Inspection on 08/11/05 for George Potter House

This inspection was carried out on 8th November 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

George Potter House 27/09/07

George Potter House 24/05/06

George Potter House 01/04/05

George Potter House 09/09/04

George Potter House 15/04/04

George Potter House 20/10/03

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

CARE HOMES FOR OLDER PEOPLE George Potter House 130 Battersea High Street Battersea London SW11 3JR Lead Inspector Jon Fry Unannounced Inspection 8th November 2005 10:50 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 George Potter House DS0000019091.V258121.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. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service George Potter House Address 130 Battersea High Street Battersea London SW11 3JR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7223 3224 020 7223 6984 Sovereign (Geoge Potter) Ltd Miss Adri Jane Leonie Skipper Care Home 69 Category(ies) of Dementia (33), Old age, not falling within any registration, with number other category (36) of places George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Levels No of Service Users 8am – 2pm 2-8pm 8pm-8am TN CA TN CA TN CA 51-553 8 3 7 2 3 56-603 9 3 8 2 4 61-653 10 3 9 2 5 66-694 10 4 9 2 5 Reviews The organisation must ensure that the above minimum staffing levels remain under review and that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users. Distribution of Staff The number and distribution of nurses care staff and ancillary staff must be reviewed at regular intervals. If at any time the evidence indicates that there is insufficient staff of any categories available to meet the assessed needs of service users, the NCSC will require additional; staffing as appropriate. Exception to age of one service user Agreement is given for the home to continue caring for the service user currently resident in the home who is aged 39. However, an urgent review must take place by the 30/09/03 to look at her needs, as this home is not suitable for this service user long term. The service user has a mental health problem as well as a mild learning difficulty. From the assessment made at the time of placement it is not clear why this home was deemed suitable for her. 19th April 2005 2. 3. 4. Date of last inspection Brief Description of the Service: George Potter House provides accommodation and nursing care for sixty-nine older people. This may include thirty-three individuals with dementia. The home is owned by Sovereign (George Potter Ltd) and is situated in Battersea, within easy reach of local shops and Clapham Junction train station. Accommodation is provided over two floors serviced by a lift. The upper floor unit is for residents with dementia. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over six hours by three regulation inspectors on the 8th November 2005. The inspectors spoke individually with fifteen residents, one visitor, the manager and seven members of staff. A number of records were examined, as well as a tour of the home. A monitoring visit had previously been made to the home on the 9th August 2005. Requirements were made following this visit regarding the poor cleanliness of the home, the poor state of repair of some seating provided for residents and to make sure that potentially hazardous cleaning materials were kept locked away at all times. A further visit was made on the 31st August 2005 and it was found that the home had taken action to address the above Requirements. An Enforcement Notice was also issued in August 2005 concerning the poor condition of carpeting in the communal hallways of the home. This Notice requires the registered persons to replace the carpets and comply with the applicable Regulations or be liable to prosecution without further notice. The registered provider has stated that this work is due to be fully completed by January 2006 as required by the CSCI. A specialist Pharmacist inspector made an unannounced inspection visit to the home on the 23rd August 2005 and their findings are included within this report. What the service does well: What has improved since the last inspection? George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 6 The work of the manager and her team continues to show improved outcomes for the residents living at the home. The cleanliness of the environment has improved since the previous inspection visits in August 2005. Ten new chairs have been provided in the communal lounges and one length of new carpet has been fitted in a ground floor hallway. Hazardous substances such as cleaning materials are now kept safely locked away. An Environmental Health Officer visited the home in November 2005. They reported that the hygiene of the premises was ‘very good’ and recommended the home for a Food Safety Award. 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. George Potter House DS0000019091.V258121.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 George Potter House DS0000019091.V258121.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): 1 and 3. Resident’s benefit from their needs being appropriately assessed before admission. The home has produced a Statement of Purpose and Service User Guide that provide satisfactory information on the home to prospective residents. EVIDENCE: There is an appropriate procedure to make sure that the individual needs of a resident are assessed before they move into the home. These assessments were seen within the care files examined on the day of inspection. The Statement of Purpose and Residents (Service User) Guide give satisfactory information for prospective and present residents about the home. Both documents have been updated to include a clear statement about charges and interest for money held on behalf of residents by the home. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 9 A Requirement was made at the last inspection for the home to ensure that the placement of one resident under the age of 50 be reviewed with the involvement of the placing Local Authority. This meeting had taken place and the manager said that further social opportunities were being looked at for this individual. George Potter House DS0000019091.V258121.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, 9 and 10. Individual care plans require further development to ensure that all care needs are fully addressed. The documentation must be further personalised to the individual. Individual health needs are addressed. Care documentation such as wound and pressure sore assessments require further development to ensure these are detailed in content and fully address the identified problem. Arrangements for the safe ordering, storage and recording of medication are in place and staff have access to a pharmacist for advice to protect the health of service users. Errors in recording the receipt of medication made it difficult to assess if all service users had received their correct medication and poor practice in administration of medication may put the health and welfare of service users at risk. EVIDENCE: Each resident is provided with an individual care plan. The inspectors looked at six care plans within both units of the home and these were seen to be reviewed on a monthly basis. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 11 The home must continue to identify ways to make the care plans more personalised to residents and to clearly say how individual needs and preferences are to be addressed. Any generic pro-forma documentation used must be personalised to the individual with all statements that do not apply clearly struck out. This is not done consistently within the care plans and results in very generalised plans of care with statements made such as ‘may use sign language’ or ‘encourage self performance’. Two out of the six care plans contained a life history. In one instance some good background information was seen to be available within a social work assessment but the relevant section in the care plan included the note ‘unable to ask resident or relative’. Assessments completed around pressure sores or wounds must clearly detail actions taken to address individual needs. If a resident is identified as being at risk of developing a pressure sore then clear actions must be recorded within the plan of care. Direct care was generally seen to be delivered politely and respectfully. One instance was however observed on the ground floor where a resident in a wheelchair was taken to the dining room for lunch without the staff member informing them beforehand. Notices were also displayed on the walls of first floor communal lounges referring to one resident not being given grapefruit and the correct use of wheelchairs on the unit. This information must be displayed in the staff office and not in a residents lounge. The use of whiteboards in communal hallways to display resident’s names should also be reviewed. The manager reported that there was a shortage of linen at the home at the time of inspection. The quantities must be audited and new linen purchased immediately as required. The findings of the Pharmacist Inspector following the visit undertaken on the 23rd August 2005 were as follows: All medications in the offices, and records relating to receipt, storage, administration and disposal of medication were examined. The manager, deputy manager and two staff members were interviewed. All medication not supplied in the monitored dosage system was counted and compared to the records of receipt and administration to ensure service users were receiving medication as prescribed George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 12 From these observations and discussions all medication was stored securely and under the correct storage conditions and alterations to medication clearly documented. Regular audits are performed of medication records. Two service users did not have the receipt of medication recorded accurately and five service users did not have the amount of medication carried over from one month to the next recorded on the current administration record making it difficult to calculate whether these service users had been given their medication in accordance with the doctors directions. There were no missing entries indicating administration/non-administration of medication on the administration records. One service user had been administered medication that had been prescribed for another service user. It was the same medication and the quantity in stock and administration records confirmed that the correct amount of medication had been given. One service user admitted for respite care was being administered medication supplied in an unlabelled compliance aid. Staff could not be sure that the medication in the compliance aid was the medication that was supposed to be administered. A new supply had been ordered and was obtained on the day of inspection. Another service user was supplied medication in a monitored dosage system supplied from the pharmacist that did not allow individual medications to be identified. Staff could not identify the individual medications putting the health of the service user at risk if the doses of medication were altered. The amount of medication in stock and completed records indicated that all other medication had been administered correctly unless otherwise recorded and where service users continuously refused medication appropriate action is taken. George Potter House DS0000019091.V258121.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, 14 and 15. Daily activities are available to residents but this provision could be further improved. The meals served are generally to a good standard. Further improvements could be made within the first floor unit to make sure that individual needs are fully catered for. EVIDENCE: Social care plans have been developed for each resident by the activities coordinator and these are now reviewed on a monthly basis. Areas for development include making sure that the documents provide a detailed plan of care for each resident. One care plan stated that a resident enjoyed 1-1 sessions and these should be done on a daily basis but failed to say what kind of activities should be provided within this session. All members of care staff must ensure that they are fully aware of the social and emotional needs of residents and the monthly review process must be used to develop the care plans in place. The social care plans are currently kept in a separate file and these must be included within the main care plan for each resident. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 14 A list of planned activities was displayed in the home and included Christmas entertainment, parties and a trip to see the Christmas lights in central London. One resident spoke about the fireworks display held at the home and another resident said they “liked the parties”. A visitor stated that the Birthday celebrations for residents were lovely but thought that there could be “more activities available”. Residents gave positive comments on the food provided. Comments included “the food is good”, “food pretty good” and “ a nice dinner”. The lunch served on the day of inspection was presented well with a choice of chicken and pineapple or beef with peppers with fresh fruit and yoghurt available. Biscuits and cake are served with the mid morning and mid afternoon tea and coffee. Only one dining room on the first floor was in use with the majority of residents taking meals in their own rooms or in the communal lounges. The home should look at the communal areas available on this floor with a view to making more dining room space available. Three minor issues on the first floor were highlighted regarding the lack of condiments provided and making sure that food is covered when being taken to residents. Old ice cream cartons should not be used to store sugar and cereals within the dining room. The home should further consider how residents could be consulted on issues such as the menus as formal resident meetings are not held currently. Different ways of presenting food could also be looked at particularly for residents with dementia. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 15 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 and 18. A satisfactory complaints procedure is in place that is supplied to residents on admission to the home. The organisational procedure details the actions to be taken should there be any allegation or suspicion of abuse. All staff must be provided with training on the protection of vulnerable adults. EVIDENCE: The Residents (Service Users) Guide contains the complaints procedure for reference by individuals. The contact details for the CSCI are included within this document. The home keeps a record of any complaint along with actions taken and outcomes. One complaint had been recorded since the last inspection of the home. The manager was still looking into this issue. The organisational procedure outlines the action to be taken should there be any allegation or suspicion of abuse. Copies of the local authority policies and procedures for the protection of vulnerable adults (POVA) were not available at the time of inspection. One POVA issue has been investigated by the home since the last inspection took place. A Requirement has been made for the home to confirm whether a referral was made to the POVA list. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 16 The manager reported that there had been no recent training provided around abuse awareness. A Requirement has been made for the home to ensure that all care staff working at the home have received this training. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 and 26. Minor improvements have been made to the décor and furnishings since the previous inspection. Further work must take place to create a pleasant environment for residents. The continued lack of sustained investment reflects poorly on the home and the registered provider. The bathroom facilities meet the needs of residents currently accommodated. The home is maintained to a good standard of cleanliness and kept free from offensive odour. This standard must be now be kept to at all times. EVIDENCE: A new carpet had been laid in one corridor of hallway in the ground floor unit at the time of inspection. This has improved the appearance of this area and the provider must ensure that the replacement of communal carpeting throughout the home is carried out as planned. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 18 New carpeting was seen to be required in the communal lounges throughout the home. The manager reported that this work was planned along with the replacement of the hallway carpets. Part of one first floor lounge area was being used for storing hoists. A dining area on this floor was not being used at all. The home should consider how best to use the available communal space on this floor and to also try to make these areas more homely for residents. Ten new chairs had been provided in the communal lounges following a Requirement made at the inspection visit to the home in August 2005. Two older chairs in a first floor lounge still require immediate replacement and others in use present poorly. All areas of the home seen at the time of this inspection were clean, tidy and free from offensive odours. This standard must be kept to consistently and not be allowed to drop as happened previously following the April 2005 inspection. A number of bedrooms were seen to be well maintained but this standard is not consistent throughout the service. Minor maintenance issues were found such as broken toilet seats in two ensuite bathrooms. As stated within the April 2005 inspection report, doors to resident bedrooms should be fitted with protective panels to prevent further damage from observed wheelchair scrapes etc. The Requirement has been re-stated for a full audit of individual bedroom accommodation to be carried out as the manager stated that this had not yet been completed. This will make sure that a consistent standard of good quality accommodation is provided. A planned programme for the replacement of the windows throughout the home is still not in place and these are repaired by the homes handyman as required. The staff locker room and provided toilets also require decoration and new flooring. Both issues were commented on by staff members at the time of inspection. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staffing levels are adequate to meet the care needs of residents currently accommodated. The training provision for care staff must be improved to make sure that they are fully able to meet the needs of residents. Residents are protected by the homes recruitment procedures. EVIDENCE: Comments from residents regarding staff included “got nice people here”, “nice people, nice manners”, “the staff are good” and “the staff are responsive”. The manager reported that there had been fewer training opportunities for care staff since the April 2005 inspection. There is no organisational programme of training and the manager does not have control of a training budget for the home. Recent courses provided for care staff include moving and handling and in-house sessions on constipation and pressure sores. It is essential that further training be provided around abuse awareness, dementia and person centred planning. The individual training records must be kept up to date and it is recommended that this be done at each supervision session. An in-house induction pack is in use for new staff. These training materials require review to ensure that these are consistent with the national Skills for Care common induction standards. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 20 NVQ training is still not in place for care staff. It is noted that this was the situation at the time of the April 2005 inspection visit. The home carries out appropriate checks including Criminal Records Bureau (CRB) checks on staff before they start work in the home. This process helps to ensure the protection of residents. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38. The manager and her staff team continue to make progress in improving the care provision at the home. These developments must be more effectively supported by the organisation in terms of available resources and physical improvements to the home. The systems in place for consultation with residents and their representatives could be improved. More regular supervision must be given to staff providing direct care to residents. This will further support the development of good practice within the service. Further checks need to carried out on the building and equipment to ensure the health and safety of residents, staff and visitors to the home. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 22 EVIDENCE: The organisation must more effectively support the manager and her staff in making improvements to the service. An organisational training programme is not currently in place and the manager stated that she is not in control of the financial budget for the home. The slow progress in making physical improvements to the home also impacts on staff morale and reflects badly on the provider. A system for staff supervision is in operation but the home must make sure that full-time staff receive a minimum of six supervisions annually. The manager reported that the nursing staff have now been trained to give supervision and care staff are now receiving around four 1-1 sessions annually. The organisation should additionally make sure that the manager of the home receives regular supervision from her own line manager. A quarterly relatives meeting was being held on the day of inspection. Residents meetings are not currently held and the manager reported that she chats with residents regularly on an informal basis. It is strongly recommended that the home look at how the views of residents could be formally and regularly obtained. An annual development plan must also be put in place for the service and this should be informed by the views of residents, their family and friends as well as other stakeholders such as visiting health professionals. Regular checks are carried out on equipment and the building to ensure the safety of residents, staff and visitors to the home. An Environmental Health Officer visited the home in November 2005. They reported that the hygiene of the premises was ‘very good’ and recommended the home for a Food Safety Award. Records showed regular checks on the fire alarm system, hot water outlets and checks on the water system for Legionella. Consistent monthly checks must however be made on First Aid boxes as these were not happening in the ground floor unit. Records for annual gas safety checks, portable appliance testing and five yearly electrical installation checks were not available at the time of inspection. Records of freezer temperatures showed levels outside of the recommended range with no actions taken recorded by staff. The bath hoists required servicing as from September 2005 and it was not clear whether these had been completed. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 23 The inspectors were informed that the lift had previously been out of order for seven weeks and this had not been reported to the CSCI. The manager must ensure that all incidents adversely affecting the welfare of residents are notified to the Commission. George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 3 X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 2 George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12 (1) 15 (2) care plans are generated from a comprehensive assessment and detail the action which needs to be taken by staff to ensure that all individual aspects of the health, personal and social care needs of the residents are met, care plans must be individualised for each resident and include all relevant information such as background and likes & dislikes, the plans must be signed by the resident or representative where appropriate. Requirement The Registered Persons must ensure that: Timescale for action 01/03/06 2 OP8 12 (1) 17 (1)(a) The Registered Persons must ensure that: wound assessment documentation is consistently completed for all residents as required, 01/03/06 George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 26 clear actions must be recorded within the care plan to address identified health needs. 3 OP9 13 (2) The Registered Persons must ensure that the receipt of all medication is recorded accurately. (Requirement issued following pharmacist inspection 23/08/05). The Registered Persons must ensure that all medication is administered from appropriately dispensed and labelled containers. (Requirement issued following pharmacist inspection 23/08/05). The Registered Persons must ensure that medication for one service user is not used for another. (Requirement issued following pharmacist inspection 23/08/05). The Registered Persons must ensure that staff are able to identify the individual medications that they administer. (Requirement issued following pharmacist inspection 23/08/05). The Registered Persons must ensure that the home is run in a manner that respects the privacy and dignity of residents. This is with reference to personal information being displayed in communal lounges and ensuring that care staff communicate effectively with residents at all George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 27 01/09/05 4 OP9 13 (2) 01/09/05 5 OP9 13 (2) 01/09/05 6 OP9 13 (2) 01/09/05 7 OP10 12 (1) 12 (4) 01/12/05 8 OP10 16 (2) (c) 9 OP12 12 (1-3-5) 15(2) 25(1) times. The Registered Persons must ensure that sufficient quantities of linen / bedding are available at the home at all times. The Registered Persons must ensure that detailed care plans are in place with regard to individual social needs / activities. All care staff must be aware of the social and emotional needs of residents. Sufficient resources (financial / equipment) must be made available to support the provision of activities at the home. 01/12/05 01/03/06 10 OP15 16 (2) (i) The Registered Persons must ensure that: condiments are provided for residents use with each meal, food is covered when being taken to residents, suitable storage is provided for tea, coffee and sugar as available in communal areas. 01/12/05 11 OP18 13 (6) The Registered Persons must ensure that: a copy of the Local Authority POVA procedures are kept at the home for reference purposes, written confirmation is supplied to the CSCI that a referral was made to the POVA list with reference to the recent POVA issue at the home. 01/01/06 12 OP19 23 (2) (b) The Registered Persons must ensure that the carpet in both DS0000019091.V258121.R01.S.doc 01/02/06 Page 28 George Potter House Version 5.0 13 OP19 23 (2) (b) the ground and first floor communal lounges is replaced. The Registered Persons must ensure that: doors to resident bedrooms must be re-painted and protective panels fitted to prevent further damage, hallways must be repainted as part of a planned short-term programme of decoration, chairs provided for residents use are in good condition and suitable for purpose, toilet seats are secure and in good repair throughout the home, the curtains provided in the ground floor communal lounge are replaced, replacement tablecloths for the dining areas are provided. 01/03/06 14 OP19 23 (2) (b) The Registered Persons must ensure that a full audit of bedroom accommodation is carried out. This must identify areas for re-decoration and for the replacement of worn carpeting and furnishings. A planned programme for renovation / replacement as required must be formulated and be supplied to the CSCI within the timescale specified. The Registered Persons must ensure that 50 of care staff have obtained, or are studying for, the NVQ Level Two award. The Registered Persons must ensure that all care staff receive DS0000019091.V258121.R01.S.doc 01/03/06 15 OP28 18 (1) (c) 01/04/06 16 OP30 18 (1) (c) 01/04/06 George Potter House Version 5.0 Page 29 training in abuse awareness, dementia and person centred care planning. Full and up to date records of training must be kept for each staff member. The Registered Persons must ensure that the training materials for new care staff are to Skills for Care common induction standards. The Registered Persons must ensure that a system for reviewing and improving the quality of care provided at the home is established. This system must provide for consultation with residents and their representatives. 19 OP36 18 (2) The Registered Persons must ensure that all care staff receive a minimum of six 1-1 supervisions annually. (Pro-rata for part-time staff). Full records must be kept to evidence this provision. The Registered Persons must ensure that: monthly checks of First Aid boxes are carried out, freezers are operating within recommended temperature ranges, bath hoists are serviced as required. 20 OP38 13 (4) The Registered Persons must ensure that satisfactory and up to date records for annual gas safety checks, portable electrical DS0000019091.V258121.R01.S.doc 17 OP30 18 (1)(c) 01/03/06 18 OP33 24 (1-2-3) 01/04/06 01/01/06 19 OP38 13 (4) 01/12/05 01/12/05 George Potter House Version 5.0 Page 30 21 OP38 37 (1-2) appliance tests and five yearly electrical installation tests are kept in the home. The Registered Persons must ensure that notifications are made in writing to the CSCI as required. 01/12/05 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 OP9 Good Practice Recommendations It is recommended that the quantity of medication carried over to the next month is recorded on the administration record for all medication not supplied in the monitored dosage system. (Recommendation made following pharmacist inspection 23/08/05). It is recommended that the use of whiteboards in communal areas to display residents names or information is reviewed. It is strongly recommended that social / activity care plans are included within the main care plan document for each resident. It is recommended that the home look at the current usage of communal areas on the first floor. This is with a view to making more dining space available for residents. It is recommended that the home look at ways of making the first floor lounges more homely for residents. It is recommended that the staff locker room be redecorated and new flooring provided. The home should look at ways to effectively consult residents about the way the home is run. Consideration should be given to holding regular residents meetings. 2 3 4 5 6 7 OP10 OP12 OP15 OP19 OP19 OP33 George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 George Potter House DS0000019091.V258121.R01.S.doc Version 5.0 Page 32 - 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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