Inspection on 10/07/06 for Firstlings

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Firstlings 10/07/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Firstlings Firstlings 7 The Street Heybridge Maldon Essex CM9 4NB Lead Inspector Jane Offord Unannounced Inspection 10th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Firstlings DS0000067731.V305045.R02.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. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firstlings Address Firstlings 7 The Street Heybridge Maldon Essex CM9 4NB 01621 853747 01708 478151 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) Maple Care Homes Limited Manager post vacant Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability (1) of places Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 32 persons) One person who requires care by reason of a physical disability, whose name was made known to the Commission in July 2003 The total number of service users accommodated must not exceed 32 persons Date of last inspection Brief Description of the Service: Firstlings is a large detached three-storey property which was originally constructed as a vicarage. The home changed ownership on the day of inspection and is now owned by Sohal Healthcare, which is a company owning several other care homes in the eastern area. The home is registered to accommodate 32 elderly people (over the age of 65) including 1 place for a resident with a physical disability. There is one room used for respite care. The accommodation is all in single rooms, with twenty-five rooms offering ensuite toilet facilities, one room also has a private bath. Communal bathing facilities comprise four bathrooms (all with assisted baths). The main lounges/dining rooms are on the ground floor with quiet sitting areas on the first and second floors. There is a shaft passenger lift serving all three floors and stair lifts to all floors. Firstlings is situated on a busy main road with regular public transport services. Local shops in Heybridge are close-by, with the main town centre of Maldon approximately half a mile away. Car parking is available at the front of the building. Outdoor space has been improved with the rear garden having been landscaped. There is an internal courtyard that is accessible from a number of doors on the ground floor and has wheelchair ramps. The fees for the home range between £480 and £600 depending on the accommodation, the needs of the resident and the funder. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that looked at the core standards for care of Older People. It took place on a weekday between 10.00 and 16.00. The acting manager was available throughout the day to assist with the inspection process. Ownership of the service was changing hands during the day. The new owner is Sohal Healthcare. During the day a number of residents, staff and visitors were spoken with. Two residents’ files, care plans and daily records were seen, two new staff files, the policy folder, the complaints log, menus, duty rotas and the activities programme were all inspected. A tour of the building was undertaken and part of a medication administration round was observed. The system for managing residents’ personal monies was explained and minutes of staff and residents’ meetings were seen. On the day of inspection the home was clean and tidy. In spite of a degree of anxiety among the staff about the change of ownership the care delivery was calm and residents looked comfortable and well dressed. The lunch looked appetising and was clearly enjoyed by the residents. What the service does well: The building is well maintained and the décor is attractive and fresh. Furniture and soft furnishings are colour co-ordinated and appropriate for the client group. The meals are well presented and there is a wide choice offered. Cakes are all homemade and residents are offered wine or sherry with some meals. The residents are consulted about their preferences for the menus. Residents’ health needs are monitored and consultation with appropriate health professionals is undertaken when a concern is raised. Specialised equipment is available to help maintain independence as long as possible. Residents’ files contain a personal profile/life story work and efforts are made to ascertain a resident’s final wishes and record them. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 7 contacting your local CSCI office. Firstlings DS0000067731.V305045.R02.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 Firstlings DS0000067731.V305045.R02.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): 3, 5, 6. Quality in this outcome area is good. People who use this service can expect to have their needs assessed and assurance given that they can be met prior to admission to the home. This judgement has been made using available information including a visit to the home. This service does not offer intermediate care. EVIDENCE: Information given to people who enquire about the service offered by Firstlings includes a commitment to pre-admission assessment of needs and an offer of visits and sampling meals prior to admission. If the decision is taken to enter the home there is a trial period of four weeks and then there is a review held to establish if the resident is happy with the service and wishes to remain. Both the residents’ files seen contained documentary evidence that a preadmission assessment of need had taken place. Areas of care that were Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 10 considered were mobility, diet, continence, communication, medication and past medical history. The resident’s mental health and memory were also assessed. Their social activities and preferences were recorded. Firstlings DS0000067731.V305045.R02.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. People who use this service can expect to have a care plan and have their health needs met. They can also expect to be protected by the home’s medication policy and be treated with respect but they cannot be assured that all their assessed needs will be reflected in their care plan or that monitoring of stored medication takes place. This judgement has been made using information available including a visit to the home. EVIDENCE: Two new residents’ care plans were seen. They contained interventions for areas of care such as mobility, personal hygiene, diet, continence and social activities. In addition there were assessments for moving and handling and risk of falls. One resident had had a serious fall before admission and there was a note on record saying, ‘XXXX is a happy person but is nervous about falling again’. One heading was, ‘How can things in the resident’s life be improved?’ The intervention for the resident who had had a fall was, ‘Make an introduction to the physiotherapist for treatment for the immobile arm’. Further records showed that this had happened and the resident had been given a series of exercises to perform. During the day one of the carers was Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 12 heard reporting to a senior member of staff that they had helped XXXX to do their exercises and they had done them with pleasure. Tissue viability assessments (Waterlow scores) were recorded. One resident had a score of 15, which falls into ‘High risk’ category. There was no care plan intervention to give preventative guidance to protect the resident. Another resident was registered blind but there were no interventions related to that need other than that the risk of falls was reduced if the resident walked with a carer. Each resident had a night needs care plan compiled by the night staff. All the care plans had evidence of regular reviews. A senior carer spoken with said they had responsibility for the care plans of residents on the top floor and they reviewed them with the night staff, monthly. Records that were signed and dated confirmed that. The medication policy covered administration, storage, ordering and disposal of medicines. There was guidance about altering medication, for example by crushing tablets, and agreement signed by a GP for residents to have ‘homely remedies’ if required. The medicine trolley is kept locked in the clinic room/cupboard. The drugs refrigerator in the clinic room contained medication requiring storage at a low temperature. The refrigerator does not have an integral thermometer and no records are being made of temperature checks to ensure the refrigerator is functioning within safe limits. Some medication administration records (MAR sheets) were seen and no gaps in signatures were noted. The administration of the medication was undertaken at lunchtime by a senior carer who said they had had training from the pharmacy that supplied the monitored dosage blister packs (MDS). Administration was safe and hygienic and help was offered to residents sensitively when required. The controlled drugs (CD) register was seen and two prescriptions of CDs were checked at random. They tallied with the records in the register. One resident has to use oxygen sometimes so the home has a stock that is kept in a cool hallway that is not a thoroughfare. There is a yellow caution sticker on the wall and the cylinders are all locked to the wall with chains and a padlock. Staff were observed knocking on doors prior to entry and offering residents choice about where they wanted to sit or have their meal. Residents and visitors spoken with said that the staff were caring and could not do enough for them. One resident said, ‘The girls are very good at what they do, it is not always easy for them’. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 13 Firstlings DS0000067731.V305045.R02.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 for this outcome area is good. People who use this service can expect to be encouraged to maintain contact with their family and friends, to be offered meaningful activities and have a well balanced and appealing diet however they cannot be assured that the staff will react calmly to ‘unsocial’ behaviour. This judgement has been made using available information including a visit to the home. EVIDENCE: Both the residents’ files seen had recorded the contact details of the next of kin and when they wanted to be contacted. During the day a number of visitors came and went and were seen spending time with residents in the communal rooms and individual bedrooms. One visitor spoken with said they visited nearly every day and were always welcomed. Their relative had been in the home for three years after moving from a home where they were unhappy with the care. The visitor said they had commented to staff one day that their relative had gained weight since being in the home and their wheelchair was no longer suitable. The staff had ordered a new chair that was delivered on the day of inspection. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 15 The home has an activities co-ordinator who works a few hours a week. There is a programme of activities available that are open to any resident but optional. These include gentle exercises, pat the dog, bingo and other games and quizzes. One of the carers said that they organise activity sessions too and these can include hangman, big snakes and ladders, reminiscence therapy and looking at photographs, the royal family are firm favourites. Holy communion is celebrated in the main lounge once a month and a lay preacher takes a service once a month. A hairdresser visits every week. There are external entertainers who visit sometimes and the home organises some outings. At least two visitors spoke with the acting manager during the day to confirm that they would be available to help with the planned trip to the promenade later in the week. Residents and visitors spoken with all said that special occasions are celebrated such as birthdays, Christmas, New Year and Easter. One visitor said their relative needed to be hoisted now so they were anxious about going on a long trip in the minivan. The home recognised the anxiety and instead took the resident to the hotel next door for afternoon tea. The resident had really enjoyed the treat. The daily records of another resident said, ‘YYYY was visited by their spouse today and they watched the tennis on television this afternoon’ Lunch on the day of inspection was liver and bacon casserole with potatoes and carrots. One resident who had had a stroke had a plate guard to help them manage their meal independently however they did not have a spoon to manage the gravy. They picked the plate up to drink the gravy and two members of staff wrested the plate from the resident and spoke sharply about the behaviour to the resident. The menus seen showed a choice of main dish and dessert at lunchtime each day such as chicken and mushroom pie with mashed potatoes, broccoli and carrots or fish cakes with potatoes, tomatoes and mushrooms. For dessert there was a choice of spiced apple charlotte and custard or chocolate mousse. Sunday lunch is a roast meal with wine and sherry offered if residents wish. Teatime has a hot snack such as smoked haddock or cheese and tomato on toast with sandwiches and a milk pudding. In the kitchen the cook said they always try to offer the residents a meal they would enjoy. At present there is only one special diet but they recently had a resident on dialysis who needed a low sodium diet. A dietician had been consulted to help devise appropriate menus for the resident. All the cakes are home made and on the day of inspection there were rock cakes and jam tarts in the kitchen. There are high calorie drinks for residents who are not managing a full diet. The store cupboards were well stocked, as were the refrigerators and freezers. The cook said they have twice weekly deliveries of seasonal local fruit and Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 16 vegetables so the only frozen vegetables they keep are peas and beans. Residents can have a cooked breakfast if they request it and the cook said they do scrambled eggs fairly often for some residents. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 17 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 for this outcome area is good. People who use this service can expect to have their complaints taken seriously and be protected from abuse. This judgement has been made from available information including a visit to the home. EVIDENCE: The complaints policy was seen and offers robust management of any complaints with a written response detailing outcomes of any investigation. The complaints log had one complaint since the last inspection and CSCI have not received any. The complaint was from a resident about a bedside light and clock not working and a blocked sink. The record showed each problem had been dealt with and a signature from the resident two days later was recorded to say that the complaint had been handled to their satisfaction. Previous inspections have found that the home has all the required protection of vulnerable adults (POVA) documentation so that was not inspected on this occasion. Some staff spoken with had had training in POVA and some had not, however staff were all very clear about their duty of care to residents and what they would do if they had any concerns. Firstlings DS0000067731.V305045.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26. Quality for this outcome area is good. People who use this service can expect to live in a clean well-maintained home with specialised equipment available to maintain independence. This judgement was reached using information available including a visit to the home. EVIDENCE: The home employs two part time maintenance people who share the day-today repairs. There is a system for staff to report items that require attention and the maintenance person records when it has been attended to and any other outcome such as a referral to manufacturers. The building is in good repair and the outside grounds looked attractive and were accessible to residents. The internal décor is co-ordinated and the furniture and furnishings appropriate for the client group. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 19 Residents had the use of walking aids and were assisted to maintain independence as much as possible. All the communal rooms were wheelchair accessible. Staff spoken with said that pressure relieving equipment, such as special mattresses and cushions, was obtained from the community nurses. If a member of staff thought that a resident needed special equipment a referral was made and the community nurses came to do an assessment. Staff said equipment was supplied very quickly. The laundry was seen and looked clean and tidy. The washing machines had a sluicing programme to manage soiled linen. Staff spoken with said that soiled laundry is transported to the area in alginate bags that are loaded directly into the machines to avoid unnecessary handling of potentially contaminated items. The infection control policy was seen and gave clear guidance on the use of protective clothing such as gloves and aprons. Liquid soap and paper towels were available in all bathrooms and toilets seen. There are dedicated laundry staff rostered each day. Residents and visitors spoken with all said that the laundry service was good and that the correct clothing was returned to rooms clean and nicely pressed. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 20 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 for this outcome area is poor. People who use this service can expect to be cared for by adequate numbers of staff but cannot be assured that they have had all the required recruitment checks done or received updated training sessions. This judgement has been reached using available information including a visit to the home. EVIDENCE: Two new staff files were inspected. Both files contained proof of identification, two references, a job description, the job application and a contract of employment. There was evidence of an induction programme being undertaken and signed off as areas were covered. It included instruction in Health and Safety, fire awareness and procedures, professional conduct, promoting continence, moving and handling, preventing tissue breakdown and helping to maintain residents’ independence. It covered policies on infection control, food safety and hygiene, control of substances hazardous to health (COSHH) regulations and protection of vulnerable adults (POVA) guidance. Neither file contained a recent photograph of the member of staff nor any evidence that a POVA 1st check or a criminal records bureau (CRB) check had been done. The acting manager said they had requested CRBs but had not received them. One member of staff had been working in the home since April 2006. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 21 The duty rotas were seen and showed adequate staff rostered to meet the residents’ needs. Staff spoken with said it was a supportive staff team and they felt that there were enough staff for the work. The duty rotas showed the ancillary staff rostered as well as the care staff, however the jobs and hours of the ancillary staff were not indicated. The acting manager’s shifts and hours were not recorded on the rotas. When this was pointed out to the acting manager they immediately, with the help of the administrator, produced newly constructed rotas to meet the requirements. One member of care staff spoken with said they had covered all the mandatory training and also had instruction in caring for people with Parkinson’s disease, diabetes, looking after an unconscious patient and the medication training offered by the local pharmacy. They had been given training by the community nurses and could administer residents’ insulin. The training had involved instruction, practice and assessment of competence. Some ancillary staff spoken with had not received training in POVA, Health and safety or COSSH. One member of staff in the laundry had not had training in managing loads. General risk assessments seen identified ‘back strain’ as a specific risk in the laundry area. There are twenty care staff employed by the service and seven have achieved a qualification of NVQ level 3. The acting manager has enrolled on an NVQ level 4 course for care management. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 22 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 for this outcome area is poor. People who use this service can expect to have their views sought and their financial interests safeguarded but they cannot be assured that the person in charge of the home is registered with the commission, that staff have supervision or that the present practices protect their health and safety. This judgement was reached using available information including a visit to the home. EVIDENCE: The home, with the knowledge of CSCI, has not had a registered manager for nearly two years for a variety of reasons. Now the change of ownership has taken place there is an expectation that an application will be made for the acting manager to be registered as the manager. The new owner and the acting manager confirmed this on the day of inspection. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 23 Previously the system for managing residents’ personal monies has been safe. It was seen on the day of inspection and found to be the same as before. Minutes were seen of meetings held with residents. They recorded that menus were discussed and new choices for meals proposed, the distribution of towels was explained and some proposals for outings put forward. Residents receive quality assurance questionnaires annually and the collated responses indicate that they are happy with the accommodation and present level of care. Staff spoken with said they do not have supervision. This was confirmed by the acting manager. There is a system of six monthly appraisals for all staff. Records were seen of fire instruction given to staff including fire precautions and prevention. The most recent training was last April but prior to that the training had been every three months. Staff explained that the cleaners trolleys are stored in the staff area when not in use but the cleaning agents are stored in cupboards, one on each floor. The cupboards on the ground floor and the top floor do not have securing mechanisms. The COSHH folder was seen and was not complete. There were agents seen in the building that were not recorded in the folder. Some fire doors in communal areas and corridors have automatic release mechanisms but not all of them. A number of fire doors were seen to be wedged open, in corridors, communal rooms and residents’ own rooms. Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 24 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 1 X 1 Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 25 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 OP7 OP9 Regulation 15(1) 13 (2) Requirement Assessed needs of a resident must be reflected in the care plan. Provision must be made for taking and recording the temperature of the medication refrigerator at least daily. Instruction must be given to staff to ensure they can manage any situation of ‘unsocial’ behaviour in way that maintains the dignity of the resident. The duty roster must reflect all staff working in the home and the hours they work. All checks required for recruitment of staff must be completed before employment and evidence retained in staff files. Staff must receive training appropriate for the work they perform to protect themselves and the residents from harm in the course of doing their job. An application to appoint a registered manager must be sent to CSCI. Timescale for action 10/07/06 31/07/06 3 OP12 12 (4) (A) 10/07/06 4 5 OP27 OP29 17 (2) Sch. 4 (7) 17 (2) Sch. 4 (6) 10/07/06 10/07/06 6 OP30 18 (1) (c) (i) 30/09/06 7 OP31 8 (2) 31/08/06 Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 26 8 OP36 18 (2) 9 OP38 13 (4) (a) (c) 10 OP38 13 (4) (c) 23 (4) (c) A programme of staff supervision 30/09/06 must be implemented so staff have supervision at least twice a year. Cupboards that are used to store 31/07/06 agents that fall under COSHH regulations must be secured and details of all such agents be added to the COSHH folder for staff reference. All fire doors that are required to 10/07/06 remain open during the day must be fitted with self-closure devices to protect resident safety. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Firstlings DS0000067731.V305045.R02.S.doc Version 5.2 Page 28 - 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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