Inspection on 20/08/07 for Grove House

This inspection was carried out on 20th August 2007.

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

Grove House 08/09/08

Grove House 20/06/06

Grove House 06/12/05

Grove House 11/08/05

Grove House 21/10/04

Grove House 27/04/04

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

CARE HOMES FOR OLDER PEOPLE Grove House 7 South Hill Grove Harrow Middlesex HA1 3PR Lead Inspector Diane Roberts Key Unannounced Inspection 20th August 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 DS0000017573.V342939.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. DS0000017573.V342939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove House Address 7 South Hill Grove Harrow Middlesex HA1 3PR 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 8864 5216 020 8864 5216 ndmca.kritikos@virgin.net Mrs Dympna Kritikos Mr N Kritikos Mrs Dympna Kritikos Care Home 5 Category(ies) of Old age, not falling within any other category registration, with number (5) of places DS0000017573.V342939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons who can manage the stairs without physical assistance may reside on the first floor. You may only accommodate service users in the bedrooms located on the second storey When they have been subject to an assessment by a competent person representing the service user and nominated by the placing agency. In the case of a service user who is self funding, the assessment must be undertaken by a competent person who is independent of the home - Occupational Therapist, CPN or Care Manager. This assessment must clearly state that the service user is able to ascend and descend the stairs to the ground floor without the assistance of staff. A copy of this assessment must be retained in the home and be available for inspection. Any such assessments held at the home, must be subject to regular external review in accordance with the changing needs, abilities or condition of the service user. 20th June 2006 Date of last inspection Brief Description of the Service: Grove House is a care home that provides personal care and accommodation for up to 5 older people. The service can meet Greek-language needs. Mr and Mrs Kritikos own the home. The registered manager is Mrs Kritikos. Grove House is a family owned and run care home. Mr and Mrs Kritikos live on the premises with their family. The home is located in Sudbury, Harrow, on a quiet residential road. It is within a few minutes walk from local shops and other amenities. There are local public transport facilities in the vicinity, which include a public bus and train service. Sudbury Town underground train station is within a few minutes walk from the care home. The home was opened in 1995, and consists of a semi-detached house, with parking for approximately four cars at the front drive area of the house. There are two single bedrooms for service user accommodation on the first floor, and one on the ground floor. There is also a shared bedroom on the ground floor. The home has an enclosed, well-maintained garden with a seating area, that is accessible to service users. The current scale of fees is £450 to £465. A service user guide is available on request. DS0000017573.V342939.R01.S.doc Version 5.2 Page 5 DS0000017573.V342939.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the annual inspection programme for this home. The manager/proprietor was available on the fieldwork day of the inspection. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. 2 residents and 2 staff were spoken to during the inspection. Four residents and one relative’s also completed feedback sheets. All these comments were taken into account when writing the report. Following the last key inspection, significant shortfalls were noted in relation to the safe administration of medication. An agenda for action was set and two random follow up inspections were undertaken, with an accompanying pharmacist. It was noted that the manager and her team had made significant efforts to address these matters and the agenda was reduced. It was noted at this inspection that the manager is failing to maintain the standards reached earlier in the year and this is reflected in the body of the report. In light of this the CSCI are current considering whether further action will need to be taken in order to protect residents. What the service does well: What has improved since the last inspection? Since the last inspection improvements have been made to the address shortfalls noted in the premises. In addition to this the lounge and hallway have been redecorated. The manager has introduced an updated medication policy and more staff have achieved NVQ qualifications. DS0000017573.V342939.R01.S.doc Version 5.2 Page 7 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. DS0000017573.V342939.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 DS0000017573.V342939.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 and 3. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. Basic assessment systems are in place that need to be developed, to ensure that residents are fully assessed and assured that their needs can be met prior to admission. Information provided to residents and purchasers needs to accurately reflect the home so that informed choices can be made. EVIDENCE: There is currently one vacancy at the home and there have been no admissions since before the last inspection. It was therefore not possible to review the admission assessment process but the documentation the manager would use was inspected. Whilst there is a form to complete this requires a review. The form needs to evidence that it is a pre admission assessment, with a date and ensure all areas are covered including preferences in relation to care and lifestyle. The form also needs to evidence that residents have been assessed in relation to the limitations in the home, i.e. no lift and that DS0000017573.V342939.R01.S.doc Version 5.2 Page 10 residents know the prospective limitations with regard to care and lifting equipment etc. The service users guide and statement of purpose are in place and available on request. The statement of purpose needs updating to accurately reflect the range of service users the home provides care for, i.e they do not take people with dementia and the condition on their registration certificate regarding use of the stairs and an appropriate OT assessment. They also need to say whether they are a home for life, as they do not provide lifting hoists etc. and help with bathing etc. may not be possible. Residents were seen to have contracts in place. The content of this document should be reviewed in relation to Standard 2 of the National Minimum Standards to ensure it protects residents appropriately. DS0000017573.V342939.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 and 10. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. Care systems are not sufficient to evidence that the team have a proactive, resident led approach to care provision and ensure needs are met giving positive outcomes for residents. There also remain shortfalls in relation to the safe administration of medication. EVIDENCE: The manager has a care planning system in place. The system was seen to be quite complex with many forms and information sheets either not dated, out of date or conflicting with information provided in other areas of the plan. The manager needs to review the care planning system so that she can provide a clear current picture of the residents assessed needs and how the team at the home plan to meet those needs, with the involvement, where possible, of the resident or their representative. Some care plans were available that had been written in May 2007 and there was no further evidence of review. These were seen to be basic and did not contain enough detail to show how the residents DS0000017573.V342939.R01.S.doc Version 5.2 Page 12 assessed need would be met. Some documents dated 2005 had been signed by residents but there was not further evidence of their involvement. Whilst there was some nice written information, personal histories and preferences, more work needs to be done to ensure that the care plans are person centred and that they promote the self worth and independence of the individual. Daily records are held communally and are completed by using a coding system, which identifies that the resident has been washed, dressed etc. These give limited information on the person, how they are and any detail on the care provided. Additional notes in the communal record comment on activities and hospital appointments etc. This system should be reviewed with a view to providing individual information. The shortfalls in relation to care planning were discussed with the manager. Records show that the residents see their GP in a proactive way and residents spoken to confirmed this. They often visit the GP at the surgery. At the time of the inspection, none of the residents was acutely unwell and none were seeing the district nurse etc. Records also show that residents have access to chiropodists, dentists, opticians etc. Although care plans stated that residents were to be weighed monthly records show that this is inconsistent at times and the care planning system does not have a nutritional risk assessment in place. Risk assessments on file were not up to date and evidence of review was limited. Residents with identified risks, such as falling out of bed, did not have the appropriate risk assessment in place. Risk assessments must also be individual to the resident unless there is an issue that is a risk for all residents. Risk assessments were not in place for manual handlings or for the risk of falls. As the manager does not have lifting hoists in the home this must be done as a matter of priority to ensure the health and safety of both the residents and staff. This was discussed with the manager. If no hoists are being provided then advice should be sought and consideration given to purchasing other moving and handling equipment. Following significant shortfalls in relation to the safe handling of medication noted at the last key inspection, two random inspections with an inspecting pharmacist were carried out in July and August 2006. It was noted that the manager and her team had made significant improvements to address matters and only three agenda items remained. The manager uses a nomad system to manage and administer medication. This was inspected. The mar sheets were seen to be clear and neat and now were being signed rather than ticked, following administration. However signatures must be made in pen and not in pencil, as this is a legal record. It was also noted that the manager was only signing for checking in medications on one item when all items should be signed for when checking in. On checking the nomad system it was disappointing to note that medication administered that morning had not been completed with tablets still left in the pack. Staff need to be more careful and know the medicines well enough to be aware that one is missing – still in the pack. This was highlighted to the DS0000017573.V342939.R01.S.doc Version 5.2 Page 13 manager. The MAR sheet had been signed to say that this tablet had been given. It was also noted that on some occasions one resident chooses not to take their iron tablet and this was left in the nomad box, but the MAR sheet had been signed to say it had been given. The manager and team at the home need to tighten up their administration methods and ensure that records are accurate so that residents can be assured that they are having the correct medication. The manager has a basic homely remedy policy in place, which she states has been agreed by the attending GP, although there is no evidence of this. A new medication policy was seen to be in place, dated September 2006, this was acceptable. The manager has provided medication training in house. This was policy based and included some observation of practice. Consideration should be given to attending an external pharmacy facilitated training course. Residents spoken to and who commented, were very happy living at the home, they enjoyed the family atmosphere and spoke positively about the staff team. They went on to comment that they had choices, that staff treated them respectfully and that they ‘enjoyed the banter between them which was fun’. Other comments included; I am not lonely anymore, I feel part of the family’ and ‘ I am happy and content here’, ‘they always discuss my needs, whatever I might require’. DS0000017573.V342939.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using this service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. Whilst residents’ are happy, a more proactive approach is needed towards thier social needs to ensure that these are met in both a group and individual way. EVIDENCE: Each resident has a 24 hrs care plan in place that relates to daily routine and personal preferences, these were written primarily in 2005, signed by the residents and have been reviewed every year with no changes. When crossreferenced with other documents within the care planning system this information is contraindicated and does not appear up to date. This is disappointing as it contains some valuable, person centred information. It may be of value to review these with the residents and ensure that an up to date picture is provided and that residents’ current choices are taken on board. On speaking to residents, the confirmed that they had choices during the day with regard to getting up, going to bed etc and where they spent their time. There are no real care plans in place that assess individual residents social needs. Social preferences are listed in the care plans but on discussion with residents it is clear that these are not up to date. Due to the number of DS0000017573.V342939.R01.S.doc Version 5.2 Page 15 residents and the nature of the home, the staff team are aware of preferences but do need to evidence an individual proactive approach to meeting social care needs. This includes involvement in household tasks and promoting selfworth/independence etc. Records in the communal diary show that residents do go out of the home with relatives and the manager. They go out to lunch, go to the library, spend time in the garden, listen to music, go shopping, to the park and have barbecues. Residents’ families are encouraged to visit and take part in events at the home. Residents spoken to confirmed that their visitors were made welcome. Some of the residents do attend a local church with the proprietor. Lunchtime was seen to be a relaxed affair with some residents eating in the kitchen and others in their rooms. From observation choices are offered during the meal and whilst the meal is set, residents are offered alternatives and changes as required and as the manager is aware of their individual preferences. The manager takes note of specialist dietary needs as required and this includes a diabetic diet and a soft diet. Fresh fruits and vegetables are available and the set menu is varied and nutritious. No nutritional records are kept that show what residents have actually had against the set menu. This was discussed with the manager. Residents spoken to were happy with the food at the home and confirmed that the manager consults with them over what they may like to eat. They also confirmed that they have treats like chocolate etc. The care staff undertake the cooking and very often eat with the residents and have the same food as them. DS0000017573.V342939.R01.S.doc Version 5.2 Page 16 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. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. Whilst there are systems in place to listen to peoples concerns, shortfalls in relation to staff training in adult protection could undermine this and negatively affect outcomes for residents. EVIDENCE: The manager has a complaints procedure in place, which is available in the service users guide. Residents’ spoken to and who commented had no concerns about the home and said that they would have no hesitation in discussing anything with the manager. Since the last inspection the manager has recorded two complaints and demonstrates an open approach to these issues. Both complaints, recorded in the communal diary, were seen to be minor in nature and dealt with promptly. It is recommended that the manager set up a separate complaints recording system that can be kept confidential if required. Records show that the home has received compliments and these relate to the homely feel that Grove House provides. At the current time none of the residents are accessing local advocacy services. It is recommended that the manager make this type of information available to residents via the service users guide. The manager has an up to date adult protection policy in place and a copy of local social service guidelines. Training records submitted to the CSCI show that only 50 of the DS0000017573.V342939.R01.S.doc Version 5.2 Page 17 staff team have received training in this subject. This should be addressed to help ensure the protection of vulnerable adults. DS0000017573.V342939.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using this service experience an good outcome in this area. This judgement has been made using available evidence including a visit to this service. A homely environment is provided for residents that is comfortable and clean to live in. EVIDENCE: A partial tour of the home was undertaken. Since the last inspection work has been undertaken to address the overall condition of the porch to the home and on the day of the visit a new floor had been laid which will then be tiled. Areas of the home had also been repainted and this included the lounge, hallway and woodwork. Residents’ bedrooms were well decorated and clean and residents’ confirmed that they had been consulted on the choice of colour. Overall the Grove House is very homely and the residents who live there like this approach. Residents spoken to were happy with their rooms and the facilities overall. DS0000017573.V342939.R01.S.doc Version 5.2 Page 19 The manager has completed a fire safety risk assessment but this was seen to be out of date and requiring a review. Other fire safety arrangements such as servicing of equipment were seen to be in order. Records showed that the smoke detectors are checked regularly to ensure that they are operational. Thermostatic valves control water temperatures and no window restrictors are required as only small windows open. The home has a covered deck area to the rear and a good-sized garden which is well stocked with flowers and shrubs. Residents spoken to enjoyed using this facility on fine days. Some areas of the home, such as the deck required tidying to ensure that there are no tripping hazards for residents. The home is clean overall and no odours were noted. Hand washing facilities are available and training records show that in the past 50 of the staff have attended infection control training. It is recommended that this training is provided for other staff and that the manager obtains a copy of the local infection control teams’ current advice on infection control in residential homes. DS0000017573.V342939.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. The home has a stable staff team, which should benefit residents but a significant lack of training could be putting residents at risk and adversely affecting the quality of care they receive. EVIDENCE: The home has a stable staff team and no staff turnover since the last inspection. No agency staff are used and at the current time the staffing levels are maintained at two during the waking hours and the manager and her family/staff members cover the home at night. There is no fixed rota but records of the staff on duty are recorded in the daily diary. In addition to this there is also a cleaner in the mornings during the week and care staff also take on cooking and cleaning duties. Since the last inspection more of the staff have achieved an NVQ qualification at level 2 or above. This now takes them over the 50 required standard and should help with improving standards in the home. The manager is undertaking her NVQ assessor’s award. There has been no new care staff employed since the last inspection. A new ancillary worker has recently commenced work at the home and this file was checked. There were significant shortfalls with the recruitment process, with DS0000017573.V342939.R01.S.doc Version 5.2 Page 21 the manager relying on second party information from a company who have employed the worker to be in the country. The manager was relying on this employer to undertake a CRB and had not completed a pova first check. No application form had been completed for Grove House. The manager needs to ensure that she has a robust recruitment procedure in place to help ensure that residents are protected. Training records submitted to the CSCI show that there are significant shortfalls in relation to staff training. This particularly relates to fire safety and manual handling which are 5 and 3 years out of date respectively. Some staff have undertaken health and safety training in 2005 and others first aid but this requires review as some will need an update. Records show that some staff have been attending additional training in continence management, diet and nutrition, infection control and dementia (2003). The manager needs to address these shortfalls and have a suitable plan in place to ensure that these significant gaps in training do not reoccur. DS0000017573.V342939.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. A proactive management approach and a robust quality assurance system in the home would improve outcomes for residents and reduce health and safety shortfalls. EVIDENCE: The manager is suitable qualified to run the home and has many years experience working in care settings. She is currently undertaking the NVQ assessor’s award. From discussion and evidence in the home it may be of value of the manager attended some training current approaches to care planning and quality assurance systems. These subject matters were discussed DS0000017573.V342939.R01.S.doc Version 5.2 Page 23 with the manager. Due to the small size of the home, staff meetings are not held formally. The manager has a basic quality assurance system in place that consists of satisfaction questionnaires for residents and relatives. Relatives had been asked for feedback in November 2006 and the results were available for inspection. These were seen to be very positive about all aspects of the care and facilities at the home. The manager has no other internal audit systems in place and these were discussed as they would be of value in addressing and monitoring some of the shortfalls noted in the body of this report. The manager needs a more proactive approach to developing systems that underpin good care practices in the home and be less reliant on the inspection process to instigate changes. The manager does not hold any monies on behalf of residents. The proprietors purchase items and then they are reimbursed. The manager needs to take a more proactive approach to health and safety. Many of the residents do not have sufficient risk assessments in place and it was noted that one resident, using a bed rail, did not have the correct protective cover, with the manager just using pillows. The risks of this practice were discussed with the manager on the day and she was advised to purchase the correct equipment to go with the bed rail. The manager also needs to undertake some risk assessments around the home to ensure that risks are minimised, for example, with the steps leading down to the garden etc. Accident records were inspected and cross referencing with the communal diary and residents care plans, accidents that had occurred were not always recorded in the accident book. The need for this legal record was discussed with the manager. DS0000017573.V342939.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 DS0000017573.V342939.R01.S.doc Version 5.2 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 OP1 Regulation 4 and 6. Requirement The registered person must provide a statement of purpose that accurately reflects the home, its registration with the CSCI and any limitations to the premises or care that prospective residents may need to be aware of. The registered person must ensure that pre-admission assessments of service users fully evidence what the service user’s needs are and whether the home can meet them. Previous timescale of the 10/09/06 not met. The registered person must ensure that residents have an up to date care plan in place that outlines their current needs. This must be kept under review and where possible involves them or their relative in the process. Where risk assessments are completed for residents, the registered person must ensure that these outline the current risk and subsequent management and be kept under DS0000017573.V342939.R01.S.doc Timescale for action 30/10/07 2 OP3 14 30/10/07 3 OP7 12 and 15 14/11/07 4 OP8 12 and 13 30/10/07 Version 5.2 Page 26 5 OP9 13(2) 6 OP12 16 7 OP18 10, 13(6) 8 OP29 19 9 OP30 18 10 OP33 24 11 OP38 13 regular review. The registered person must ensure the safe administration of medication in respect of ensuring all medicines are checked into the home, all medications are given as prescribed and that medicine not given are not signed for as given. All records pertaining to the management of medicines must be made in pen. The registered person, through assessment and consultation, the team at the home must ensure that residents’ individual social care needs are met and that their independence and self worth is promoted and that records are maintained to evidence this. The manager must ensure that all the staff working at the home have up to date training in adult protection matters to help ensure that residents are protected. . The registered person must ensure that they have a robust recruitment procedure that is followed to help ensure that residents are protected. The registered person must ensure that all staff receive essential (statutory) training within a suitable timescale. This includes food hygiene, fire safety, manual handling, health and safety and first aid. The registered person must ensure that a robust quality assurance system is in place that continues to obtain feedback from residents, relatives and visiting professionals and is backed up by an internal audit system. The registered person must ensure the health and safety of DS0000017573.V342939.R01.S.doc 01/10/07 30/10/07 30/10/07 30/10/07 30/11/07 30/11/07 30/10/07 Page 27 Version 5.2 12 OP38 13 and 17 residents by using the correct equipment in relation to the use of bed rails and lifting equipment. The registered person must maintain accurate records of accidents that occur in the home to residents and the action taken, if required, thereafter. 30/09/07 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 2 3 Refer to Standard OP2 OP30 OP31 Good Practice Recommendations The residents contract should be reviewed to ensure it meets the minimum requirements as set out in Standard 2. It is recommended that the manager obtain local infection control team policies on infection control and accesses more training for the staff team on this subject. The registered manager should review her time/staff management to ensure that she has enough time to develop and update systems in the home, which promote a proactive approach to care and business management. The manager should complete risk assessments for the premises and safe working practices in the home and address any risks identified following the assessment. 4 OP38 DS0000017573.V342939.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. 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