Inspection on 27/09/07 for Girvan

This inspection was carried out on 27th September 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

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

CARE HOMES FOR OLDER PEOPLE Girvan 3 Upper Sea Road Bexhill on Sea East Sussex TN40 1RL Lead Inspector Melanie Freeman Key Unannounced Inspection 27th September 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Girvan DS0000069896.V346078.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. Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Girvan Address 3 Upper Sea Road Bexhill on Sea East Sussex TN40 1RL 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) 01424 218838 01424 218838 edwina@girvancare.co.uk Emardee Ltd Mrs Edwina Sara Langley Care Home 13 Category(ies) of Dementia - over 65 years of age (0) registration, with number of places Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category age - (OP) Dementia - (DE(E)). The maximum number of service users to be accommodated is 13. 2. Date of last inspection New Service Brief Description of the Service: The home is registered to accommodate up to thirteen older people who have a dementia type illness. The registered provider originally purchased the home as an individual and has now registered the home under the new provider of Emardee Ltd. Accommodation is provided on three floors, stair lifts are available to assist residents to access first and second floor accommodation. All the bedrooms are single apart from one shared room, seven of the bedrooms have en-suite facilities. Communal areas consist of a pleasant lounge and dining room on the ground floor, and a small ‘quiet’ lounge on the first floor. Girvan is a detached property situated a short distance from the town centre, railway station and sea front in Bexhill on Sea. The home provides care and support to residents who are both privately funded and those who are funded by Social Services. The home’s fees as from 01 July 2007 range between £390- £450 per person per week. Additional costs are charged for chiropody (approx £10) hairdressing, newspapers and magazines, charges are made for any activity not provided by the care staff. The homes literature states that ‘carers will strive to preserve and maintain the dignity, individuality and privacy of all service users within a way and caring atmosphere, and in so doing will be sensitive to service users ever changing needs’. Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Girvan Care Home will be referred to as ‘residents’. This is the first inspection report completed since Girvan Care Home has been registered under the new registered provider of Emardee Ltd. This was a key inspection that included an unannounced visit to the home, and follow up contact with resident’s representatives and visiting health and social care professionals. The unannounced visit included a meeting with the registered manager who facilitated the inspection process and received the inspector’s feedback at the end of the inspection. On the day of the home assessment the inspector was able to spend much of her time meeting with residents and their visitors and observing practice, and noting how residents needs are being met. Resident’s lifestyles within the care home were also looked at along with measures taken to promote residents individuality. The inspector was able to eat a midday meal with the residents in the communal dining room and review the arrangements for providing suitable diets. Staffing arrangements reviewed included the management structure and measures put in place to monitor the quality of care and services in the home. A tour of the premises was undertaken and a range of documentation was reviewed including the homes service users guide, care plans, duty rotas, medication records, and recruitment files. The care documentation pertaining to two residents were reviewed in depth along with a number of policies and procedures and records relating to health and safety. During the assessment visit most of the residents were spoken to informally and one relative was interviewed in private Following the visit two residents representatives were contacted by telephone along with two social/health care professionals. Four surveys were also completed by resident’s representatives the contents of which have been used to inform the inspection process. Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 6 Information provided by the home within the Annual Quality Assurance Assessment (AQAA) has also been included in this report. What the service does well: What has improved since the last inspection? What they could do better: The home needs to confirm in writing to the prospective resident or their representative that with regard to the needs assessment completed the home can meet the needs of the prospective resident. The nutritional needs of residents need to be fully assessed and responded to with specialist advice and training. Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 7 The Safeguarding Adults (Adult Protection) procedure needs to be updated and all staff need to receive appropriate training on this subject along with training on the Mental Capacity Act to ensure any allegation or suspicion of abuse is dealt with appropriately. The infection control practice in the home needs to be improved to ensure safe practice is followed at all times. Quality assurance measures that respond to resident’s views need to be established and reported on. Up to date policies and procedures need to be established and followed to ensure best practice is followed in the home. 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. Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures ensures prospective residents are suitably assessed prior to their admission by a competent person, who ensures that the home admits only those residents who’s needs can be met by the home. Intermediate care is not provided at Girvan. EVIDENCE: Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 10 The home has a suitable statement of purpose and service users guide that is combined within a manual that was available on request. This document contains terms and conditions of residency and the last inspection report. This was found to be up to date and to reflect the homes current registration. An assessment of the admission process included the review of the last two admissions to the home and the relating documentation. This confirmed that the pre admission assessment process is thorough, completed by the registered manager usually in the prospective residents place of residency or in hospital. The assessments were seen to be competed to a good standard and to involve resident’s representatives and health care professionals as necessary. In addition it was noted that each resident had a copy of a signed terms of conditions of residency held within their individual files. Although the registered manager said that all prospective residents or their representatives are advised verbally if following the assessment the home is able to meet their care needs this is not confirmed in writing in accordance with the required documentation. Residents in the home have varying levels of dementia and staff were seen to deal with the specialist care needs of residents in a sympathetic and positive way. Relatives spoken to said that they were able to visit Girvan before considering it as a permanent placement for their relative. One relative said that when she visited Girvan ‘it was so lovely’ that she knew it was right. Intermediate or rehabilitative care is not provided at Girvan Care Home. Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s health and care needs are set out in an individual plan of care. Resident’s care needs are met taking into account resident’s dignity with evidence of regular input from health care professionals as necessary. The arrangements for medicine administration in the home were found to be safe. EVIDENCE: The care documentation pertaining to two residents was reviewed as part of the inspection process and each of these residents were met with during the inspection visit to the home. Most of the care documentation was very good and included informative daily records that talk about the individual. Full assessments are recorded and plans of care are developed from these. The plans included personal preferences Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 12 and choices and the regular reviews completed are very person centred. Records included regular weights, nutritional assessments, dementia care plan, a personal profile, and important occasions to be remembered. One resident however has recently returned from hospital and although she has temporary care plans in place to ensure her care is appropriate and responsive to the advice provided by visiting health care professionals. The homes on going care documentation needs to be updated and the registered manager confirmed that this would be completed. One resident is very frail and underweight and records indicated that she is now eating and supplements are being provided to support her diet. Discussion with the registered manager identified that staff had not been trained in fortifying foods and that semi-skimmed milk is the only milk used in the home. This matter was clarified further with her along with the need for training and liaison with the community dietician. All feedback received from visiting relatives and residents were very positive about the standard of care delivered at Girvan and complemented the way staff responded and supported residents. When asked what the home did well a relative said ‘care for residents individual needs, always kind and reassuring has a safe and confident feeling for them nothing is too much trouble if they need help they are never felt to be a nuisance’. The medicine records examined were found to be full and accurate and practice observed was seen to be safe. The storage arrangements allow for safe and appropriate storage. The home however does not have suitable storage arrangements for controlled drugs and the inspector was advised that this would be provided in the near future. Some residents are on medicines on an ‘as required’ basis and the need to provide individual guidance to staff on when to give this medication was discussed with the registered manager along with the need to have a record of each staff members signature who administers medicines for auditing purposes. Residents were seen to be treated very well during the inspection and staff interacted with a friendliness and treated each resident as an important individual with their own likes and preferences. Residents were able to go where they wanted to, although advised that it was very cold outside. They were also able to have beverages when they wanted to and how they wanted. Girvan DS0000069896.V346078.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are enabled in maintaining links with people from outside the home and resident’s choices are respected. The activities/entertainment and food available in the home promotes a home like environment with individual choices promoted. EVIDENCE: The activities and entertainment available in the home are mostly co-ordinated by the care staff who spend individual time with residents or do some group activity, shopping trips and walks are undertaken if staff are available. Residents are able to spend time where they want to and during the inspection visit it was noted that one resident spent much of his time sitting in the dining room listening to music and eating his meals very slowly. Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 14 Residents were seen to enjoy spending time with each other and visitors. Visitors are able visit whenever they like and visitors spoken to said that they were always warmly welcomed and staff are ‘always polite’ they commented on the activities provided in the home, which included the celebration of birthdays and special events, and the general ‘caring atmosphere’. Relatives however did feel that further outings/shopping and regular walks would be beneficial for the residents. A weekly entertainer is provided and varied television channels are available in the lounge. Music is also used therapeutically in response to individual choice. The inspector observed residents being able to spend time where and how they wanted moving around the home and garden freely with supervision as necessary. Set routines are avoided as far as possible with residents having drinks and snacks when they want and being able to determine when they would like to go to bed and what time they would like to get up in the morning. The home provides a home cooked menu that includes the use of fresh vegetables. On the day of this assessment visit the main meal was cottage pie carrots and cabbage with a banana split for dessert. Residents were given plenty of time to eat their meals in an attractive separate dining area. Feedback about the food provided at the home was very positive with one resident saying ‘the food is lovely and I always eat well. There is always fresh vegetables’ and relatives saying that their relative is eating much better since their move to Girvan and ‘I think the food is worth a mention as it seems quite important to the residents they always talk about the good home made cooking from chef’. Residents also said that they spoke to the chef regularly and that he asks them what food they like and what they have enjoyed eating. Staff were seen to be attentive to residents during the meal and assisted with food cutting when necessary. When the homes menus were reviewed it was noted that the evening meal usually includes sandwiches and this was also noted by one relative who said the nutritional status of the food could be improved by ‘avoiding too many sandwiches’. Girvan DS0000069896.V346078.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, 17 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures and practices in the home ensure that complaints made are managed appropriately. Procedures available in the home did not ensure that adult protection issues when raised would be responded to appropriately. EVIDENCE: The complaints procedure is full and comprehensive and there was evidence in the home that the registered manager has responded to two complaints raised appropriately with a resolution being achieved. One complaint related to the way a staff member spoke to a residents and the other was about the food. Everyone spoken to said that they would be happy to raise any issue with the registered manager or other staff in the home. One relative gave an example where the manager responded to a concern promptly and effectively. The homes adult protection procedure was reviewed and was found not to provide appropriate guidance to staff on what action to take following an allegation or suspicion of abuse. This procedure was discussed with the Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 16 registered manager along with the new local Safeguarding Vulnerable Adults Procedures that are now available and should be incorporated into the homes documentation. The registered manager and most of the staff have completed training on adult abuse and the manager had a good understanding of her responsibilities is respect of Protection Of Vulnerable Adults (POVA) register and had the relevant Department Of Health guidance readily available. Girvan DS0000069896.V346078.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, 20, 21, 22, 23, 24, 25 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s live in a comfortable homely environment that is maintained reflects the needs of residents. Whilst the home was found to be clean the home needs to establish thorough infection control measures in all areas to ensure best practice. EVIDENCE: The home is located within walking distance of Bexhill town centre and close to local amenities including shops and bus routes. There is a door entry system in operation, to enable staff to be aware when people are entering or leaving the building for security reasons. Girvan is a converted property that has been adapted to its present use and has retained a homely looking environment. The home is adapted to meet the Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 18 needs of residents with some limitation to their mobility, and this includes the provision of chair lifts. The home is therefore able to meet the needs of the residents currently but need to keep the needs of residents and the facilities provided under constant review to ensure all the care needs of residents are fully met. The entrance path is rather steep and mobility issues need to be borne in mind in relation to residents and visitors to the home and may need to be improved. The garden has been re designed and now provides a patio, attractive garden area with walk ways and seating. The communal rooms include a lounge and a separate dining room on the ground floor. During this visit it was noted that the first floor quiet room is being used for the sleeping night carer and therefore not suitable for resident’s use. One visiting relative said that the home would benefit from further space to see residents in a more suitable environment when visiting. Bedrooms seen during the inspection visit were individual and attractive with residents able to have their own possessions around them. Rooms were found to be suitably equipped and one resident commented on the fact that she has her own key to her room and locks it when she leaves it. The home provides eleven single rooms and one double, although suitable for the residents occupying them a couple of the rooms are rather small. The home was found to be clean and fresh. During this visit was noted that not all communal hand washing areas had suitable hand washing facilities and this was raised with the registered manager. In addition the home has a combined laundry and sluice room, which increases the risk of cross infection. The infection control measures in the home need to be reviewed to ensure that current best practice is followed. Girvan DS0000069896.V346078.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: At the time of this inspection visit there was eleven residents living in the home. The staffing arrangements allow for two carers to be caring for residents throughout the waking day with one carer and one sleeping carer working in the home at night. In addition a chef/cook works in the home daily to provide the midday meal and prepare some of the evening meal. A cleaner and hand man is also employed. This staffing currently allows for individual time for each resident and some activities in the afternoon. The registered manager advised that staff had been stable over the past six months and unfortunately due to some staff leaving this has lead to her and other regular staff working some extra hours she is however hopeful that recruitment will be successful and allow her to re-establish her regular management time. Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 20 Feedback from surveys and contact with residents visiting relatives and social/health care professionals was very positive about the staff and comments received included ‘all the staff at Girvan seem very kind and my mother often tells me how lucky she is to have found this home’ ‘staff are helpful and kind, polite to visitors and always ready to talk about any concerns’. The recruitment files pertaining to the two staff were reviewed as part of the inspection process and identified that the recruitment practice on the whole was good. One staff was recruited via an agency, and although her references were not available the responsible individual confirmed that he had copies of these. The records seen included application forms, terms and conditions of employment, Criminal Records Checks and POVA checks. The registered manager was reminded to retain a recent photograph of each employee and evidence that they are given a copy of the General Social Care of Conduct. Staff training is being organised and the manager uses a matrix to organise and record the training provided and attended. Contact with staff confirmed that staff training is well promoted with staff able to attend all the necessary training. Staff records confirm that there is a commitment to train staff so that they achieve a National Vocational Qualification in care level 2. Most care staff working at the home have already achieved this. Girvan DS0000069896.V346078.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, 32, 33, 34, 35, 36, 37 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home manager provides good management but needs to ensure effective quality monitoring systems are introduced and maintained along with appropriate supervision for all staff. Resident’s financial interests are safeguarded along with resident’s safety through the homes procedures. EVIDENCE: The home’s manager has substantial relevant experience and has completed relevant care and management qualifications. She is committed to providing Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 22 high standards of care in the home and has a good understanding of person centred care. There are clear lines of accountability within the home. All feedback received about the homes manager was very positive complementing her support her availability and approach to residents. Systems to monitor the quality of care and services provided need to be further developed to ensure the home responds to residents and their representatives views. Although some questionnaires are used and responded to individually this system should be formalised with an audit of the responses and a record of action taken being made available to all interested parties. This could be recorded within the service users guide/statement of purpose. The manager confirmed that the home has no dealings with resident’s monies and that any extras costs incurred are paid by the home and then individually invoiced on a monthly basis. The responsible individual deals with all the invoices. Although the home has varied policies and procedures it was noted that some of these looked at were not up to date, these need to be reviewed and updated on an annual basis to reflect the changes in best practice and in associated legislation. Staff also need to have training on the Mental Capacity Act. The manager confirmed that the home has no dealings with resident’s monies and that any extras costs incurred are paid by the home and then individually invoiced on a monthly basis. The homeowner deals with all the invoices. Records relating to Health and safety in the home were reviewed and on the whole were found to be full and extensive. The environmental risk assessments however need to be more specific and include all areas of the home and its grounds. Girvan DS0000069896.V346078.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 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 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 3 18 2 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 3 2 Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP3 Regulation 14(1) Requirement Timescale for action 01/11/07 2. OP8 12 (1)(a) That if an admission is thought to be appropriate the home confirms in writing that having regard to the assessment made that the home can meet those needs to the prospective resident or their representative. 01/11/07 Nutritional assessments/screening to be completed for all residents linked to the care plan with appropriate referral for specialist advice as necessary. That staff receive training on the nutritional needs of residents with dementia and how to meet them. That the home updates its safeguarding vulnerable adults (adult protection) policy and procedure and further training is provided to all staff to include the Mental Health Capacity Act. That the infection control practice in the home is reviewed and improved in respect of the sluicing of dirty laundry. DS0000069896.V346078.R01.S.doc 3. OP18 13 (3) (6) (7) (8) 01/11/07 4. OP26 13(3) 01/11/07 Girvan Version 5.2 Page 25 5. OP37 24 That all the homes policies and 01/02/08 procedures are updated to reflect best current practice and associated legislation. 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 Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Girvan DS0000069896.V346078.R01.S.doc Version 5.2 Page 27 - 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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