Inspection on 18/06/07 for Gerald House

This inspection was carried out on 18th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gerald House 12/06/06

Gerald House 12/01/06

Gerald House 11/08/05

Gerald House 10/03/05

Gerald House 21/06/04

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

CARE HOMES FOR OLDER PEOPLE Gerald House 4 Gerald Road Oxton Birkenhead Wirral CH43 2JX Lead Inspector Beate Field Unannounced Inspection 18th June 2007 10:30 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 Gerald House DS0000018888.V335979.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. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gerald House Address 4 Gerald Road Oxton Birkenhead Wirral CH43 2JX 0151 652 1606 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) Mr George Alan Shone Mrs Kamini Shone Mrs Kamini Shone Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named adult with a learning disability under 65 years of age in an overall total of 18 Two named adults under 65 years of age in an overall total of 18 Date of last inspection 12th June 2006 Brief Description of the Service: Gerald House is a detached property situated in Oxton, near Birkenhead, Wirral. The home is registered to provide personal care to 18 older people. Variations are currently in place to enable 3 adults under 65 to reside at the home. The accommodation is provided on two floors with access to the first floor by stairs and a passenger lift. The home has 15 bedrooms, which, are all used as single rooms. A number of bedrooms have en-suite facilities. There are bathrooms and bedrooms on both floors of the home. Residents have access to a large lounge and dining area. Outside there are car parking spaces to the front and a reasonably sized, enclosed rear garden. Gerald House is located in a residential area. There are some local shops within walking distance and the home is on a bus route to Birkenhead. At the time of this inspection, the weekly fees for the home ranged from £375.00 to £410.00. Additional charges are made for hairdressing, newspapers and chiropody. A service user guide and a statement of purpose, which describe the services offered is available to new residents, their relatives and professionals before a resident comes to live at the home. A copy of the most recent inspection report can be obtained from the manager. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is based on a site visit to the home over a 7 hour period and is also informed by information received about the service since the last inspection and by questionnaires completed by the manager, residents, their relatives and health and social care professionals who visit the home. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager/owners. A tour of the home was undertaken. The inspector spoke with residents and staff and made observations of the care given by staff. What the service does well: What has improved since the last inspection? There has been ongoing improvement to the decoration of the premises. A fuller record is being made of reviews of care plans. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 6 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. Gerald House DS0000018888.V335979.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 Gerald House DS0000018888.V335979.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): 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs assessed before moving to the home and benefit from being able to make trial visits. EVIDENCE: The manager visits all prospective residents to carry out an assessment before they are offered a place at the home. The records of two new residents who had moved to the home since the last inspection were seen. The assessment documents identified the main areas of need for each of the residents and provided the basic information from which a care plan could be developed. Residents spoken with had been asked about their needs during the Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 9 assessment. Written assessments by social workers were available as appropriate. Residents spoken with and staff confirmed that prospective residents are able to visit the home on an introductory basis. During these visits they can meet staff and current residents and view the home. Contracts were available for the new residents and were in the process of being signed by the resident and/or their representative. The contracts covered the required information. Some residents said they had a copy of their contract, some said they had not received one and some could not remember having received a copy. Evidence that residents who had been at the home for over 12 months had been given up to date written information on the fees payable at the home could not be located during the visit. Residents spoken with were unsure if they had received this information. The owner/manager reported that this information is available. Gerald House DS0000018888.V335979.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. Staff are aware of the needs of residents and how to meet them, however, staff are not provided with sufficient written information to meet the needs of residents. Residents are treated with respect. EVIDENCE: A sample of residents’ care plans were seen. Care plans are kept separately from the main care file and are made directly available to staff. These plans indicate the basic needs of residents but do not provide sufficient information for staff around the action to be taken to meet these needs. For example, how staff are to support residents with their personal care needs, mental health needs and how to manage any difficult behaviours is not indicated. The contact residents have with their relatives and any support needed to manage Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 11 their finances is not clearly detailed. A discussion took place with the manager around the action that needs to be taken to address this. The staff spoken to were aware of the needs of the residents whose records were inspected, and how to meet these needs. Records show that the occurrence of falls is minimal. Risk assessments in relation to falls were examined. These assessments do not provide sufficient guidance to staff on the actions to be taken to minimise the risk of falls. The assessments do not indicate how to make sure a safe environment is provided, how nutritional and medication factors may be significant. This needs to be addressed so as to provide detailed information on falls prevention. There was evidence to show that reviews are being undertaken on a monthly basis. A fuller record is being made of reviews of care plans. However, the review did not always refer back to the plans of care for individual residents. It is important for the ongoing care and support of residents that reviews identify any progress or regression in their needs and any amendments to the ways in which staff provide support are identified and recorded. In this way the home can demonstrate that they are providing each resident with the support that is necessary to keep them safe. It is recommended that further information be gathered for all residents around their social history in accordance with the wishes of the residents. This should include details of their family and work history and significant life events. This information would further inform care planning. The residents spoken to and most who returned questionnaires said that they are well cared for at the home. When asked about the care they receive from staff, residents said, “the care is very good,” “we are well cared for” and “I feel safe here.” The records at the home and a discussion with the manager indicated that referrals are made to health professionals in accordance with the needs of residents. A record is made of visits by health professionals and the outcome is documented. Comments received from a health care professional indicated that the manager manages the needs of residents well and has “improved their self esteem and confidence.” A sample of the medicine administration record (MAR) sheets and corresponding medications were inspected and found to be correctly maintained. Staff who administer medication have been trained in the administration of medication by the manager. The manager and some staff have attended an accredited training course. Some staff have also completed training around giving medication as part of an NVQ in care of the elderly. The manager is currently looking at arranging for further staff to receive accredited training in the safe handling of medication. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 12 Staff were observed to treat residents with respect. Staff were observed to speak to residents in a respectful manner and knocked at bedroom doors before entering. The residents interviewed said that the staff respect their privacy and are “polite,” and “friendly.” Staff receive guidance on promoting the dignity of residents. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The wellbeing of residents is promoted by the flexibility of the daily routines, visitors being made welcome to the home and the provision of well balanced, appealing meals. EVIDENCE: Records show that a range of activities are made available for residents. These include local walks, going out for an evening meal, exercises, dancing, games, videos and films, quizzes and reminiscence. Not all the residents wish to join in with group activities and they can choose to spend time on their own, observing the others or following an individual interest. In general residents and their relatives were happy with the range of activities provided. Some questionnaires indicated that more outings should be made available. This was Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 14 brought to the attention of the manager who agreed to talk to the residents about this. Visitors are welcome at the home at reasonable times. Residents can see visitors in private in their bedrooms or in the dining room. The residents who were spoken with said they felt their visitors are made to feel welcome. Observations and a discussion with residents indicated that the routines of daily living are flexible. Residents said they make decisions about their day-today lives at the home, such as when they will get up and go to bed and what they will do each day. Residents who go out unaccompanied or with friends are asked to let staff know where they are going and when they expect to return for reasons of personal safety. The residents’ bedrooms that were seen had been personalised with items brought in from their own homes. Information about advocacy services is available. The religious needs of residents are met. The local priest attends to provide Holy Communion, and the home will support residents of other faiths who wish to attend church or to be visited by the clergy. A four-week menu is in place and residents who do not wish to take the main meal on offer are provided with an alternative. The menus have been put together around the likes and dislikes of residents and are reviewed with them from time to time. Residents who spoke with the inspector and those who completed questionnaires said that the range and quality of food is generally good. The food provided reflected the cultural needs of the residents. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know how to make a complaint and staff know how to manage complaints and adult protection matters. This ensures that the wellbeing of residents is safeguarded. EVIDENCE: There is a complaints procedure available. Residents who were spoken with and those who returned questionnaires said that they would know how to complain if they needed to. Residents described the staff and the manager/owners as approachable and helpful. The questionnaire returned by the manager showed there had been no complaints to the home in the last 12 months. No complaints have been made to CSCI about the home in this period. The home has a copy of Wirral Borough Council’s adult protection procedures. In addition the home has it’s own procedures, which provide a quick reference guide. The home’s adult protection procedure needed some work as it did not clearly identify the role of Social Services in adult protection matters and Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 16 referred to the manager investigating allegations of abuse. This was brought to the attention of the manager who agreed to address this. No allegations of abuse have been made at the home over the past twelve months. The manager and staff were very well aware of the procedure to follow should they suspect abuse. Staff have received training around adult protection during their NVQ training. Records showed that some staff had also attended a World Abuse Awareness training event. It was not possible to ascertain if all staff had received training around adult protection from the training records available. The home has a procedure around managing aggression and restraint which describes practices that are not appropriate for the home. This was discussed with the manager who agreed to amend this when updating the adult protection procedure which is contained within the same document. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and satisfactorily maintained. Risk assessments of factors that present a possible hazard to the residents’ well being need to be recorded to demonstrate that they are being adequately safeguarded. EVIDENCE: A tour of the home was undertaken and a sample of bedrooms seen. The home was clean and generally well maintained. At the time of the visit the carpets in the dining room and lounge were showing signs of wear and tear. The manager/owner has identified this and is taking steps to address this. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 18 Furniture and fittings are in a domestic style. The garden is well maintained and provides a pleasant area for residents to access. Questionnaires returned by residents indicated that the home is always clean. Residents spoken with confirmed this also. Most of the bedrooms have an en-suite WC and wash hand-basin. The three rooms without this facility have the use of a WC just by the door. The owners are considering plans to make all of the bedrooms, en-suite. The bedrooms seen were personalised. Residents are encouraged to personalise their rooms with items of furniture, pictures and ornaments brought in from home. Two of the home’s three bathrooms have adapted bathing facilities; the third is fitted with a shower. Aids and equipment to support residents with a disability are provided throughout the home. Ramped access is provided at the front door. A passenger lift and a staff call system are in place. Hot water delivered to resident’s bathrooms and showers is thermostatically controlled. Hot water delivered to the washbasins in resident’s bedrooms is not controlled in this way. The manager/owner reported that a risk assessment has been undertaken and where an individual resident may not be able to manage the hot water, appropriate actions would be taken. A record of this risk assessment was not available during this visit. The radiators at the home are not guarded. These were not on at the time of the visit but the manager said that the temperature is not controlled. Again the manager/owner reported that a risk assessment has been undertaken and that the radiators are not considered to present a risk to residents. A record of this risk assessment was not available during this visit. In order to safeguard residents a record of the risk assessment undertaken in relation to the unregulated water in residents bedrooms and unguarded radiators needs to be documented. This provides evidence that all risk factors have been considered, appropriate action has been taken where necessary and gives staff guidance on any action needed to safeguard residents. It is strongly recommended that the water to the washbasins in residents’ bedrooms is regulated to ensure it does not exceed 43 degrees centigrade and that design solutions are put in place to safeguard residents from risks from hot radiator surfaces. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are appropriate for the current group of residents. An improvement needs to be made to the records of staff training as it was not possible to tell if all staff have had the training they need to meet the needs of the residents. EVIDENCE: Rotas identify that from Monday to Friday the home is staffed (during day-time hours) by the manager and two carers. At other times two carers are on duty. At night the home has one wakeful carer and one sleeping member of staff on call. Separate cooking and domestic staff are employed. Staff interviewed said that there are always sufficient staff available to meet the needs of residents. Residents interviewed said that there are always staff available to assist them. The questionnaires returned by residents indicated that staff are generally available when needed. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 20 Information provided by the owner shows that 70 of the home’s care staff have an award at NVQ level 2 or above, in care. Three other staff are working towards the award. Three staff files were examined during the inspection and in general all of them contained the information required. Application forms, two references and confirmation of CRB clearances were evidenced. One record held no record of qualifications, this appears to be as the usual application form was not used. This was brought to the attention of the manager to be addressed. Records showed that staff receive a brief induction. This covers the home’s policies and procedures, day-to-day routines; resident’s care plans and health and safety issues. The manager/owner reported that the home takes advantage of induction training courses provided by Wirral Borough Council that include food hygiene, moving and handling, first aid, adult protection and fire awareness. The manager/owner reported that additional training is provided in the management of medicines, diabetes control and adult protection. The staff training files seen did not contain a clear record of the training staff had undertaken. It was therefore not possible to evidence what training staff had received, what is needed and when refresher courses are due. Staff spoken with reported that they have received the required health and safety training but could not recall when they had received it. Staff should have access to a more thorough induction, which meets the standards of Skills for Care. A more detailed evidence based recording system should be put in place to identify that the Skills for Care workforce training targets have been met and any learning needs identified for staff. Staff were observed to be friendly and polite towards residents. This creates a pleasant and relaxed atmosphere within the home. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is in general run in the best interests of the residents. Some improvements are needed to the records required for the protection of residents. EVIDENCE: The home’s manager/ joint owner has successfully completed an NVQ level 4 in management and is also an NVQ assessor. Both owners/manager have had a number of years experience in providing care to the elderly. The joint owners share the record keeping and both are involved in the day-to-day care of the Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 22 residents. Comments from residents were positive about the support they receive from the manager and the staff. The home has systems in place for reviewing and improving the quality of care provided at the home. Questionnaires are sent to residents and relatives twice a year. This includes a separate questionnaire about the activities provided. Questionnaires should also be sent to visiting professionals as to how the home is achieving goals for residents. Staff meetings are held on a regular basis. The owner reported that the home has been given the Investors in People Award. They undertake an annual quality assurance survey amongst the residents and visitors to gain their opinion about the care and support provided at Gerald House. The homeowner undertakes annual appraisal interviews with staff and is undertaking, bi-monthly supervision. Records of the meetings were seen during the inspection. This addresses practice issues and career development needs. Records showed that a member of staff had been suspended and reinstated. There were no records to support this decision-making. As indicated at the last inspection of the service, there is a need to ensure that all staff disciplinary matters are recorded and include outcomes and any actions taken. An attempt to refer to non-recorded discussions and actions would not be accepted in any formal proceedings that might occur later on. The owners have purchased a set of policies and procedures for use in the home. A sample were seen and some had not been reviewed in over 5 years. It would be good practice to review these procedures on a regular basis as part of the home’s quality assurance systems. The financial affairs of residents’ are managed by the residents themselves, or by their family or a solicitor. The home looks after the personal allowances for some residents. The records of this were seen and were found to be in order. Residents are able to bring personal possessions to the home. Some improvements are needed to the records required for the protection of residents. A discussion with the owner/manager indicated that notifications under regulation 37 of The Care Homes Regulations have not been made to CSCI. A record of the reasons residents are no longer living at the home had not been consistently made. This information needs to be clearly recorded in a record book that cannot be altered. A sample of safety check records were seen for the electricity, gas, passenger lift, bath hoist and checks of the fire safety systems and were appropriately maintained. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 23 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 2 3 Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Not applicable. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered persons must ensure that the residents care plans contain clear information as to how staff are to meet the residents needs. The outcome of reviews need to be clearly documented in the care plans so that staff have up to date information around meeting the needs of residents. The registered persons must ensure that risk assessments in relation to falls are comprehensive in order to provide clear guidance to staff around what they need to do to prevent a fall. Timescale for action 18/07/07 2. OP7 15 18/07/07 3. OP19 13 18/07/07 The registered persons must ensure that a record of the risk assessments undertaken in relation to the unregulated hot water in resident’s bedrooms and unguarded radiators is documented. The registered persons must ensure that clear records are DS0000018888.V335979.R01.S.doc 4. OP30 18 18/06/07 Gerald House Version 5.2 Page 25 maintained of the training staff have received so as to provide evidence that staff have had training appropriate to the work they perform. 5. OP36 17 The registered persons must ensure that staff disciplinary actions are recorded and details of the investigation and the outcome are maintained on the member of staff’s file. The registered persons must ensure that CSCI is notified of death, illness and other events that occur at the home in accordance with Regulation 37 of The Care Homes Regulations 2001. The registered persons must ensure that a record is made of the date on which a resident leaves the home, is transferred to another home or hospital, the name of the other home and hospital and date of transfer and if the resident died at the care home, the date, time and cause of death. 18/06/07 6. OP37 37 18/06/07 7. OP37 17 18/06/07 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 OP7 Good Practice Recommendations It is recommended that further information be gathered for all residents around their social history in accordance with the wishes of the residents. Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 26 2. OP19 It is strongly recommended that the water to the washbasins in resident’s bedrooms be regulated to ensure it does not exceed 43 degrees centigrade. Staff should have access to a more thorough induction, which meets the standards of Skills for Care. Questionnaires should be sent to visiting professionals as to how the home is achieving goals for residents. 3. 4. OP30 OP33 Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Gerald House DS0000018888.V335979.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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