equipment Regulations of 1992. The Manager had provided risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff. She had also provided a written statement of the policy, organisation and arrangements for maintaining the safe working practices in the Home. The Manager ensured that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She had also ensured, with the assistance of the Fire Service that fire safety notices were posted in relevant places around the Home. Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 2 3 2 2 2 STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 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 OP2 Regulation 5 Requirement The Registered Providers must include in the statement of terms and conditions of residency/contract for living in the Home, information on the rights and obligations of the Residents and Registered Providers and who would be liable if there were a breach of contract. A separate telephone and telephone line must be provided for Residents to use in private. (This issue is outstanding from the inspection report of 5 January 2006) The Manager must ensure that all Residents are asked about their funeral plans within a short time of their entry into the Home. Timescale for action 31/07/06 2 OP10 16 31/08/06 3 OP11 12 19/07/06 4 OP15 16 A choice of at least two meals must be 19/07/06 provided at the main lunchtime meal of the day, and an alternative to sandwiches provided at all teatime meals. In bedroom 1 a light and light shade 19/07/06 must be provided within the ensuite bathroom; it must also be cleaned and DS0000065783.V288388.R01.S.doc Version 5.1 Page 25 5 OP19 23 Alvaston Manor tidied. 6 OP19 23 In bedroom 15 the dysfunctional medic-bath must be removed and a shower installed. (This issue is outstanding from the inspection report of 5 January 2006) In the toilet by the dining room the toilet cistern must be attached to the wall. (This issue is outstanding from the inspection report of 5 January 2006) The Registered Providers must repair the broken sash cords in the windows in bedrooms 5, 9 and 10. (This issue is outstanding from the inspection report of 5 January 2006) The toilet in bathroom 23 must be cleaned. The foot of the fire escape from the first floor must be kept clear of undergrowth at all time. The staff call lines in toilets need to be re-sited to ensure that Residents can reach them. (This issue is outstanding from the inspection report of 5 January 2006) All single bedrooms must be provided with at least two double electric sockets and all double bedrooms with four double electric sockets. All bedroom doors must be fitted with a lock that can be operated from both the inside and outside of the room by the Resident. Each Resident must be provided with a key to their bedroom. Risk assessments must be carried out, and recorded in the Resident’s file, where it is considered by the Registered Providers and Manager DS0000065783.V288388.R01.S.doc Version 5.1 30/09/06 7 OP19 23 19/07/06 8 OP19 23 19/07/06 9 10 OP19 OP19 23 23 19/07/06 19/07/06 11 OP22 23 19/07/06 12 OP24 16 31/12/06 13 OP24 12 30/09/06 Alvaston Manor Page 26 that the Resident is not able to hold the key to their bedroom. (This issue is outstanding from the inspection report of 5 January 2006) 14 OP25 13 Hot water for baths must be stored at 31/08/06 least at 600 C and distributed at 500 C. It must leave the taps at 430 C or 20 C. (This issue is outstanding from the inspection report of 5 January 2006) Radiators throughout the Home must be risk assessed and any necessary protective measures introduced to prevent Residents from being scalded or burned. Room radiator controls must also be provided on those radiators still needing this. (This issue is outstanding from the inspection report of 5 January 2006) 30/09/06 15 OP25 13 16 OP26 13 & 16 17 OP28 18 The Registered Providers must provide 31/10/06 a washing machine that can wash items at a minimum of 650 C for at least 10 minutes. (This issue is outstanding from the inspection report of 5 January 2006) The Registered Providers must ensure 31/12/06 that at least 50 of care staff are trained to NVQ level 2 in Care as soon as possible. The Registered Providers must provide 19/07/06 a written account of their formal ‘inspections’ of the Home, on a monthly basis, following the requirements laid down in Regulation 26 (4) & (5). The Registered Providers and Manager 31/08/06 must establish and maintain a system for reviewing and improving the quality of care provided in the Home. This must be done by ensuring that Standards 33.1 to 33.7 are addressed. DS0000065783.V288388.R01.S.doc Version 5.1 Page 27 18 OP31 26 19 OP33 24 Alvaston Manor (This issue is outstanding from the inspection report of 5 January 2006) 20 OP38 18 Three staff identified during the inspection must receive training in Food Hygiene. (This issue is outstanding from the inspection report of 5 January 2006) The Registered Providers must ensure the Home complies with the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. (This issue is outstanding from the inspection report of 5 January 2006) 30/09/06 21 OP38 Health and Safety Regulation 19/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP7 OP7 OP7 No. 1 2 3 Good Practice Recommendations At the front of each Resident’s files the preferred name of the Resident should be recorded. In the front of each Resident’s file the designated keyworker for the Resident should be recorded. Copies of the Home’s contract or statement of terms and conditions of residency should be signed by a Registered Provider or Manager and the Resident/Representative and filed within each Resident’s file. The keyworker’s monthly update of Resident’s records should be shown to the Resident, where this is deemed possible. A record should be made on each occasion of any comments made by the Resident and the Resident DS0000065783.V288388.R01.S.doc Version 5.1 Page 28 4 OP7 Alvaston Manor should be asked to sign the record. Alternatively, the file should record when the Resident is unable to review their file due to their limitations. 5 OP7 When staff use the Resident’s record of events to ask other staff to carry out tasks, the tasks should be addressed on each entry following until the staff member requesting the task signs it off as no longer needed. The armchairs in the lounges should be provided with covers to prevent Residents from perspiring when seated. Plans should also be made to replace these chairs. The Registered Providers should improve the bathing facilities to allow Residents to use the bathroom closest to their bedroom. The Registered Providers should provide hearing loop systems in both lounges, and in the dining room if this room is occasionally used for activities. All care staff and domestic staff should be given a master key to Residents bedrooms. Sufficient senior staff should be trained as First Aiders to ensure that at least one First Aider is on duty on each shift, both day and night. Five staff identified during the inspection should receive training in Infection Control. 6 OP19 7 OP21 8 OP22 9 10 OP24 OP38 11 OP38 Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alvaston Manor DS0000065783.V288388.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!