CARE HOMES FOR OLDER PEOPLE
Fern Lodge 24-26 Compton Road London N21 3NX Lead Inspector
Tom McKervey Key Unannounced Inspection August 2007 10:10 14
th & 16th 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 DS0000010673.V336929.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. DS0000010673.V336929.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Fern Lodge Address 24-26 Compton Road London N21 3NX 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) 020 8360 6219 020 8364 1240 Mrs Angela Hunt Mrs Angela Hunt Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places DS0000010673.V336929.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th September 2006 Brief Description of the Service: Fern Lodge is a privately owned registered care home for 20 older people located in a residential area of Winchmore Hill, North London. It is situated within a few minutes walk of public transport services and close to a number of amenities such as shops, churches and GP surgery. The registered provider, Mrs Angela Hunt is also the registered manager of the home. Accommodation is provided on the ground floor and first floors in ten single rooms and five shared bedrooms, all of which meet the minimum spatial standards. None of the bedrooms have en suite facilities, though they are all fitted with wash hand basins. A lift provides access to the first floor. The home has a large garden and patio at the rear of the premises, which is accessible through french windows. The stated aim of the home is to ensure that the individuality of care to service users is emphasised; that staff provide this, pay attention to detail, and are highly experienced and professional in their care of the elderly. The fees for the service range from £385 to £395 per week depending on single or double occupancy. A copy of this report and the home’s Statement of Purpose can be obtained from the manager of the home. DS0000010673.V336929.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over two days in a period of six hours. It was necessary for me to cancel part of the inspection on the first day due to an unforeseen staffing shortage in the home, which necessitated the manager having to provide care duties to the residents. The manager was free to assist in the inspection on my second visit when sufficient care staff were available. The inspection was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. The inspection process included a tour of the premises and reading residents’ case files. I also spoke to many residents and discussed with them, their experiences of living in the home. The proprietor’s son who is the business manager for the home was present at the inspection and provided valuable assistance in the process. There were no visitors to the home during the inspection. I observed how the staff interacted with the residents and how they provided care and support. I read staffs’ records and interviewed three staff about their experiences of working in the home. What the service does well:
There is a homely and relaxed atmosphere within the home, and residents are very satisfied with all aspects of care provided for them. There is good information provided about the service to enable potential users of the service to decide whether the home can meet their needs. Admissions are not made to the home until a full needs assessment has been undertaken to ensure that the service is appropriate for a person’s needs. New residents are provided with a Statement of Terms and Conditions/Contract; this sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. DS0000010673.V336929.R01.S.doc Version 5.2 Page 6 The people who live in the home have access to a wide range of healthcare professionals and their medication is administered safely. Regular contact with friends and relatives is encouraged and the residents are satisfied with the standard of their meals. People who live in the home feel safe and any complaints are taken seriously. All staff have been trained in protecting residents from abuse. People who use services are encouraged to personalise their bedrooms. The home is clean and tidy and smells fresh and the management has a good infection control policy to safeguard the residents. There is sufficient staff available to meet the needs of the people using the service. The service ensures that all staff receive relevant training to meet the needs of people who use the service. There is a good recruitment procedure that ensures that residents’ welfare is safeguarded. The manager has many years of experience of running the home, and the home is generally safe and well maintained. What has improved since the last inspection?
A new format for residents’ care plans was implemented, which provide more comprehensive information about the people who live in the home. The dosette medication boxes are now more clearly labelled to prevent mistakes occurring, and all medication is signed for immediately after administration. The Commission for Social Care Inspection is informed about any incident affecting the welfare of residents. All staff records are retained in the home and are available for inspection. No staff are employed without first carrying out a CRB check. Staff meetings are held regularly and are recorded. The practice of using wedges to keep fire doors open has ceased. DS0000010673.V336929.R01.S.doc Version 5.2 Page 7 What they could do better:
Ten requirements have been made in this report, mainly relating to the management and administration of the home. Two requirements made at the last inspection have not yet been met and have been restated in this report, with a new timescale for compliance. In the “Timescale for Action” column, the date in ordinary type relates to the timescale given at the last inspection. The date in bold type relates to the new timescale. Further information about unmet requirements can be found in the relevant standard. Unmet requirements can impact upon the welfare and safety of service users. Failure to comply by the revised timescale may lead to the Commission for Social Care Inspection considering action to secure compliance. Residents’ care plans must be reviewed at least monthly to ensure that any changes in their needs are noted and addressed. A record of residents’ meals must be kept, to ensure that they receive a wellbalanced and nutritious diet. The shower on the first floor must be repaired, and the overhead light in a specific resident’s bedroom must be in proper working order. A specific resident’s wishes regarding a change of room must be respected. Residents meetings must be held to enable them to have a say in the running of the service. (Restated requirement). A business and financial plan must be sent to the Commission. This should include plans for major items of expenditure, for example, replacement of furniture and equipment and redecoration. Formal staff supervision must take place at least six times per year so that individual staff’s performance is monitored and they have an opportunity to discuss issues pertaining to their role as carers. Important documents and records must be better structured so that they can be accessed easily and they are available for inspection.
DS0000010673.V336929.R01.S.doc Version 5.2 Page 8 The registered person must ensure that a written fire risk assessment and emergency plan are available for the home and that these are reviewed sixmonthly. A copy must be sent to the local CSCI area office. (Restated requirement). 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. DS0000010673.V336929.R01.S.doc Version 5.2 Page 9 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 DS0000010673.V336929.R01.S.doc Version 5.2 Page 10 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 People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. The home provides a Statement of Purpose and Service User Guide that are specific to the individual home, and the resident group they care for. Admissions are not made to the home until a full needs assessment has been undertaken. New residents are provided with a Statement of Terms and Conditions/Contract; this sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. EVIDENCE:
DS0000010673.V336929.R01.S.doc Version 5.2 Page 11 There is a Statement of Purpose and Service User Guide for prospective and new residents, which give detailed information about the service. I examined the case files of two new residents. There was evidence that in the case of one person who was placed by the local authority, a needs assessment had been carried out by the placement officer and the manager of the home, before admission. In the case of the other person who was self-funding, the manager did the assessment, which was thorough and covered all areas of need. There was a photograph of each resident at the front of their files to aid identification. A signed contract was provided for the self-funding resident, which explained what service was provided for the fees and what was excluded. DS0000010673.V336929.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use this service experience adequate outcomes. This judgement has been made using available evidence including a visit to this service. Each individual has a care plan, but it is not used as a working document and does not consistently reflect the care being delivered. Staff treat residents with dignity and respect. The people who live in the home have access to a wide range of healthcare professionals and their medication is administered safely. EVIDENCE: I sampled four care plans, including those of the two new residents. The manager introduced a new care plan format at the beginning of the year, but it
DS0000010673.V336929.R01.S.doc Version 5.2 Page 13 was evident that the staff were finding the new system too complex and difficult to understand. The manager stated that she intended to revert to much simpler care plans. The care plans did contain very good assessments; for example, physical health, mobility, communication and nutrition. However, the care plans were not being reviewed on a monthly basis, which could lead to residents, changing needs not being recognised. Daily records were not always made about how care objectives were being met, although there was a form for this in the new care plan format. A requirement is made about this issue. At the time of the inspection, no resident had a pressure ulcer. There were pressure-relieving mattresses and pads available. I saw records of residents being seen regularly by the G.P. Other appointments were for hospital outpatient departments, dentists, chiropodists etc. However, these records were poorly structured and were not easily retrievable from the files and I have made a requirement under Standard 37, (Record keeping), to address this. There were records of residents being weighed monthly. One person was self-medicating. On my first visit, this resident did not have a key to her room and she did not have a lockable facility for securing her medication. However, by my second visit this had been addressed appropriately. I examined the medication records and found that the Nomad dosette containers were properly labelled and there were no errors in the administration of medicines records. I spoke to several residents. They all said they were treated well by the manager and her staff who they described as friendly and caring. They said that personal care was provided discreetly and the staff knocked on their door before entering. DS0000010673.V336929.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. People who use this service are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. Regular contact with friends and relatives is encouraged. The residents say they enjoy their meals, but there are no records kept to confirm that they have choice about their food and meals are well balanced. EVIDENCE: Residents’ interests, likes and dislikes are recorded when they are admitted to the home. DS0000010673.V336929.R01.S.doc Version 5.2 Page 15 Various activities are provided to ensure that residents are stimulated. These include social club outings, (Thursday Club). Some residents are often taken out for lunch by relatives. Entertainers come to the home and provide music sessions and residents told me that bingo and sing-a-longs are popular. Some residents were reading newspapers and others were watching television. One person goes out every day to the local café. However, as noted above re care plan records, these activities are not always logged in the residents’ daily records. A requirement is made about this. I noted that there were many visits from friends and relatives recorded in the visitors book. Residents told me that they can receive visitors at any time and can see them in their rooms or in the quiet lounge. A nun visits the home to administer Holy Communion for those who wish to receive, and others attend local churches. With one exception, which I have addressed under Standard 23, the residents to whom I spoke, were happy with their accommodation and said they had plenty of choice, for example, they could choose when to rise and go to bed. They could also refuse to take part in activities that don’t suit them. There was a menu for the week in the kitchen, but the manager said that this was not always followed. Residents told me that staff ask them each day what they wished to eat for their main meal. While this is evidence of choice being offered, a record was not being kept of what individuals ate as evidence of that choice and that the residents were having a balanced and nutritious diet. A requirement is made to address this issue. The people who live in the home said they were happy with their meals and they could have snacks and drinks in the evening if they wished. DS0000010673.V336929.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. Residents say that they are happy with the service provision and feel safe and well supported. The home keeps a full record of complaints, which ensures that residents’ concerns are taken seriously Training of staff in the area of protection of residents from abuse is regularly arranged by the Home. EVIDENCE: The home has an appropriate complaints procedure, a copy of which was displayed in the entrance hall. A copy of the local authority’s Adult Protection Procedures is also available for reference. DS0000010673.V336929.R01.S.doc Version 5.2 Page 17 One complaint was recorded in the complaints log. This matter had been dealt with properly and to the complainant’s satisfaction. The residents to whom I spoke expressed satisfaction about their care and said they were confident that the manger took their concerns seriously. Staff records showed that they had attended training in protecting people from abuse. I discussed this topic with three staff who demonstrated a sound knowledge of this issue and how to report any concerns. DS0000010673.V336929.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23 & 26 People who use this service experience adequate outcomes. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. People who use services are encouraged to personalise their bedrooms. The home is clean and tidy and smells fresh and the management has a good infection control policy to safeguard the residents. A specific resident’s wishes regarding the suitability of their bedroom have not been respected, which restricts their right of choice. There are some minor maintenance and repair issues that need to be addressed to improve the comfort and welfare of the people who live in the home.
DS0000010673.V336929.R01.S.doc Version 5.2 Page 19 EVIDENCE: I carried out a tour of the premises. There was a homely atmosphere throughout the home and the main lounge and quiet room were attractive and comfortably furnished. There are twelve places available in the dining area for potentially twenty residents, but some people eat in their armchairs on chair tables or they can eat in their rooms if they prefer. The garden was particularly attractive and well maintained and wheelchair users can access this area via a ramp. I visited several bedrooms and tested the call alarms and found that they worked well and the response time from staff was good. The bedrooms contained residents’ personal possessions that they brought with them when they were admitted. One resident told me they were not happy with their room, which they described as not having a poor outlook and was too small. This person told me that they had told the manager that they would like to move to a particular room that was vacant but had been refused. I regarded this as a reasonable request, which was an issue of a resident exercising their right to choose. I spoke to the manager and business manager, who agreed to discuss this with the resident. In the meantime, I am making a requirement for the resident’s wishes to be respected about this matter. I found that the building was generally well maintained and the standard of decoration was good, but the following deficits were noted; The over-bed light in one resident’s bedroom wasn’t working and the shower on the first floor was faulty. Requirements are made for these matters to be addressed. At the time of the inspection, the home was very clean and tidy. There is an infection control procedure in place and staff are provided with disposable gloves and aprons when carrying out personal care.
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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): All these standards were assessed. People who use this service experience good outcomes. This judgement has been made using available evidence including a visit to this service. There are consistently enough staff available to meet the needs of the people using the service. The service ensures that all staff receive relevant training that is focussed on delivering improved outcomes for people using the service. The service has a good recruitment procedure that clearly defines the process to be followed to ensure that residents’ welfare is safeguarded. EVIDENCE: The manager informed me that two care staff had retired since the last inspection, but they had been replaced by two new staff. The rotas showed that there are usually sufficient care, catering and cleaning staff on duty at all times to meet residents’ needs, but as noted in the
DS0000010673.V336929.R01.S.doc Version 5.2 Page 22 summary, on my first visit, there was an unforeseen shortage of staff that day and consequently, part of the inspection was postponed. However, the manager coped very well with the situation and residents’ care was not compromised. The staff and residents to whom I spoke, said that the staffing levels were sufficient to meet their needs. The records of the new staff showed that they had a written induction when first starting work at the home. The records also showed that references had been obtained and they had been screened by the Criminal Records Bureau. At the time of this inspection, two staff had completed National Vocational Qualifications at level 2 and two were currently training for Level 3. In discussion with three staff, I was satisfied that they were aware of their responsibilities as carers. One person had been trained in mandatory health and safety subjects. The other members of staff had only recently started working and were waiting to attend this training. DS0000010673.V336929.R01.S.doc Version 5.2 Page 23 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, 34, 37 & 38 People who use this service experience adequate outcomes. This judgement has been made using available evidence including a visit to this service. The manager has the necessary experience to run the home and they are aware of, and work to, the basic processes set out in the National Minimum Standards. The residents’ are not consulted about their views about the service, which could prevent them from having an input into the running of the home. However, staff meetings are held, which enables the staff to influence the quality of the service. Supervision of staff is inconsistent, which could result in them not receiving adequate support in caring for the residents. A business and financial plan is not available. This should include a schedule of
DS0000010673.V336929.R01.S.doc Version 5.2 Page 24 major items of expenditure to show that the service continues to develop. The home is generally safe and well maintained, but a fire risk assessment of the property must be carried out to safeguard residents, visitors and staff. EVIDENCE: The manager is also the proprietor of the home and has been running the service for some thirty years. She is held in high regard by the residents and the staff who describe her as very “hands on” when caring for the residents. The proprietor’s son is the business manager for the home and he was present during the inspection. The manager is a qualified nurse, but has not undergone any management training. However, she informed me that she has enrolled on the Registered Manager Award course and will be starting this in September 07. Residents’ meetings are still not being held, which was a requirement from the last inspection. In discussion with the manager, she agreed to start holding these meetings, which are necessary to ensure that the residents have a say in running the home. In the meantime, this requirement is restated. An audit of the residents’ and other stakeholders’ views about the service has not been carried out. A requirement is made for this to be done as part of the home’s quality assurance programme. Meetings are held with the staff group, which they said were useful in discussing day to day issues in the home. The manager does not take responsibility for the finances of any service users in the home. Neither does she have power of attorney for any residents. The residents manage their own finances or this is done on their behalf by their relatives. A business and financial plan was not available at the time of the inspection. A requirement is made for this to be sent to the Commission to confirm that there is continuous development of the service. This should include major items of expenditure, for example, replacement of furniture and equipment and redecoration. DS0000010673.V336929.R01.S.doc Version 5.2 Page 25 There were records of some formal supervision of staff. However, these were not carried out regularly, (should be at least six times a year). A requirement is made for this to be implemented on a regular basis, so that individual staff performance is monitored and they have an opportunity to discuss issues pertaining to their role as carers. Records pertaining to the residents were not easy to follow nor easily retrievable, particularly care plans and health appointments. The majority of activities that the residents partake in were not recorded. A requirement is made for important documents and records to be better structured so that they can be accessed easily and be available for inspection. At the previous inspection it was required that a fire risk assessment and emergency plan be produced for the home and reviewed at least six-monthly. The manager has appropriate documents for this purpose, but had not yet started to working on them. This requirement is restated. I saw safety certificates for gas, water, electric and fire installations and fire alarms were tested weekly. Fire drills also take place and the lift had been serviced in the past year. The home has employers liability insurance. DS0000010673.V336929.R01.S.doc Version 5.2 Page 26 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X 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 2 2 2 x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 2 X 2 2 2 DS0000010673.V336929.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(b) Timescale for action Residents’ care plans must be 30/09/07 reviewed at least monthly to ensure that any changes in their needs are addressed. A record of residents’ meals must be kept to ensure that they receive a well-balanced and nutritious diet. The shower on the first floor must be repaired. The overhead light in a specific resident’s bedroom must be in proper working order. A specific resident’s wishes regarding a change of room must be respected. Residents meetings must be held to enable them to have a say in the running of the service. (This requirement is restated from the previous inspection. The timescale for compliance was 30/04/07. 7. OP34 25(1)(2)( 3) A business and financial plan 31/10/07 must be sent to the Commission. This should include plans for
DS0000010673.V336929.R01.S.doc Version 5.2 Page 28 Requirement 2. OP15 17(1)(a) Sch 3(m) 23(2)(b) 23(2)(b) 12(3) 16(2mn) 24 30/09/07 3. 4. 5. 6. OP19 OP19 OP23 OP33 30/09/07 30/09/07 30/09/07 31/10/07 major items of expenditure, for example, replacement of furniture and equipment and redecoration. 8. OP36 18(2) Formal staff supervision must 30/09/07 take place at least six times per year so that individual staff’s performance is monitored and they have an opportunity to discuss issues pertaining to their role as carers. Important documents and 30/09/07 records must be better structured so that they can be accessed easily and they are available for inspection. A written fire risk assessment 30/09/07 and emergency plan must be drawn up for the home and these must be reviewed sixmonthly. A copy must be sent to the local CSCI area office. This requirement is restated from the previous inspection. The timescale for compliance was 30/04/07 9. OP37 17 Sch 3 10. OP38 13(4a) 23(4acv) 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 Refer to Standard OP37 OP12 Good Practice Recommendations Residents’ health records and appointments should be structured in a way that they can be easily retrieved. A record should be kept in each resident’s file of the activities they participate in.
DS0000010673.V336929.R01.S.doc Version 5.2 Page 29 DS0000010673.V336929.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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