Inspection on 01/12/05 for The Firs

This inspection was carried out on 1st December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Firs 08/03/10

The Firs 24/11/09

The Firs 24/11/08

The Firs 12/08/07

The Firs 10/10/06

The Firs 22/07/05

The Firs 01/03/05

The Firs 18/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Firs and 16 Margaret Road, The 141 Malvern Road Worcester Worcestershire WR2 4LN Lead Inspector Andrew Spearing-Brown Unannounced Inspection 1st December 2005 11:00 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 Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 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. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Firs and 16 Margaret Road, The Address 141 Malvern Road Worcester Worcestershire WR2 4LN 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) 01905 426194 Eldahurst Limited Mrs Sandra Lynne Ghalamkari Care Home 19 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (19), of places Physical disability over 65 years of age (15) Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The Firs may accommodate a maximum of 15 people in categories OP, and PD(E) and DE(E). 16 Margaret Road may accommodate a maximum of 4 people. The Firs may only accommodate a maximum of 2 residents with a dementia type illness. Margaret Road may not accommodate any person with a physical disability. 22nd July 2005 Date of last inspection Brief Description of the Service: The Firs provides board, accommodation and personal care for fifteen people over the age of sixty-five years with physical disabilities. The registered manager recently applied for a variation in the certificate of registration, which was approved by the CSCI as detailed above. 16 Margaret Road is a separate semi-detached house that is divided from The Firs by their joint back gardens. The two properties are registered as one care home. This home is located in the St Johns area of Worcester. The two buildings are adapted and extended domestic dwellings providing four single bedrooms in Margaret Road and eleven single bedrooms and two double bedrooms in The Firs. There is one single room in The Firs that measures slightly less than ten square meters. All other bedrooms meet or exceed the National Minimum Standards. A shaft lift is provided in The Firs and a stair lift in Margaret Road. The registered proprietor is the company Eldahurst Limited. The responsible individual and the registered manager is Mrs Sandra Lynne Ghalamkari. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day. The previous inspection, which was also unannounced, took place during July 2005. The home had no vacancies on the day of this inspection. The main focus of this inspection was to assess the progress made in relation to the requirements from the previous inspection. In addition some of the key standards were inspected. A number of standards have not been inspected during the current inspection year but will be as part of future inspections. On the day of this inspection the registered manager was on duty for the majority of the time. Certain areas of the home were seen including some bedrooms and all communal rooms. During the inspection a number of documents seen included medication records, some staffing records and some health and safety records. What the service does well: What has improved since the last inspection? Following the last inspection an immediate improvement notice was issued regarding the safe administration and recording of medication. Improvement was noted during this inspection although further improvement is necessary. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 6 New carpeting is in place along the ground floor corridor and lounge area. A new washing machine is now in place. Since the previous inspection the majority of staff have attended in house training in dementia care. Training plans for 2006 are in hand. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5. Standard 6 is not applicable to The Firs and Margaret Road The lack of a suitable statement of terms and conditions means that residents are denied information upon their individual rights. Potential residents and their representatives are able to visit prior to admission during which the home can assess care needs. Specialist dementia care training assists staff to meet care needs and protect well being. EVIDENCE: A copy of a blank statement of terms and conditions was seen as part of the previous inspection. It was noted that a number of amendments were needed within that document. At the time of this inspection no resident had been issued with these terms and conditions. As this standard has been in place since the introduction of the National Minimum Standards in April 2002 appropriate action needs to take place without further delay. The Firs and especially Margaret Road is registered to care for a specific number of older people with a dementia type illness. The previous inspection report highlighted the need to ensure that suitable training is provided for all members of staff in dementia care. It was pleasing to note that 18 members Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 9 of staff have recently attended in house training provided by an external trainer using materials supplied by the University of Sterling. Although no vacancies existed at the time of this inspection the registered person made reference to a number of individuals who had recently had a look around the home to view the facilities available. Intermediate care is not offered at The Firs and Margaret Road. The home has no plans to provide such as service in the future. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Care plans and risk assessments were insufficient and inconsistent and therefore failed to protect residents in that they did not give the necessary detail regarding residents care needs to ensure that care staff are able to provide the level of input required. Some progress has been made with regard to the administering and recording of medication however serious concerns remain. The shortfalls noted continue to leave residents at potential risk. EVIDENCE: A small number of care plans were viewed during the inspection. As a result of some concerns care plans will be reassessed as part of forthcoming inspections. It was noted on one file that an assessment information sheet the information was limited and would not be sufficient for a member of staff to carry out the care task identified, therefore relying on memorised knowledge. Information regarding oral hygiene stated ‘x wear dentures – yes’. No additional Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 11 information was recorded such as fitting or cleaning. Information regarding food, drink and nutrition was blank. One care plan stated ‘ to have all needs catered for by staff’. Risk assessments were similar in that they were either scant or none existent. Some recording on the daily notes gave cause for concern. It was noted that no follow up action was recorded in relation to a sore area. On another residents daily notes no mention to another sore was made after an initial mention. The terminology used also gave such for concern for example ‘ very messy this evening’. The registered manager has established a good professional relationship with medical practitioners. It was pleasing to note that during a visit by a nurse practitioner from a local surgery arrangements were made to carry out a medication review of all residents registered at that surgery. This is good practice. The overall management of medication had significantly improved since the last inspection. The office is now laid out better and able to accommodate a new medicines trolley. This trolley was not however secured to the wall. The inside of the trolley was clean, tidy and well organised. A nominated person did not have solely responsible for the key to the trolley during the shift as is necessary. As part of this inspection a sample number of Medication Administration Record (MAR) sheets were viewed as well as a number of the Medication Dispensing System (MDS) blister packs. Since the last inspection the registered person has made a number of changes to the administering procedures to alleviate some of the previous concerns. These measures included the purchasing of the trolley as well having two members of staff administer medication and sign a separate sheet to demonstrate that the process was undertaken. The MAR sheets were generally satisfactory although a number of shortfalls were identified. The section at the top of each sheet headed ‘ Allergies’ was in some cases completed by hand; however others remained blank. Any known allergies must be recorded here. If no allergies are known then ‘none known’ must be recorded. A relatively small number of gaps were noted whereby the member of staff administering the medication had failed to either sign the MAR sheet or explain by means of a code why medication was not given. The majority of medication was signed into the home and onto the MAR sheets appropriately. A number of incidents whereby this information was not suitably recorded was noted and brought to the attention of the registered person. In addition it was noted that two persons had not signed hand written amendments to the MAR sheets. Sticky labels must not be used to enable amendments to be made to any MAR sheet. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 12 Eye drops requiring refrigeration were held within the fridge in the kitchen. It was noted that one eye preparation, which needs to be discarded 28 days after opening, had no date of opening written upon it. As the item was dispensed from the pharmacist during October 2005 the home could not guarantee that it had not exceeded the 28-day timeframe. One tube and one tub of ‘over the counter’ cream were found in a toilet and a bathroom. Although these were ‘over the counter’ items they were prescribed to individual residents, in one case the named resident no longer resides at the home. Creams and ointments must not be held in communal areas due to the risk of cross infection, and must only be used in relation to the person for which it was prescribed. An unopened bottle of indigestion remedy was found in a residents bedroom. Although it appears likely that this medication was brought in by a 3rd party it was apparent that staff had either failed to notice this item or had failed to bring it to the attention of the registered person. If appropriate residents should be able to self-administer medication however a risk assessment is required which needs to take into account the risk of others accessing it. The registered person is aware of additional training regarding medication provided by Hereford and Worcester Training and Development Services. Some staff have attended this and it is anticipated that others will do so in the foreseeable future. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Activities organised by the home provide stimulation and interest for residents. EVIDENCE: At the time of the last inspection the visit coincided with an organist arriving to play music in the large lounge, these visits take place on a regular basis. Information displayed around the home showed a number of forthcoming events including a Christmas concert with a number of different entertainers as well as a visit from Worcester Operatic and Dramatic Youth Society due to visit. Arrangements are made to attend a pantomime at a local theatre. A lively game of hangman was taking place within the lounge whereby staff and residents were using a chalkboard. Standard 15 which concentrates upon the diet offered to residents was not assessed on this occasion; it was however noted that the main mid day meal consisted of either Cornish pasty or faggots with mashed potato, kidney beans, carrots and gravy. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were assessed in any great detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at The Firs and Margaret Road EVIDENCE: Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 15 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 The home overall is comfortable and clean. Improvements are need in relation to ensuring infection control measures are in place EVIDENCE: The Firs has a lounge, a parlour and a dining room. The dining room is situated within the conservatory, which can be effected by extremes of heat. The registered manager has in the past explored replacing the roof with a more conventional type however this has not yet taken place. Since the last inspection new carpet has been laid throughout the above communal areas. The home was clean and sufficiently tidy. No offensive odours were noted. Since the last inspection a new washing machine with a sluice facility to ensure that disinfecting of any soiled laundry takes place has been fitted. Antibacterial soap was not always available in areas where staff should be able to wash their hands. Paper towels were not provided resulting in staff having to use cotton towels, which is not in line with good infection control procedures. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 16 Several residents’ bedrooms were viewed. All those seen demonstrated that residents are able to bring personal belongings into the home with them. A previous inspection report highlighted the need to ensure that suitable means of preventing scalding from radiators and hot pipes was in place. The majority of radiators now have covers fitted, however one very hot radiator was behind a chair in the lounge. An officer from the Environmental Health Department of Worcester City Council visited the home on 21st and 29th November 2005. The registered person advised that matters highlighted during these visits are either now addressed or will be addressed from now on. None of these matters were of serious concern. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 17 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): 28 and 29 The lack of suitable documentation regarding the recruitment of staff demonstrated that procedures are not sufficiently robust to ensure the protection of residents. EVIDENCE: At the time of this inspection a total of 6 members of staff were reported to hold an NVQ (National Vocational Qualification) level 2. As the home currently employees 24 members of staff this equals 25 of staff who are qualified. The National Minimum Standard for older people states that 50 of staff should be qualified by the end of December 2005. A number of staff files were viewed including those of two newly appointed members of staff. Neither of these files contained the required documentation, as two written references were not in place. No application forms were on file. The registered person is aware of the requirement to obtain a POVA (Protection of Vulnerable Adults) first check prior to employment commencing. A CRB (Criminal Records Bureau) discloser is also required prior to a person working unsupervised. Approximately 50 of the remaining staff files were checked for evidence of a CRB disclosure. The required documentation was found in every file viewed. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 18 Staff contracts were not on file; these have recently been drawn up and are shortly to be issued to all members of staff. The registered person discussed some of her plans for staff training during 2006. Possible training events for 2006 at the home include continence care, dying and death, health and safety and infection control. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 19 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): 34, 35, 36 and 38 Effective and appropriate staff supervision needs to be introduced. Shortfalls in some health and safety practices potentially place residents at risk. EVIDENCE: Documentation to record staff supervision is now available although the process of formal supervision had not commenced at the time of this inspection. No cash is held on behalf of residents, any expenditure such as hairdressing is invoiced to the resident’s representative. A copy of the employers liability insurance was on display. Since the previous inspection testing to the hard electrical wiring has taken place. The inspection consisted of a 20 testing and 20 visual. A number of items of work are required, although none of these items adversely affect electrical safety the work is needed. The registered person is currently Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 20 awaiting a quotation for the work. Once the work is completed the registered person must notify the local office of the CSCI. In addition the registered person intends to instruct the electrician to carry out an inspection and test portable electrical appliances throughout the home. A bottle of Hibiscrub (Chlorhexidine based cleansing solution external use) was accessible to residents. Cleaning materials including a bottle labelled ‘bleach’ were stored in unlocked cupboards in both the main house and Margaret Road. All hazardous items must be held securely at all times. Cleaning materials should be stored separately from food items. Two wheelchairs were stowed in a corridor recess area near to the dining room. One of these chairs was noted to be without a footrest in place. Another wheelchair within a bedroom was also without a footrest. The registered person must ensure that residents safety is paramount while using items of equipment. Since the previous inspection hoists over baths have received a service as required under the Lifting Operations and Lifting Equipment Regulations 1998. These items of equipment must now be serviced every six months and suitable documentation retained. The passenger lift has a service history available for inspection however no service history exists for the stair lift in the Margaret Road property. The stair lift is subject to the same regulation mentioned above and must therefore be subject to servicing and have documentation available for inspection. Temperature records within the kitchen were viewed. These records demonstrated that a fridge operating at a level too high was replaced following the last inspection. The records seen were satisfactory although gaps when no recording was taken were noted; throughout the whole of November 2005 records were only maintained on 14 days therefore on less than 50 of occasions. Temperature records were not maintained regarding the fridge within the kitchen area at Margaret Road. Training records were seen. It was apparent that some training was not recorded however it was evident that the majority of carers have undertaken first aid training and food hygiene. As a result the registered person is able to ensure that a first aider is always on duty and a person who has undertaken the required level of training carries out any catering duties. The last moving and handling training was provided in September. The registered person needs to be able to demonstrate that all staff received suitable and appropriate training. Fire safety training is carried out regularly. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 21 The registered person has over recent months purchased a number of new lounge chairs to replace some that were unlikely to meet The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). . Two chairs were within the lounge without the necessary labelling to demonstrate compliance. Residents bedrooms contain furniture which is believed to belong to residents currently residing within that room. Risk assessments must be undertaken upon these items of furniture. Any chairs belonging to the home must fully comply with the fire regulations. The previous inspection identified a number of fire doors without any selfclosing devises fitted. As a result fire doors were wedged open. The registered person advised that she had these devises on order and that they would then be fitted. In the meantime a risk assessment must be undertaken. Records demonstrating the safe working order of portable electrical appliances need to be maintained and available for inspection Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 22 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 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X 2 2 STAFFING Standard No Score 27 X 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 2 X 1 Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 23 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 OP1 Regulation 4 Requirement The Statement of Purpose must be amended so that it includes all the information detailed in Regulation 4 and Schedule 1. Copies must be made available to the Commission for Social Care Inspection and available in the home to any service user or their representative. (Previously part met – not assessed as part of this inspection - timescale extended.) 2 OP1 5 A Service User’s Guide, which includes all information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to the Commission for social Care Inspection, all current, and any prospective, service users. (Previously part met – not assessed as part of this inspection - timescale extended.) 31/01/06 Timescale for action 31/01/06 Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 24 3 OP2 5 (1) The statement of terms and conditions must be amended so that it includes all the information detailed in Standard 2.2. Each service user must be provided with a copy at the time they move into the home. (Previous timescale of 31/05/05 and 30/09/05 not met. A new timescale is given by which time this requirment must be met) 28/02/06 4 OP7 15 (1) The registered person must ensure that service user plans cover all aspects of care as set out in Standards 7 and 3. (Previous timescale of 30/04/05 not met. A new timescale is given by which time this requirment must be met) 15/02/06 5 OP7 13 (1) (b) The registered manager must ensure that necessary follow up action is taken and recorded in relation to service users welfare and needs. The registered manager must ensure that risk assessments are undertaken in relation to all areas of residents care. 01/12/05 6 OP8 13 01/12/05 7 OP8 12 (4) (a) The registered manager must 31/01/06 ensure that the terminology used within care plans and daily notes is in line with good practice and maintains residents rights to privacy and dignity. Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 25 8 OP9 13 (2) The registered manager must ensure that medication administration records are completed adequately and at the time of administration. (Previous timescale given following the inspection held on 22/07/05 of immediate and on going not met. This requirement must be fully met) 01/12/05 9 OP9 13 (2) The registered manager must 01/12/05 ensure the security of medication by having the trolley chained to the wall and the keys held by a nominated person. 10 OP9 13 (2) The registered manager must ensure that Medication Administration Record (MAR) sheets show all known allergies. In the event of ‘none known’ the MAR sheet must reflect this information. The registered person must ensure that a record is maintained of all medication received into the home. (Previous timescale given following the inspection held on 22/07/05 of immediate and on going not met. This requirement must be fully met) 01/12/05 11 OP9 13 (2) 01/12/05 12 OP9 13 (2) The registered manager must ensure that handwritten MAR sheets are checked for accuracy by two people and signed by both. 01/12/05 Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 26 13 OP9 13 (2) The registered manager must ensure that the date of opening is recorded on medication such as eye drops as well as other medication not included within the monitored dose system. The registered manager must ensure that creams and ointments are not left within communal areas such as bathrooms. The registered manager must ensure that the homes self administrating procdeures includes reference to residents purchasing their own over the counter items. The registered manager must ensure that risk assessments are carried out on all the identified radiators and pipes. Appropriate action must be taken to either eradicate or reduce the risk of scaling. Risk assessments must also be carried out on any other radiators and / or pipes that although not identified by the inspector pose a similar risk. (Part met – most radiators now covered, exposed pipes to be completed) 01/12/05 14 OP9 13 (2) 01/12/05 15 OP9 13 (2) 01/12/05 16 OP25 13 (4) 31/01/06 17 OP26 13 (3) The registered manager must ensure that suitable facilities are available to prevent the risk of cross infection such as antibacterial soap (Previous timescale of 31/03/05 and 31/08/05 not met) 31/01/06 Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 27 18 OP28 18 The registered manager must provide an action plan detailing how the 50 level of staff qualified to NVQ level 2. Recruitment procedures must be developed and implemented in accordance with the requirements of Regulation 19, Schedule 2 and Standard 29. (Previous timescale of 31/03/05 and 05/07/05 not met). A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (This requirement was not assessed as part of this inspection. The previous timescale remains in place) 31/01/06 19 OP29 19 01/12/05 20 OP33 24 31/10/05 21 OP36 18 All members of staff must receive formal supervision that includes all aspects of practice, philosophy of care in the home and career development needs at least 6 times a year. (Previous timescale of 31/05/05 and 30/09/05 not met. An extended timescale is given) 31/01/06 22 OP38 13 Risk assessments must be carried out and recorded for all the safe working practices topics covered in Standards 38.2 and 38.3 (This standard was not fully assessed as part of the inspection carried out on 01/12/06. The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection) 30/04/05 Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 28 23 OP38 13 (4) The registered manager must ensure that all hazardous items, including cleaning materials are held securely at all times. The registered manager must ensure that wheelchairs have footrests in place at all times. The registered manager must make suitable arrangements to ensure that fire doors do not have to be propped open to afford service users ease of passage. (Previous timescale of 30/04/05 and 05/07/05 not met) 01/12/05 24 OP38 13 (4) 01/12/05 25 OP38 23 (4) 01/12/05 26 OP38 13 The registered manager must ensure that adequate temperature records regarding ‘fridge, freezer and hot food at the point of serving are maintained within the kitchen. (Previous timescale of immediate and on going part met). 01/12/05 27 OP38 13 (4) (5) 23 (4) (b) The registered manager must ensure that all staff attend mandatory training. (Previous timescales of 31/05/05 and 31/10/5 not met. New timescale given) 28/02/06 28 OP38 23 The registered manager must ensure that all soft furniture such as chairs provided by the home meet The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). DS0000018684.V267950.R01.S.doc 31/12/05 Firs and 16 Margaret Road, The Version 5.0 Page 29 (Part met – the timescale set had not elapsed. The previous timescale remains in place) 29 OP38 13 The registered manager must 31/01/06 ensure that suitable documents are available to demonstrate that the stair lift is maintained and serviced as required. (Previous timescale of immediate (05/07/05) not met. New timescale given to obtain suitable documentation) 30 OP38 23 (4) (c) The registered manager must ensure that the weekly and monthly in house fire and emergency lighting tests are carried out and suitably recorded. (This standard was not fully assessed as part of the inspection carried out on 01/12/06. The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection) The registered manager must ensure that the servicing of the fire extinguishers and fire alarm is carried out as required and suitably recorded. (This standard was not fully assessed as part of the inspection carried out on 01/12/06. The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection) 05/07/05 31 OP38 23 (4) (c) 05/07/05 Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 30 32 OP38 13 (4) The registered manager must ensure that suitable arrangements are in place to ensure the safe working order of portable electrical appliances. (Previous timescale of immediate (05/07/05) not met. New timescale given to obtain suitable documentation) 31/01/06 33 OP38 23 (4) (a) The hatch between the kitchen and dining room must remain closed when not in operation for serving meals especially while cooking duties are undertaken. (This standard was not fully assessed as part of the inspection carried out on 01/12/06. The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection) 05/07/05 Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations A programme of routine maintenance and renewal of fabric and decoration should be produced and implemented. (Not assessed on this occasion) A monitoring system should be implemented to ensure water temperature valves are working efficiently and risks from Legionella bacteria are addressed. (Not assessed on this occasion) A business or financial plan should be available for the establishment that is open to inspection and reviewed annually. (Not assessed on this occasion) 2 OP25 3 OP37 Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Firs and 16 Margaret Road, The DS0000018684.V267950.R01.S.doc Version 5.0 Page 33 - 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. 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