CARE HOMES FOR OLDER PEOPLE
Favordale Favordale Byron Road Colne Lancashire BB8 0BH Lead Inspector
Mrs Marie Dickinson Unannounced Inspection 10:00 31st July & 3 August 2006
rd 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 Favordale DS0000035216.V303340.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. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Favordale Address Favordale Byron Road Colne Lancashire BB8 0BH 01772 563002 01772 562304 karen.mason@careservices.lancscc.gov.uk 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) Lancashire County Care Services Miss Deborah Margaret Watson Care Home 44 Category(ies) of Dementia (14), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (3), Old age, not falling within any other category (30) Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 44 service users to include: Up to 30 service users in the category OP not falling into any other category Up to 14 service users in the category (DE) Within the total number of OP registered places, three named service users who fall into the category MD(E) may be accommodated 28th February 2006 Date of last inspection Brief Description of the Service: Favordale is registered with the Commission for Social Care Inspection to provide personal care and accommodation for forty-four people. The home is owned by Lancashire County Council and managed by Lancashire County Care Services. The property is a purpose built building, set back off the main road, with gardens to the side and rear. There is a central courtyard accessible to the residents. Accommodation offered is in single bedrooms. Some have en suite facilities provided. There are sufficient bathrooms and toilets, and various aids provided for residents to maintain independence throughout the home. The home is divided into two units for people requiring residential and dementia care. The residential unit is on two floors. The upper floor can be accessed via a passenger lift. Both units have lounge and dining areas. The home is staffed twenty-four hours a day, with a member of the management team on duty and on call at all times. Information about the service is available from the home for potential residents in a Statement of purpose and Service User Guide. Weekly charges for personal care and accommodation range between £324:50 and £360:50. Residents are responsible for additional extras such as newspapers and toiletries. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place on the 31st July & 3rd August 2006. The inspection involved getting information from staff records, care records and policies and procedures. It also involved talking to residents, staff on duty, the person in charge and visitors, and included a tour of the premises. Areas that needed to improve from the previous inspection were looked at for progress made. The home was assessed against the National Minimum Standards for Older People. What the service does well:
Residents living in the home benefited from the support of a named worker referred to as a Key worker who took responsibility to make sure care needs for individuals was personalised. Resident’s said they were happy with their carers and thought they were ‘kind’ and ‘thoughtful’. Healthcare needs were monitored and the staff worked with visiting medical professionals for the benefit of residents. Advice was sought where needed, such as for pressure care and mental health care. Residents said staff were mindful of their privacy when giving personal care. Visitors said they were made welcome to the home and described staff as ‘nice and caring’. Relatives said they were always kept informed of any changes in their relative’s care needs. There were no rules in the home and routine was personal to each resident. Arrangements were made for representatives from different religious beliefs to visit residents as they wished. The complaints procedure was easy for residents and relatives/visitors to use. Residents were confidant staff would listen to them and one relative said ‘the manager was helpful’. Adult protection was given a high profile with staff training and contractual arrangements to protect residents. Accommodation for residents was very good. The home was tastefully decorated and furnished to a high standard. Aids required to assist people to be independent was provided. Residents had a high opinion of staff in the home and described them as ‘good girls’ and ‘they are wonderful’. Gender issues were considered by having a male carer.
Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 6 The training provided for staff is excellent. Staff showed they had a good knowledge in understanding the needs of older people. They were supervised in their work and had the support of management at all times. There was a good team spirit in the home. Systems were in place to approach residents/relatives to give their view on the quality of services and facilities in the home. Small amounts of money held on behalf of residents were managed well. What has improved since the last inspection? What they could do better:
Before people are admitted to the home an assessment of need must be carried out for everyone. People already living in the home must have the benefit of a continuing assessment in order for significant changes in their needs are managed. All relevant parties should sign contracts given to residents. Disclaimers issued by the home should also be signed. To make sure residents are cared for according to their needs care plans should be written in sufficient detail for staff to follow. By writing a daily living care plan to include preferred routines and what help residents need from staff, residents will be cared for as they wish. Information required to keep staff and residents safe must be made available for staff. Residents’ dignity must also be considered by making sure there is enough staff available at all times to attend to their personal needs. Better care with laundry must be given to make sure personal clothing belonging to residents such as undergarments are returned to them.
Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 7 Detailed records need to be kept in relation to prescribed medication that is taken “when required”. Staff need to recognise more clearly when to administer, particulaly in relation to the management of aggression. Activities for residents must improve and take into account their wishes and diverse needs. The overall provision of meals served must improve. Supervision and assistance given to residents must increase in order for residents to receive a balanced nutritious diet. To make sure residents environment is always clean and fresh, consideration must be made to providing appropriate floor coverings as part of continence management. Odour control in bedrooms must improve. Sufficient staff must be employed to make sure the safety and welfare of residents is considered at all times and their needs are met properly. Staff recruitment must include requiring references from most recent employers with a satisfactory written explanation of any gaps in employment. Management should respond more effectively to requirements issued by the Commission. Supervision of staff should be regular and meetings for residents to express their comments about the service need to be increased. 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. Favordale DS0000035216.V303340.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 Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Assessments were carried out for residents, but were not always completed properly. Contracts given to people and other agreements were given to residents but not always signed. EVIDENCE: A number of residents had been admitted to the home since the last inspection. These files showed there were inconsistencies in how people are assessed prior to moving into the home. For example one resident had minimal information recorded, one resident had no information recorded and one resident had a very good assessment. It was also noted that where possible family and residents had also been involved in the process. One relative said she had been involved in her mothers’ admission and was satisfied with how this was conducted. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 10 Residents placed in the home by the local authority were given a contract for financial arrangements for payment in addition to one issued by the home outlining the terms and conditions of residency in the home. Residents or their representative must sign these and any disclaimer the home requires an agreement for. A list of belongings should also be completed for each resident on admission. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans written for residents required further development in order for staff to provide appropriate personal care for residents. Healthcare was monitored. Residents were satisfied their care needs were met and they considered staff were respectful to them. Medication was managed safely. EVIDENCE: Each resident had a plan of care. The format for care planning was good and showed identified need, action to be taken to meet needs, frequency, and person responsible. Completing these for the benefit of residents and staff required further development. How identified needs are to be supported was not always clear as no action for staff was recorded on frequency and who would be responsible, for example key worker. One resident liked to read and had limited concentration span due to dementia. No guidance was written on how to sustain interests, or written instruction on how this need would be managed such as key worker involvement. Other records were better detailed
Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 12 such as ‘prefers a shower’, and ‘enjoys activities’. Sensory checklist statements were used and entries included ‘supposed to wear glasses for reading’. A brief record was made of residents past history. This helped staff to understand people as individuals, their likes, and dislikes. Some of the residents on the residential unit said they sometimes ‘talked about their care with staff.’ One relative said she was involved in her mothers care. Some residents who lived in the home for a while had a night care plan that showed how care was to be provided during the night. Reviews of care plans were not regular. One resident who had lived in the home for a number of years who required dementia care had not had her care plan reviewed to take into account her changing circumstances. Daily records showed how some residents particularly on the dementia unit presented challenging behaviour, but there was no written guidance on how this was to be managed. Reference to this in risk assessment referred to ‘see confidential file’. This information needs to be readily available for staff who have to manage these situations. Staff worked to a key worker system, having responsibility to make sure care needs are personalised for residents. Resident’s benefited from additional specialist support where needed. This included healthcare and mental health care need. Pressure care was promoted and pressure-relieving aids were used where needed. Clinical procedures such as dressings were carried out in the privacy of residents’ bedrooms. Residents confirmed staff in the home were mindful of their privacy, for instance they kept the bathroom and toilet doors locked when they were helping them. This was also observed during inspection. They also thought staff were ‘kind’ and ‘work hard’. Management of laundry did compromise resident’s dignity as one relative was particularly concerned undergarments went missing, and felt that as they were not in the laundry meant someone else had them as her mother had been given other peoples. Relatives visiting confirmed they were kept informed of matters that involved their relative. One visitor said staff were ‘very nice and caring’, however there were times during the day when they were not available to see to residents personal needs. She said she was uncomfortable being asked by residents to take them to the toilet as staff were either on their own or not about. She has heard residents complain they were too late to make it to the toilet, which is embarrassing. The home operated a monitored dosage system for the administration of medication, which was dispensed into controlled dose packs by a local pharmacist. An appropriate recording system was in place to record the receipt, administration and disposal of medication. Medication given as when necessary requires more detail as to when this would be given, particularly
Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 13 when the medication perscribed is for people with dementia. All staff responsible for administering medication had been trained. Favordale DS0000035216.V303340.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Resident’s lifestyle could be improved upon. Residents were generally satisfied with their care in the home. Activities were limited. Visitors to the home were made welcome. Catering arrangements were not satisfactory. EVIDENCE: Residents choice in relation to daily living was observed, for example residents said there were no rules imposed on them such as when they went to bed or got up in the morning. They had their own routine personal to them ‘the girls knew’. One resident said she ‘couldn’t fault anyone, although sometimes they are short staffed’. She was disappointed as ‘There wasn’t much going on’. A record of residents’ interests and preferences was held on the care plan. One relative had concerns about the lack of activities and put this down to a lack of staff. Residents also gave mixed views about this and there was an overall opinion that these were not very good. Comments included ‘not much to do’ and ‘I get fed up just sitting about’. Residents considered staff gave them as much time as they could but said they were ‘run off their feet’. Staff said it was at times difficult to manage activities, due to managing residents personal care and
Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 15 other activities such as laundry and supporting residents with meals. Activities in the dementia unit were not person specific although one resident was seen to help staff return laundry. Several residents talked about their family visiting. Staff were thoughtful and were friendly. Birthdays were celebrated with family in the home where possible. Visitors to the home said they ‘never had any problem when calling in the home and relatives were kept up to date with changes in care’. Residents were supported to continue to practice their chosen religioRepresentatives from local churches visited the home on a regular basis for prayers and communion. Arrangements were made for residents to have meetings. Agendas included for example activities, health and safety, smoking, and menus. Comments from residents about the food were varied. Some felt they were all right, but some thought lately the meals had deteriorated. Examples of meals provided were given and one resident questioned whether she was getting ‘value for money’. A relative also indicated the food served sometimes was poor and not up to expectations. Menus were discussed with the residents at their meetings. Choices were given sometimes at meals. Explanation as to the standard included difficulties occurring on occasions as the carers get behind with their work and don’t come for the food on time. When it is kept hot it can spoil. Lately one of the cooks has been off sick and so carers have been helping out. Staff were observed offering support to those people who could not manage to eat their meal without assistance. The number of residents in the dementia unit requiring assistance with eating required more staff for this purpose. Three residents required full assistance to eat and a number required supervision. This meant that because there was only two staff, from observations made, one resident had to wait and resulted in her meal being taken away cold and a supplement drink given instead. One relative said ‘dinner times are awful as sometimes there is only one staff on duty’. Favordale DS0000035216.V303340.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents had access to a clear up to date complaints procedure and staff had up to date policies and procedures for adult protection. EVIDENCE: Residents said they knew who to speak to if they had any concerns. All residents were given a copy of the homes complaints procedure when they came to live at the home. Residents said they had no complaints against the staff, only concern they had too much to do. Residents felt staff had their welfare at heart. One resident said ‘the manager is ‘very helpful’. One relative visiting said she was able to say if she was unhappy about anything. Staff working at the home said they were trained in adult protection and were aware of the abuse policies and procedures, which included whistle blowing. Staff confirmed they had regular contact with the area manager of Lancashire County Care Services and could approach her with any problem. Staff contracts precluded them from financial reward or assisting in or benefiting from the service users’ wills. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,23,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a clean well-maintained safe environment. Aids and adaptations were provided to maximise independence. Resident’s rooms suited their needs. EVIDENCE: The home has recently had major refurbishment work carried out. Aids and adaptations have been provided to meet with residents needs. These include a passenger lift, ramped pathways, grab rails and aids specific to support independence in toilets bathrooms and bedrooms. The home is divided into two units, residential and dementia. Entrance to the home and dementia unit is by keypad access. Both units have lounge and dining room combined. Bathing facilities has improved with the provision of specialist baths and shower facilities. Some bedrooms are en suite and every resident has been provided with new furniture. Some residents had their own furniture in their
Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 18 rooms they brought with them. One resident said ‘it felt like home’. Residents said they liked their rooms and thought the home was kept clean, however one visitor did not share this view. Most areas in the home were clean and fresh during inspection. Two bedrooms however did have a bad odour problem staff said they needed to deal with daily. Water temperatures were monitored and the laundry looked clean and organised. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The level of staffing was not satisfactory to meet the needs of residents. Recruitment practices were not good. Staff were trained to care for residents safely. EVIDENCE: The home was fully staffed during the inspection, however the current level of staffing did not meet with residents needs and requires reviewing. The home has been altered in lay out and is now operating on two floors in addition to residents being more dependent on staff support. Observations showed staff were left working alone during staff meal and break times and residents requiring the assistance of two had to wait. Visitors expressed concerns. One comment described the situation as ‘dangerous.’ Another relative said there is ‘not enough staff’ to look after everyone as they should. Some residents felt staff did not have enough time for them. One resident said ‘they don’t have time to look around, it’s very disappointing.’ Residents were very happy with the staff in the home describing them as ‘good girls’ and ‘they are wonderful’. A male carer is employed and in addition to looking after personal needs of male residents was descried by women residents as an ‘absolute gem’. ‘I didn’t think I would like a male carer, but he’s brilliant and I don’t mind him helping me’. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 20 There had been a recruitment drive with the opening of the dementia unit. Several new employees records showed how recruitment practice was carried out. Employment checks were incomplete. These included not obtaining references from most recent employers; gaps in employment not explained, and one reference only on file. However Criminal Record Bureaux enhanced checks and Protection of Vulnerable Adults check had been obtained prior to staff working in the home. In addition to induction training, all staff were trained in essential mandatory training such as moving and handling. Senior staff were also trained in medication administration. The percentage of staff having completed NVQ level 2 and above was over 50 . All employees had other training such as dementia care awareness. Staff said the opportunity for training was good and most had enjoyed the dementia care awareness course. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Guidance and support was given to staff by the management team and from the area manager of Lancashire County Care Services. The home is not always run in the best interests of the residents. Resident’s financial interests were protected. The health and safety of residents and staff was considered. EVIDENCE: Assistant managers are employed to support the registered manager to maintain a management presence in the home at all times. Lancashire County Care Services as Registered Provider have the overall responsibility in the management of the home. Senior management visit the home unannounced every month and send a report of this visit to the Commission. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 22 A quality assurance audit had been carried out with residents/relatives. The means of seeking residents and staff views about the home was both formal and informal with resident’s, staff and management meetings. The frequency of residents meetings needs to increase. Requirements made at the last inspection have not been addressed in a satisfactory way. Residents and relatives expressed general satisfaction about the care and facilities in the home. Whilst staff were praised for their efforts, relatives and residents thought their value was compromised. Supervision was being given to staff but this needed to be given regular. Supervision included policies and their understanding and work performance. Assistant managers had some responsibility for this as each manager had a number of staff they were responsible for. Staff teamwork was evident and discussions with the team showed how they were committed to providing high standards for the residents. Residents who are able manage their own finances continue to do so. Small amounts of money are managed for residents wanting this service. Records were kept of transactions made on behalf of people providing a clear audit trail. Written working procedures and training opportunities were available to support development of good care practice. All new staff members were receiving induction and essential training. Arrangements had been made for some essential mandatory training to be renewed. Fire safety procedures and training was given to staff with regular fire drills carried out. Safety certificates for electric and gas installations had been approved by an engineer when the refurbishment of the home was completed. Policies and procedures were available for reference. The storage of cleaning products was satisfactory. Management kept the Commission informed of any significant incident. Favordale DS0000035216.V303340.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 X 2 2 X X N/A 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 1 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 3 X X 2 STAFFING Standard No Score 27 1 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? 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. 2 Standard OP3 OP3 Regulation 14(1) (a-d) 14(2) (a)(b) 15(2) (b)(c) 13(4)(c) Requirement People must have an assessment prior to admission. The assessment of residents needs must be kept under review and revised having regard to change in circumstances. Care plans must be kept under review and changes to care needs recorded. Risk assessments must be completed showing how to manage, reduce, or eliminate potential risks. The manager must make suitable arrangements to ensure the dignity of residents is respected by making sure sufficient staff are available to attend to residents personal needs at all times. Improvement in activities is required for residents individually and as a group. Previous timescale of 31/03/06 not met Residents must be provided with suitable, wholesome, and nutritious food, which is varied and available as required.
DS0000035216.V303340.R01.S.doc Timescale for action 01/09/06 01/09/06 3 4 OP7 OP7 01/09/06 01/09/06 5 OP10 12(4)(a) 01/09/06 6 OP12 16(2)(m)( n) 29/09/06 7 OP15 16(2)(i) 01/09/06 Favordale Version 5.2 Page 25 8 OP15 12(1) (a)(b) 9 OP26 16(2) (k)(c) 18(1)(a) 10 OP27 11 OP29 Schedule 2 Schedule 2 12 OP29 The manager must make sure the home is conducted so as to make proper provision for the care and supervision of residents requiring assistance at meal times. Bedrooms must be kept odour free and floor covering suitable to deal with continence management. Lancashire County Care Services must employ sufficient staff to meet the needs of the residents. Previous timescale of the 30/04/06 not met Two written references must be obtained, including a reference from the people’s last place of employment. Applications for employment must include a full employment history, together with a satisfactory written explanation of any gaps in employment 01/09/06 29/09/06 29/09/06 01/09/06 01/09/06 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 6.
Favordale Refer to Standard OP2 OP2 OP2 OP9 OP10 OP33 Good Practice Recommendations It is recommended all relevant parties sign contracts issued by the home. It is recommended disclaimers required by the home is signed by the resident/relative. It is recommended a list of residents belongings is completed for all new residents into the home. It is recommended medication prescribed to be administered when necessary be detailed as to the circumstances it would be given. It is recommended better attention be given to returning resident’s personal clothing after laundering. It is recommended residents meetings be held regularly.
DS0000035216.V303340.R01.S.doc Version 5.2 Page 26 7. OP36 It is recommended supervision of staff is kept up to date. Favordale DS0000035216.V303340.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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