Inspection on 31/07/07 for Fassaroe

This inspection was carried out on 31st July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fassaroe 28/05/08

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Fassaroe 5-7 Warwick Road Walmer Deal Kent CT14 7JF Lead Inspector Joe Harris Key Unannounced Inspection 31st July 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fassaroe DS0000068842.V346012.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. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fassaroe Address 5-7 Warwick Road Walmer Deal Kent CT14 7JF 01304 361894 01304 382149 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) Fassaroe Ltd Post Vacant Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28) of places Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service Brief Description of the Service: Fassaroe is a 28-bedded home for older people with dementia care needs. The service came under new ownership in January 2007. The home is situated in a quiet street off the main road leading into the seaside town of Deal. Local shops and amenities are close by and the town is approximately ½ mile away. The home is also close to the beach. There is a reasonable bus service into Deal and Dover. The home itself is situated over two floors, with the main communal spaces being on the ground floor and bedrooms on both floors. The home provides single accommodation for all service users. There is a garden surrounding the building. The home has the benefit of a good-sized and well-equipped laundry and large kitchen. The current weekly fees for the service at the time of the visit range from £377.38 (KCC rate) to £600.00 (depending on the room size and service users needs). Information on the Home services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection process culminated in a site visit to the home on 31st July 2007. The site visit commenced at around 10am and finished at approximately 5.30pm lasting for about 7.5 hours. The manager was not present at the time of the visit due to pre-arranged annual leave. However, the inspector was able to talk with the deputy manager, the registered provider, the head of finance and administration, service users, care staff and ancillary staff. A tour of the premises was conducted viewing communal areas, some bedrooms, bathing facilities, the laundry, kitchen and gardens. A range of documents and records were examined including those pertaining to service users (residents), staff, health and safety, medication and the day to day management of the home. The Annual Quality Assurance Assessment (AQAA) had not been completed and returned prior to the commencement of the inspection, so therefore could not be taken into consideration. Additionally, it was not possible to complete resident surveys due to this reason. What the service does well: Fassaroe came under new ownership in January 2007 and a new manager has been in place for the past 6 months. The home is considered as a new service. There is a relaxed and welcoming atmosphere in the home, which, in the most part, is decorated and furnished to a good standard. There is a relatively experienced staff team supported by a good range of ancillary staff. The home is well staffed, ensuring that carers have time to engage in individual activities with residents. The manager is an Adult Protection trained trainer who has put into place more robust staff training and processes in this regard. There is a range of formal and informal activities within the service providing residents with a choice of suitable activities and pastimes. Visitors are welcomed into the home and this was commented on by one visitor spoken with during the site visit. Residents and visitors alike noted that the quality of the food in the home is good and meals are taken in a relaxed and congenial setting. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 6 requirements and 5 recommendations have been made as a result of this inspection process. A number of the issues raised relating to the continued development of the service, which show evidence of being addressed. The home must ensure that all health and safety documentation and service checks are updated and more closely monitored, especially with regard to fire safety and periodic service certificates. A relevant service user’s guide and contract covering the terms and conditions of residency need to be developed and provided to all current and prospective residents and/or their representatives. An action plan detailing environmental works setting out realistic timescales for action needs to be developed. The home needs to update medication policies and procedures to ensure that they are in accordance with the Royal Pharmaceutical Society guidelines. Recommendations based on good practice have been made surrounding the issues of assessing the competency and appraisal of care staff and continuing to update mandatory training. Service user individual plans and risk assessments should be further developed to ensure clear guidance is given to staff so that needs can be met consistently and risks minimised. Additionally pre-admission needs assessments could provide greater focus on the dementia care needs of prospective residents. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 7 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. Fassaroe DS0000068842.V346012.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 Fassaroe DS0000068842.V346012.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, 5 and 6. Quality in this outcome area is adequate. Prospective service users have access to adequate information about the home and their needs are assessed. The home does accept clients for respite care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new home management has developed a statement of purpose setting out the aims and objectives of the home and the facilities available. This document contains all the required information. A service user’s guide is available, but this has not yet been updated. Although some of the information regarding the physical environment remains appropriate, this document needs to be updated and provided to each prospective service user/referrer at the point of referral. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 10 Refer to requirement 1. It is also advised that both documents should be displayed or readily available in the lobby of the home. A contract covering the terms and conditions of residency is in place, but this has yet to be updated under the new ownership. An established statement of terms and conditions is in place for the provider’s other homes. All service users and their representatives need to be provided with an up to date contract of residency, which are to be signed and a copy retained on file. Refer to requirement 2. The home conducts a pre-admission assessment in respect of all referrals to the home. This process includes a visit to the prospective service user’s current accommodation by the manager and/or deputy manager. The home ensures information is received from care management where appropriate. A preadmission assessment is completed by the manager addressing all care and support needs, although this could be expanded to include a greater focus on dementia care needs and elements of risk. Refer to recommendation 1. The prospective resident and their family are invited to spend time in the home to aid orientation and enable people to make an informed choice about moving in. This process is flexible and determined by the service user’s needs and wishes. It was reported that the home accept clients requiring respite care and the assessment process is followed as above. There were no clients receiving respite care at the time of the site visit. The home does not have dedicated respite care facilities with the emphasis on social inclusion. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. Residents needs are set out in an individual plan of care and healthcare needs are met. Residents are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An individual plan of care is developed for every resident and 3 individual files were examined through the course of the site visit. The home uses an established care plan format, which provides generic areas of need based on a nursing model. The care plans generally address assessed needs, but the guidance for staff to meet the needs can be further developed providing specific instructions and actions to promote consistency, especially with regard to dementia care needs. Refer to recommendation 2. It was also advised that the home should establish pen portraits for each resident covering past social Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 12 and family history. A risk management process is in place, but this could also be further developed ensuring that all risks are assessed and the management plan provides clear instructions to minimise the perceived risks. Refer to recommendation 3. It was also suggested that individual plans of care are reorganised and spent information archived. Healthcare issues are appropriately monitored and documented and the files examined provided a clear trail of information from identification of a healthcare issues to referral and monitoring. All residents are registered with a local GP and receive access to complimentary health professionals such as chiropodists, opticians and dentists. The home maintains links with the local community mental health team for older people and reported that they are supportive towards the residents in the home. Medication records are suitably well-managed and up to date. The home currently uses the NOMAD medication system, but is considering changing to a blister pack system. Storage facilities are adequate, although there is not a dedicated room for medication. Medication cabinets are securely attached to a wall. An error in relation to medication administration was identified during the site visit. This was discussed with the home management and senior staff member involved. A reasonable explanation was provided, but the incident does identify a need to review and update medication policies and procedures, to ensure such an occurrence is not repeated. Refer to requirement 3. None of the service users are self-medicating and staff have received appropriate medication training prior to administering medication. It is advised that the home manager does introduce an in-house competency assessment to be carried out periodically ensuring the knowledge and capability of staff administering medication. Refer to recommendation 4. It was evident through observation and discussion that residents are treated in a respectful and dignified manner by all staff. One individual said that “the nurses (carers) are lovely, so helpful and cheerful.” A mealtime was observed, which was a relaxed and comfortable period of the day. Residents were assisted sensitively and staff appeared unflustered and organised offering choices throughout. Staff demonstrated that positive relationships have been developed with individual residents. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Residents have a range of opportunities and activities. Visitors are encouraged. A wholesome and balanced diet is offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home offers a range of activities and pastimes throughout the week. Visiting entertainers and therapists provide some structured activities and more informal pursuits are arranged by staff during quieter periods. During the site visit staff were observed spending 1:1 time with residents and organising small group activities, such as dominoes and looking through reminiscence cards. Some residents said that they have enough to do and are happy with the range of entertainment. It is advised that a range of activities suitable for each resident is documented within the social activities care plan or an activities calendar is developed. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 14 Visitors are welcomed into the home at all reasonable times of the day and one visiting relative stated that the staff and manager make her feel welcome. All resident finances and monies are held outside the scope of the home. Safe keeping facilities are provided in emergency circumstances. The home does not take an appointee role for any individual. Families or financial representatives are invoiced for any monies required. The home employs a full-time and a part-time cook throughout the week and the services of a kitchen assistant. There is a large commercial style kitchen. The cook reported that all equipment worked well and suitable for use. There is a flexible food budget enabling the cook to purchase goods as required. Fresh produce is bought from a local supplier and there were adequate stocks, suitably stored in the home. Menu records demonstrate a healthy and balanced diet with a range of choices is available. Service users and visitors commented on the quality of the food. A mealtime was observed, which was a relaxed and comfortable period. Residents were assisted sensitively and choices were offered throughout. It is advised that the cooks ensure that their food hygiene training requirements are up to date. Specially required diets for nutritional, health, cultural or religious needs are catered for appropriately and nutritional needs regularly assessed. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service user’s and relatives complaints are taken seriously and residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints procedure in place, which ensures that a response is received within 28 days from the date of any complaint or concern. The home aims to deal with all matters raised in an informal manner in the first instance, but there is a formal complaints process should this prove unsatisfactory. 2 complaints have been received via the Commission for Social Care Inspection regarding the service since the new ownership has taken over the home. Both of these issues were dealt with by the manager and provider satisfactorily. The home has adequate policies and procedures in place regarding protecting residents from forms of abuse. The manager is a trained trainer in Adult Protection issues and has ensured that all staff have received training and instruction in this area. Staff spoken with had a reasonable working understanding of adult protection issues. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 16 There has been one adult alert raised since the new ownership have taken over the home, which was subsequently closed after the initial planning meeting with no action required by the home. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. The home’s premises are suitable for purpose, although some modifications and refurbishment would be beneficial. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fassaroe is located on a quiet residential road close to the main road into Deal and a short walk from the sea front. The residential accommodation in the home is set on the ground and first floors of the building. The second floor is used as office space and a private flat for use by staff. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 18 All external doors have keypad systems and locks to ensure safety of residents from wandering into the street. There is an enclosed garden to the rear and attractive open garden at the front of the home. All bedrooms are currently used as single accommodation, although the home does have 3 bedrooms registered as double rooms. It was reported that there are no plans to use these rooms as doubles unless specifically requested. There is a large lounge/dining room and a conservatory that make up the basis of the communal space. These are bright and airy rooms in which a range of activities can take place. Many of the bedrooms are well-decorated and furnished, however one corridor housing rooms 2-6 is different in aestheti9cs to the rest of the home. All bedrooms have lino/laminate flooring and the décor would benefit from updating to provide a more comfortable and homely environment. The provider stated that radiator guards are on order for all radiators throughout the home as the majority of these are currently unguarded. The home has the use of a relatively new passenger lift and a rarely used stair lift is also in place, which could now be considered for removal. Access to the rear garden could be improved as there is a potentially difficult step for residents with reduce mobility and could cause a tripping hazard. The home also uses strip lights in the majority of hallways, which should be considered for replacement. The rear garden has a large area of shingle flooring, which represents an obstacle for some service users with reduced mobility and is, reportedly, being considered for change to a lawned area. Refer to requirement 4. There are sufficient numbers of toilets and bath/shower rooms in the home. There is only one bath available for use, but a number of shower and wet rooms including some bedrooms with en-suite facilities. The kitchen and laundry rooms are suitable for purpose and are well maintained with adequate equipment in place. The most recent environmental health officer visit raised no concerns and it is reported that the home complies with fire safety legislation. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. Residents needs are met by suitable numbers of competent and trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home operates with 4 care staff throughout the day and 3 waking night staff. In addition to this the manager works from Monday-Friday 9-5 and there is a team of support staff including a full and part-time cook, a kitchen assistant, a laundry assistant, 2 part-time domestics, a part-time maintenance man and a finance manager/administrator. Staff stated that they feel that the staffing levels are appropriate to the needs of the residents. Staff were observed in their daily practice and appeared relaxed and unflustered. They were able to spend individual time with residents outside the routines of the day. The home is working well towards achieving training targets with almost 50 of the team having gained an NVQ level 2 or above and further staff recently enrolled. Additionally the home has recently introduced the use of the Common Induction Standards alongside the service’s own induction programme. Steps have been made to address mandatory training shortfalls with evidence that Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 20 staff have attended a range of courses in 2007. It is acknowledged that there is still further work required to bring the training needs fully up to date, but significant strides have been made in this area. It is advised that, alongside training courses, the manager underpins staff competency through in-house assessments and questionnaires. Refer to recommendation 5. A number of staff files were viewed randomly including those of more recently employed staff. All required information was in place with evidence of CRB and POVA checks, two written references and proof of identity. It was noted that the home has used a number of different application forms over the recent past and it is advised that a single format is established ensuring that a full and detailed employment history is gained for each employee. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. The home is well-run and in the best interests of the service users. Some attention needs to be paid to health and safety issues, in particular fire safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager, who was not present at the time of the site visit, is currently working through the registration process to become the Registered Manager. She has a background in the care sector and has achieved all required Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 22 management training. Staff and residents stated that she is approachable and provides clear leadership. The home has begun to address quality monitoring issues and some positive steps have been taken. The provider completes monthly monitoring visits, although these could be more detailed and provide clear action plans including regular auditing of a range of records including service user plans, staff files, medication and health and safety amongst other things. The manager has introduced a monthly family meeting to provide and gain feedback about the service. A set of questionnaires has also been sent out to family members. As a growing aspect for all homes, quality monitoring should now encompass feedback from staff, professionals and any other key individuals. Once surveys are received they should be encapsulated within an annual report demonstrating the service positives and shortfalls and the actions to be taken by the home to raise and maintain standards. Refer to recommendation 6. The home does not take a role in the management or safekeeping of resident finances unless in an emergency situation. A number of shortfalls were noted in relation to health and safety issues. The home has a fire log book, but this has not been completed on a regular basis for a number of months. The home owner and deputy manager agreed to address this as a matter of priority ensuring that all weekly, monthly and quarterly tests are carried out and documented appropriately. In addition a record of fire drills and those taking part needs to be maintained. It is also advised that the current fire risk assessment is reviewed and updated. Once completed this should be sent to the local fire safety officer for ratification. Refer to requirement 5. Accident records are well maintained and environmental risk assessments have been completed. Service and maintenance certificates were viewed a number of which need to be reassessed by the appropriate professionals. The CORGI landlords gas safety and NICIEC electrical wiring certificates are both in need of renewal and PAT tests would benefit from being completed. Refer to requirement 6. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP1 Regulation 5, 6 Requirement An up to date service user’s guide needs to be developed and made available to all prospective service users and/or the referrer. An updated contract of residency is to be provided to all service users and their representatives and signed copy to be retained on file. To update and review medication policies and procedures ensuring that they are in accordance with RPSGB guidelines. The provider needs to produce an action plan detailing all works planned and a timescale within which to achieve this work. The plan should pay particular attention to the provision of radiator guards, accessibility issues and renewal of flooring and decoration. To ensure that all fire safety records are maintained and up to date and that all routine checks are completed. Update the fire safety risk assessment. To ensure that all services and DS0000068842.V346012.R01.S.doc Timescale for action 01/09/07 2. OP2 5, schedule 4 13(2) 01/09/07 3. OP9 01/09/07 4. OP19 16, 23 01/09/07 5. OP38 13, 16 01/09/07 6. Fassaroe OP38 13, 16 01/09/07 Page 25 Version 5.2 facilities are routinely checked and tested including gas safety and electrical wiring. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP3 OP7 OP7 OP9 OP30 Good Practice Recommendations To further develop pre-admission assessments to cover dementia care needs in greater detail. To ensure that care plans provide clear guidance for staff to meet individual needs. To develop risk assessments ensuring that actions to minimise all perceived risks are clearly identified. To develop staff competency assessments covering medication administration and knowledge. To continue to provide all mandatory training for staff as required and consider implementing in-house competency assessments to underpin knowledge gained. Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fassaroe DS0000068842.V346012.R01.S.doc Version 5.2 Page 27 - 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!