Inspection on 05/12/06 for Genesis Care Home

This inspection was carried out on 5th December 2006.

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

Genesis Care Home 26/06/06

Genesis Care Home 15/03/06

Genesis Care Home 25/05/05

Genesis Care Home 16/02/05

Genesis Care Home 06/07/04

Genesis Care Home 18/02/04

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

CARE HOMES FOR OLDER PEOPLE Genesis Care Home 76 Wimborne Road Bournemouth Dorset BH3 7AS Lead Inspector Sally Wernick Key Unannounced Inspection 11:00 5th December 2006 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 DS0000003942.V321848.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. DS0000003942.V321848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Genesis Care Home Address 76 Wimborne Road Bournemouth Dorset BH3 7AS 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) 01202 515713 01202 762880 Genesis Care Homes Limited Miss Andrea Louise Mangold Care Home 13 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (13) DS0000003942.V321848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2006 Brief Description of the Service: Genesis Care Home is a large, detached house, situated in the Winton area of Bournemouth. The home has ramped access and is a level walk away from nearby local shops, cafes and restaurants, churches and public houses etc. Local buses are available nearby to other parts of Bournemouth as well as Poole, Christchurch and beyond. Visitor parking for several vehicles is available at the front of the home and also on nearby streets. The front garden is mostly laid to lawn with flower borders and there is a more secluded garden with seating available to the rear of the property. The home is registered to accommodate up to thirteen older people with a mental disorder and/or dementia, within two double and nine single bedrooms. Accommodation is arranged on the ground and first floors, with a stair lift available to assist access between floors. Three rooms have en-suite facilities and there are sufficient communal bathrooms and WCs available on each floor. A comfortable lounge/dining room and adjoining sun lounge are available to residents. Twenty-four hour personal care is provided. Laundering of clothing etc is carried out on the premises. Activities are arranged on a daily basis and an inter-denominational religious service is held at Genesis every month. All meals are prepared and cooked within the home. Genesis is owned by Mrs Gene Mangold, trading as Genesis Care Homes Ltd and managed by her daughter, Miss Andrea Mangold. The Borough of Poole Social Services retains a block contract and makes the majority of placements at Genesis Care Home. Current fees range between £472 and £575 per week. A chiropodist visits the home every couple of months and charges residents 10 each visit. A hairdresser also visits and sees all residents two weekly. She charges on average of £14 each visit. See the following website for further guidance on fees and contracts. http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choos.aspx DS0000003942.V321848.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and began on Tuesday, 5 December 2006 taking two inspectors four hours each to complete. This was a ‘key inspection’ where the homes performance against the key National Minimum Standards was assessed alongside progress in meeting requirements made at the last inspection. The registered manager assisted the inspector, as did other members of care staff. Methodology used included a tour of the premises, review of records and discussions with staff. The inspector also reviewed the contact sheet for Genesis and documentation submitted by the registered provider in response to requirements made at the last inspection. The inspectors also sat and chatted with residents in the lounge in order to get a feel for what it is like to live at Genesis. What the service does well: Residents and their supporters at Genesis can be assured that their needs are assessed prior to moving in. Care plans are up to date and generally contain information that enable staff to meet individual care needs. Good medication systems are in place and there are links with other community health providers. During the inspection residents were observed to be treated with kindness and dignity. Family and friends are welcomed at the home at times, which are flexible. The Menu’s offer choice and are well balanced. Individual likes and dislikes can be accommodated. There is a complaints procedure to reassure anyone wanting to complain to the home that they will investigate and respond to their concerns in a timely and appropriate way. A suitable policy and procedure for the protection of vulnerable adults is in place and staff has received relevant training. Residents are cared for in a homely setting by caring people who are supported by good training. There are a good number of staff on duty at any time available to care for residents living at this home. DS0000003942.V321848.R01.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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000003942.V321848.R01.S.doc Version 5.2 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 DS0000003942.V321848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has assessment procedures in place to ensure that only those service users whose needs can be met are offered places there. Genesis does not provide intermediate care standard 6 therefore is not applicable to this home. EVIDENCE: Two files of residents who had come to live at the home since the previous inspection were examined. The Borough of Poole social services has a block contract arrangement with Genesis and makes the majority of placements in the home. Where the local authority is involved the registered manager receives a copy of their assessment and care plan this then forms the basis of the home’s pre-admission assessment. Written confirmation as to the outcome of the assessment is then provided so that residents and their supporters can be assured that their prospective care needs will be met. DS0000003942.V321848.R01.S.doc Version 5.2 Page 9 Previous inspections noted that there was differences between the homes own terms and conditions and that of the Borough of Poole the registered manager confirmed to the inspector that this has now been rectified. Of the two files examined the inspector noted that the pre-inspection information had not been completed and was scant in detail. For one resident previous medical history obtained was in a different language making it difficult for a complete plan of care to be established. Information relating to dementia and associated circumstances was limited for both residents and contact with other community health professionals who may have been consulted had not been fully recorded. Lack of relevant information means that residents care needs may not be assessed or met appropriately. DS0000003942.V321848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst a care planning system is in place it is not robust enough to ensure that staff have sufficient information to meet the needs of residents or to demonstrate that all the needs assessed by the home have been met. Support from community health professionals helps to ensure that the health needs of residents are generally met. There are satisfactory arrangements in place for managing medication. Residents are respected and their right to privacy is supported. EVIDENCE: Each service user has a care plan, which is based on the pre-admission assessment. Care plans are at times informative outlining the personal care needs of each resident and how these are to be met but lack detail about longer term outcomes relating to health and social care. For one resident the care plan identified the need to “divert through activities” but did not say how DS0000003942.V321848.R01.S.doc Version 5.2 Page 11 this could be achieved. For another there was weekly monitoring of blood sugar levels and although these were consistently high there was no evidence of how this was treated or what action needed to be taken by staff. A daily record evidenced personal care given and referred to resident’s mood and behaviour. Where there had been incidents of challenging behaviour by residents however these were not reflected in up to date risk assessments nor was it clear what action was being taken to promote positive long-term outcomes for those living at the home. Senior care staff confirmed that since the previous inspection the home was undertaking accident analysis and was able to identify those who were potentially more vulnerable to falls. This information has not yet been translated into up to date risk assessments. One resident who had been at the home a relatively short time had no risk assessments in place. Records evidenced that there had been contact with other health care professionals it was not always clear for what purpose or what the outcomes were. Lack of a clear record makes it difficult to establish how timely the intervention of community health providers is when staff become concerned about the health of residents. Files examined did contain moving and handling assessments but did not include a section on medication. All staff at the home has received training in person centred care and supporting those with dementia. Care plans could better reflect this for example by indicating preferences for individuals such as likes and dislikes and preferred times of rising and going to bed. Medication is stored securely within the home and a monitored dosage system is in use. A sample of medicine Administration Record charts was checked and well maintained. Allergies are recorded in line with a requirement made at the previous inspection and temperatures of the fridge used to store medicines is monitored and recorded daily. Staff, were observed to speak with service users in a reassuring, kindly and supportive manner and were discreet in carrying out personal care tasks. DS0000003942.V321848.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home satisfies recreational needs and a range of social activities provides variation and interest for the residents. Residents are assisted to maintain contact with family, friends and the wider community. The home does seek out ways in which service users may participate in daily life and making decisions however more documented evidence is required to demonstrate that residents are able to exercise choice and control over their lives to the best of their ability. A balanced and varied selection of food is available that meets residents tastes and dietary needs although fresh fruit and vegetables are not always available. EVIDENCE: Emphasis at the home is on “person centred activities” which focus on each resident and their individual needs. To assist in this information about each resident’s past life hobbies and interests is recorded often contributed by family and friends and activities are structured around individual likes and DS0000003942.V321848.R01.S.doc Version 5.2 Page 13 dislikes. The registered manager told the inspector that there are currently no group activities at the home residents were observed to be sitting comfortably in each other’s company however. Each resident has a memory box and time is spent with key workers on positive reflection. There are a variety of board games, books and videos available and residents were seen enjoying picture book colouring, reading, playing board games and talking with staff and each other. On the day of the inspection there was a homely comfortable atmosphere within the lounge and residents spoken to confirmed their well being. Visitors were at the home on the day of inspection and are able to come at a time, which is suited to the resident. Birthdays and special occasions are always celebrated and families are invited for lunch at Christmas. Where possible the registered manager confirmed that residents are offered choice and control as far as their health and general abilities allow such as food preferences, clothing for the day and choice of activities. The support the home offers in this process is not measurable however, as there is little documented evidence of how residents exercise choice or how through care plans staff are able to translate this. Daily food records evidenced that a variety of balanced nutritious food is served. Lunch on the day of inspection was curry a choice is always available however and residents enjoyed their lunch in a relaxed and unhurried fashion. Fresh fruit and vegetables were not in evidence as the registered manager stated a delivery was due the following day. Care must be taken to ensure that there is sufficient fresh produce for the whole week in order that individual choices may be accommodated and residents nutritional needs can be met. Frozen produce was stored correctly although the initial date of purchase and storage was not recorded. Dried goods had been decanted and stored correctly. Standards of hygiene within the kitchen were good although one table looked rather tired and would benefit from update or replacement. DS0000003942.V321848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A system is in place to deal with any complaints that might be made about the home to ensure that concerns will be listened to and acted upon. The home has an appropriate adult protection policy and procedure in place to ensure residents are protected from possible abuse. EVIDENCE: The home has a clear and up to date complaints procedure, which is provided to residents and their supporters on admission to the home. No complaints have been received by the home since the last inspection. An adult protection policy is in place and clearly states the action to be taken in the event of an allegation or concern. The home has up-to-date policies and procedures in place to protect residents from possible harm or abuse and staff, undertake regular training in the Protection of Vulnerable Adults. DS0000003942.V321848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to pleasant indoor and outdoor communal facilities although this continues to be compromised by demolition and re-building next door. The home is generally, pleasant and hygienic for the benefit of the people living there. Unguarded heated towel rails in bathrooms however pose a potential risk to residents. EVIDENCE: Genesis is an attractive property with mature gardens that are laid to lawn although at the current time due to the lack of fencing this area is not sufficiently secure for those residents who may wander. Given the cold weather residents prefer not to access external areas as frequently as in the summer action should be taken however to ensure that longstanding issues with neighbours over the fence will be resolved long before the warm weather. DS0000003942.V321848.R01.S.doc Version 5.2 Page 16 Those residents who wish to access external areas are supervised by staff to ensure their safety and well being. The inspector noted an amount of old furniture and debris to the side of the building this affects the appearance of the home and should be removed. Communal areas are comfortable, bedrooms are light and airy and are personalised to some degree. Some rooms are carpeted but others have floor coverings that are more suited to the individual. Bathrooms are dated but are generally clean with the exception of some downstairs toilets and the rear strapping of a bath-chair, which require intensive cleaning. Wardrobes in some rooms are not secure and present a hazard to residents. The registered manager agreed to take action to ensure that these were made safe as a matter of priority. Hand washing facilities are limited for staff and residents and it would be good practice to provide paper towel dispensers to further prevent any risk of cross infection. Previous inspection reports have highlighted the lack of heating in bathrooms and W.C’s. The only heating in bathrooms comes from heated towel rails, which have hot surfaces. The previous inspection report indicated that the towel rail in the bathroom on the first floor had been disabled although during this inspection this was found not to be the case and was found to be extremely hot presenting a real risk of scalding. The laundry was found to be in good order with sluice facilities and an up to date laundry policy. The home was free from any unpleasant odours. DS0000003942.V321848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are sufficient to ensure that the needs of residents are met. Robust recruitment procedures are in place to ensure the protection of residents living at the home. Residents are cared for by staff that mostly has relevant qualifications from abroad along with access to local training which enables them to have the skills and knowledge necessary to meet the assessed needs of residents. EVIDENCE: Staff cover at Genesis remains high enabling staff to deliver individual care to residents. The registered manager confirmed that there are normally four care staff on duty during the day, one cleaner and a further member of staff qualified in food hygiene preparing meals in the kitchen. Good staff levels mean that there is a lot of interaction with residents, which the inspectors observed contributed to a positive stimulating and friendly environment on the day of inspection. At present only one member of staff has National Vocational Qualifications (NVQ) level 2, although two further staff have commenced this programme of study and it is anticipated that more staff will begin training for this DS0000003942.V321848.R01.S.doc Version 5.2 Page 18 qualification early next year. Some staff at the home has nursing qualifications from abroad although many have no previous experience of working in a residential care home. The home has a thorough recruitment procedure and staff files evidenced that all the necessary documentation was in place to ensure the safety of residents. The home employs a number of workers from abroad. The files evidenced that the home was obtaining the right sort of information about people’s rights to work in the country and any restrictions on that work. Records are kept of training that staff undertake. These records showed that staff have access to a good range of training and receive their regular mandatory updates. In house induction had been completed for one member of staff although this was not yet in line with Skills for care. The registered manager was directed to the web site to enable her to obtain guidance on the new common induction standards see www.skillsforcare.org.uk. The home’s induction programme must be updated to reflect these changes. Examination of training files shows a variety of training has taken place for example: working with people with mental illness, learning difficulties and vulnerable adults, bereavement and listening skills, personal care, insulin management, moving and handling, first aid, anti-discriminatory practice protection of vulnerable adults and dementia care. A staff training matrix identified where staff required training and had been updated in line with a requirement made at the previous inspection. DS0000003942.V321848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced in working with older people with dementia, but has still not achieved completion of the National Vocational Qualification (NVQ) level 4 in management and care, to ensure she has the necessary qualifications to carry out her responsibilities in full. The home does review its performance through a programme of consultations, which include seeking the views of residents, staff, relatives and other visitors to Pinewood Tower to ensure the home is run in the best interests of residents however this needs to be further extended. Resident’s financial interests are safeguarded. The home generally follows practices that promote and safeguard the health, safety and welfare of service users. DS0000003942.V321848.R01.S.doc Version 5.2 Page 20 EVIDENCE: The inspection report dated 6 July 2004 states, “The registered manager, Miss Mangold, has experience of working with older people with dementia and mental disorder and is currently undertaking her National Vocational Qualifications (NVQ) level 4 in management and care”. Miss Mangold has still not achieved her registered managers award-equivalent to NVQ level 4 in management. She has had to make changes in her choice of training course, which has caused delays beyond her control and has also been absent from work for a period of months. Once she has completed her registered managers award Miss Mangold will need to undertake an NVQ 4 in care at level 4. Quality assurance questionnaires are distributed annually to relatives, G.P’s district nurses, community psychiatric nurses and care managers, although very few of these are ever returned it is recommended therefore that this practice be repeated. Similarly staff views are sought through formal questionnaires, staff meetings and supervision. Resident’s views are sought in an informal manner through their key worker although these are not generally recorded. Given the frailty of most residents it would be difficult for them to express their views in a written document. Once views are sought the registered manager reviews them but was not able to say what action had been taken as a result of the information given. It is recommended therefore that results of surveys are collated and fed back through the homes annual development plan and in a format, which can be easily understood by family, supporters and other stakeholders. In order to protect residents, it is the policy of the home not to have any involvement in their personal finances. All residents who are unable or do not wish to handle their own affairs, have a relative or other representative to support them in managing their finances. The home pays for services such as chiropody and hairdressing and keeps a record of what is owed. The amount is then invoiced to relatives or representatives for payment each month. Policies and procedures are available to guide staff in health and safety issues, Control of Substances Hazardous to Health, infection control, fire safety and moving and handling. Records demonstrate that appropriate maintenance and checks of the fire warning system, emergency lighting and fire fighting equipment are taking place to ensure resident safety. Staff regularly undertake fire drills and fire training. A record to evidence servicing of the boiler was not available although the registered manager confirmed that this had recently taken place. This document is to be forwarded to the commission for social care for verification. DS0000003942.V321848.R01.S.doc Version 5.2 Page 21 Accidents and incidents are being recorded and held in line with data protection. An analysis of incidents is taking place and is being used to minimise future accidents. This needs to be extended to care plans and resident risk assessments (see standard7). Products are stored safely and in line with a requirement at the previous inspection water tanks are properly lagged. DS0000003942.V321848.R01.S.doc Version 5.2 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X X DS0000003942.V321848.R01.S.doc Version 5.2 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. Standard Regulation 4& schedule 1. Requirement Information gained at preadmission assessment must be sufficiently detailed to formulate an effective plan of care. Care plans must contain sufficient information needed to direct care staff to care for the resident person, incorporating the outcomes of all assessments carried out. A section must be included in the care plan on medication. Risk assessments must be reviewed and updated. (Previous timescale of 01/09/06 not met) Blood sugar levels must be monitored as stated in the care plan and there should be information on what to do if levels are outside the recommended range. (Previous timescale of 31/07/06 not met). Individual resident’s ability to exercise choice must be documented in their care plan and made reference to in their daily notes. The registered persons must ensure that the heating in communal bathrooms meets the relevant health and safety DS0000003942.V321848.R01.S.doc Timescale for action 06/01/07 1. OP3 2. OP7 15 06/02/07 3. OP9 12 and 14 06/01/07 4. OP14 12 06/02/07 5. OP25 23 06/01/07 Version 5.2 Page 24 6. OP31 18 requirements and the needs of individual residents. (enforcement action may now be taken as previous timescales have not been met) It is required that the manager obtains NVQ level 4 in both management and care. 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Where daily records are kept they should demonstrate the full range of care given to residents and be descriptive where events occur outside of those predicted. It should be clear why health professionals are involved and what has to be followed through in respect of care following their visits/ interventions. To prevent the spread of infection paper towels and hand washing facilities should be provided to staff, visitors and residents. Greater care should be taken to ensure the cleanliness of W.C’s and bath aids. A minimum of 50 of care staff employed by the home should have NVQ level 2 or equivalent. The Registered manager must develop quality assurance methods based upon seeking the views of service users and other interested parties, to ensure success in achieving the aims and objectives of the home. An annual development plan must be produced reflecting the outcome of the consultation. 1. OP7 2. 3. OP26 OP28 4. OP33 DS0000003942.V321848.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000003942.V321848.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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