Inspection on 22/05/06 for Grove House

This inspection was carried out on 22nd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grove House 20/12/06

Grove House 01/02/06

Grove House 16/06/05

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

CARE HOMES FOR OLDER PEOPLE Emmanuel Christian Care Home Grove House 1 Palm Grove Claughton Prenton Wirral CH43 1TE Lead Inspector Jeanette Fielding Unannounced Inspection 22nd May 2006 08:45 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 Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 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. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Emmanuel Christian Care Home Address Grove House 1 Palm Grove Claughton Prenton Wirral CH43 1TE 0151 652 1021 0151 652 2629 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) Gladman Care Homes (Emmanual Christian Care Home) Ltd Mrs Siobhan Dean Care Home 63 Category(ies) of Dementia (23), Old age, not falling within any registration, with number other category (23) of places Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may from time to time admit persons from the ages sixty years to sixty five years of age. 17 Intermediate Care beds aged 50 years and over Date of last inspection 1st February 2006 Brief Description of the Service: Grove House is part of the Emmanuel Care Centre located in a residential area in Birkenhead, Wirral. The home is owned by Gladman Care Homes Ltd which is a wholly owned subsidiary of Four Seasons Health Care Limited. The home is registered to provide transitional care for up to 46 persons and intermediate care for up to 17 persons. All service users are accommodated in single bedrooms, each having en-suite facilities. A number of lounges and seating areas are provided to enable service users to choose where they spend their day. Service users accommodated for intermediate care have a greater input from Occupational and Physiotherapists to provide them with the skills to enable them to return home following hospitalisation and are accommodated at the home for a period of up to six weeks. The ground floor provides for 17 persons requiring Intermediate Care. The first floor provides for 23 persons who have dementia and are awaiting a place in a care home of their choosing, and the second floor provides for 23 elderly persons who are awaiting a place in a care home of their choosing. Service users accommodated for transitional care are usually accommodated for up to eight weeks. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over two days and a total of 13 hours were spent in the home. The focus of this inspection was the same as the previous inspection, that is, the care of the service users and the evidence of the care provided by the home. The initial assessments undertaken by the home and the care plans were inspected to ascertain the specific care needs of the service users and to view the evidence that this care was given. Staff records were inspected to ensure that service users were protected through a robust recruitment procedure. Staff records did not provide evidence that staff had been given appropriate training although the inspector was advised that work was taking place to include training records on the staff files. There was little evidence of improvement in the care files, care provision or staff training since the last inspection. Concerns relating to the administration and recording of medications remain despite assurances at the last inspection that these would be addressed. The home is purpose built and provides all service users with single, en-suite accommodation. A range of lounges and seating areas are provided. The home was found to be clean and there were no unpleasant odours. What the service does well: What has improved since the last inspection? What they could do better: Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 6 Assessments and care plans remain poor. Insufficient information is available to staff to enable them to provide the appropriate care required by individual service users. No expected outcomes or goals are identified for those service users accommodated for intermediate care. Some medications are still not administered or recorded appropriately by the nursing staff which has the potential for placing service users at risk. Toiletries are not appropriately stored safely or hygienically within the EMI unit to ensure the protection of service users. Safety certificates were not available for inspection to ensure that staff and service users are protected. 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. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 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 Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide are excellent, providing current and prospective service users with details of the services the home provides enabling an informed decision to be made about admission to the home. Pre-admission assessments are poor and do not give sufficient information for an effective care plan to be prepared which may place service users at risk. EVIDENCE: The owners of the home have produced an informative statement of purpose and service user guide. Full information regarding the services and facilities provided by the home is included together with additional information about the role and responsibilities of all staff. These are issued to all service users Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 9 and are available to prospective service users and interested parties on request. Many of the service users have their needs assessed by social workers or hospital staff prior to their admission although every effort is made to ensure that a member of the home’s staff undertakes a pre-admission assessment. A social assessment form is held on all files for completion by the service user, their relatives or by the home’s staff. A high number of the assessments did not clearly identify service users specific care needs in relation to them being accommodated at the home for intermediate or transitional care. No information is recorded regarding the expected outcomes, achievements or goals to be reached during the service users stay at the home for intermediate care. The information recorded by physiotherapists and occupational therapists does not give the care staff sufficient information to enable them to continue with the appropriate intervention to work with the service users and thereby achieve a level of ability and independence to enable the service user to return home. The care file for one service user accommodated for intermediate care did not identify the reason for the admission to the intermediate care unit, with all records indicating that the service user required transitional care as they had been admitted from a previous care home and was awaiting admission to another home. It is evident that the assessments on those service users accommodated for intermediate care are inadequate to enable an appropriate plan of care to be produced. Service users accommodated for transitional care are not adequately assessed to enable a plan of care to be produced. Insufficient information is recorded with regard to nursing needs or with regard to social needs. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no clear or consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: Individual care plans are produced for each service user. Due to the lack of information gathered at the time of the assessment, the care plans do not contain sufficient information for the staff to provide the appropriate level of care. Ground floor. Intermediate care unit. Little information, or inaccurate information is recorded on the care files of two service users who have wounds that require dressing by the staff. One file identifies a specific type of dressing to be applied whilst the daily report completed by the qualified nurses gave details of a different type of dressing being used. The other care file did not give any details of the type of dressing to be used but the daily report Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 11 identified a specific dressing having been applied. No mapping of wounds is recorded and no information is recorded regarding the size of the wound, or of any progress or deterioration following treatment. Care files include information regarding moving and handling of service users following risk assessments, but the moving and handling plan does not identify the weight of the service user or give information on how to move service users who have a disability or have weakness on one side following a stroke. The care file for one service user identifies a considerable weight loss in the initial assessment, but the nutritional assessment, completed at the same time states that the service users weight is usual and steady. One assessment states that the service user is at a low risk from falls, but the daily report states that the service user was walking around unsupervised. No details regarding mobility are recorded to ensure that supervision is provided. Some care files do not contain sufficient information regarding the next of kin with no contact telephone numbers or addresses being available. One service user is reported to have suffered five falls in the four weeks prior to the inspection. No evidence was found of an updated care plan to ensure the protection of the service user or of any intervention to discover the cause of the falls. The care files in this unit are inadequate and place service users at risk. First floor. Dementia Transitional Care. The care files on this unit were extremely poor. The file for one service user indicates that the plan of care was not prepared until six days following admission. The assessment form did not contain sufficient information for a plan of care to be prepared. The service user had complex care needs but the care file did not contain risk assessments, risk management plans or specific information regarding the care requirements of the service user. The daily records completed by the qualified nurses did not reflect the care given to the service user. There was no photograph of one service user which would present as a problem for agency staff who are used on an occasional basis and may place the service user at risk. A high number of accidents were recorded on this unit. The lack of risk assessments and risk management plans gave cause for concern. It is evident that the care staff do not have sufficient information to meet the needs of service users due to poor assessments and care planning. The care files in this unit are poor and place service users at risk. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 12 Second floor. Elderly Transitional Care. The care files on this unit had improved since the last inspection although additional information requires to be recorded to ensure that the service users care needs are clearly identified. The required treatment of one service users pressure sore was not clearly identified in the plan of care although staff spoken to were fully aware of the treatment they were giving and the progress of the wound. Care plans had been reviewed on a regular basis and the details recorded in the reviews were comprehensive. The diary held on this unit provided information that planned care was in place and all appointments were recorded. Medication records were inspected in all three areas of the home. Ground floor. A protocol is now in place for the staff to confirm the current medications prescription on admission from GP’s or hospitals as appropriate. Medications were found to be ordered, stored, administered and disposed of in accordance with the home’s policy and procedure. Entries on the Medication Administration Record sheet that are made by the staff should be witnessed by a second person who should then sign the sheet to indicate the accuracy of the entry. First floor. It is evident that a problem exists in the communication with the dispensing pharmacist. The medication administration record sheets provided by the pharmacy are not updated to reflect changes made to prescriptions by the doctors in the prescriptions. On one occasion, the records held by the home show that the medication received by the home differed from the prescription issued by the doctor. This discrepancy had been noted by the home’s staff and appropriate action taken to rectify this. One service user was found to have been without medication for six days. The records did not provide sufficient information to identify how this had occurred. One medication was held in the refrigerator when the instruction on the container required that the medication be held at room temperature. Photographs of individual service users should be held with the MAR sheet to provide service user identification, particularly when agency or bank staff are employed to avoid the risk of error. Second floor. One service user was found to have been administered a medication four times each day when the MAR sheet, and the container, clearly identified that this medication was to be given three times daily. The qualified nurses must ensure that the medications are administered as prescribed. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A programme of activities is provided for social stimulation of service users to enrich service users lives. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Service users accommodated for rehabilitation have a more structured day to work around the routines of the occupational and physiotherapy professionals. An activities co-ordinator is employed by the home to provide a programme of activities and social stimulation for the service users on all three floors of the home. Service users spoken to said that they enjoyed chatting with others during the day and confirmed that activities were provided although some said that they did not wish to participate. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 14 Visitors are welcome at the home and may meet with the service users in their own bedroom or in one of the communal areas. Ministers of religion visit the home on a regular basis and can provide services on request. The inspector spoke with a small group of service users who were accommodated for intermediate care who stated that they had not been given a reasonable explanation for being in the home. All felt that they could cope adequately in their own home following hospitalisation although one lady said that she could manage to do some things now that she had not been able to do when she left hospital. The relative of one service user said that the activities provided were not suited to the service users who were accommodated for dementia care. She explained that her relative had recently been in hospital where a greater number of more appropriate activities had been provided. She had expected that more activities would be provided in the home but had been disappointed in the range and quality of the activities. The care plans inspected did not provide evidence that individual preferences had been identified. The home offers a four-week rotating menu that offers a selection of meals at each mealtime. Service users are encouraged to take their meal in the attractive dining rooms to promote social interaction, but can be served their meal in the privacy of their bedroom if they wish. The menus provide evidence that a varied and balanced diet is offered to all service users. Special diets can be provided on the advice or recommendation of the GP or dietician. Meals are prepared in the main kitchen and are served individually from heated trolleys. The kitchen area was clean and the chef stated that some new equipment had been ordered and its delivery was awaited. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with some evidence that service users felt that their views are listened to. EVIDENCE: The home has produced a comprehensive complaints procedure which is detailed in the service user guide and is also displayed on notice boards within the home. The procedure gives service users and visitors to the home full information on how to make a complaint and to whom the complaint should be directed. One relative informed the inspector that they had recently made a complaint and was awaiting a response from the home. There is no evidence that staff have been given training on adult protection issues or of abuse indicators. Staff spoken to confirmed that information about abuse and the action to be taken was available but none had taken the opportunity to read it, nor had any formal training been given. Discussion with staff provided evidence that all were aware of the different types of abuse that could occur and that if they suspected it, they would inform the senior member of staff on duty. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inappropriate storage of toiletries has the potential for placing service users at risk. The quality of the building and facilities within the home are good creating a comfortable environment for the service users. EVIDENCE: Grove House is a purpose built care home located within the Emmanuel Care Home Centre. It is located close to shops, parks and is accessible by public transport. Car parking areas are provided. The home is on three floors with all areas being accessible by a passenger lift. All service users are provided with a single bedroom, each having en-suite facilities. All en-suite facilities are provided with a shower. Additional toilets Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 17 and baths are provided together with additional shower and bath rooms. Bedrooms are decorated and furnished to a high standard. A selection of communal areas is provided. The inspector observed that clean laundry, a hoist and a wheelchair were stored in one shower room on the ground floor of the home and also in one shower room on the first floor. Laundry should not be stored in this area. A large number of personal clothing was seen in the shower room on the first floor. There was no indication of who the clothes belonged to as they had not been individually marked. Care should be taken to ensure that service users personal clothing is returned to them. An unlocked cupboard in a bathroom on the first floor contained a large stock of toiletries. Specialist shampoos, provided on prescription were also stored in this cupboard. All toiletries were labelled with service users individual names but were all stored together in baskets containing specific items. All the deodorants were in one basket with toothpastes in another. The inspector was concerned to note that a large number of toothbrushes were held in another basket. It is not hygienic for several service users toothbrushes to be stored in one basket. An individual basket should be provided for each service user to prevent cross contamination and stored appropriately to prevent service users accessing them where a risk is identified. The occupational therapists have been involved in the assessment of the premises to ensure that it provides the appropriate facilities to meet the needs of service users. The home is central heated and all rooms have windows that can be opened to provide natural light and ventilation. Thermostatic valves have been fitted to all hot water outlets to ensure that the service users are not put at risk of scalding. The home was clean throughout and there were no unpleasant odours. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate checks are made on all staff to ensure the protection of service users. EVIDENCE: The home provides qualified nurses, supported by care staff to provide for the service users care needs. Agency staff are used to cover for holidays and sickness where necessary and regular staff also work additional hours at this time. A sample of staff files were inspected. Work is taking place to ensure that evidence of staff training is included in the files although much of the necessary information is not held in the home and staff are being requested to provide this evidence. Appropriate checks are made on staff prior to them working in the home to ensure that service users are protected. All applicants are required to complete an application form prior to interview. Two references are taken and verification of nursing qualifications is required to be produced. Records are held of the issues discussed at interview and gaps in employment history are investigated. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 19 A number of care staff were spoken to during the inspection. All confirmed that training opportunities were available. Two staff said that they were overworked and did not feel that they were adequately supported by the nurses on their units. No record is held of supervision or annual appraisals. All staff should be given formal supervision every two months to ensure that they are given the opportunity to discuss their performance and training needs with their line manager. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Safety certificates were not available in the home to provide evidence that staff and service users are protected. EVIDENCE: The manager is a qualified nurse and an experienced manager. She has achieved an NVQ level 4 in management and could evidence details of ongoing training. She has an open door policy and is available to service users and families each day. Staff meetings are held on a regular basis and minutes of these meetings are held. Regular meetings have also been held for service users and their families to update them on changes on the management and to provide a forum to discuss relevant issues. Opportunities to speak with the home Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 21 manager, and senior managers of Four Seasons Healthcare have been made available to service users and their relatives at a mutually agreed time. The home does not deal with any of the service users finances. Evidence was seen of tests made to the fire detection equipment and these are made at the appropriate frequency and are duly recorded. Records relating to tests made on the building and the equipment used were not available for inspection. The inspector was advised that these are held centrally by the owners of the home and arrangements are in place for copies to be held in the home. It is imperative that these copies are made available at the next inspection to ensure that staff and service users are protected. A monthly inspection of the home is undertaken by one of the senior managers of Four Seasons Healthcare and a report is produced. This report is issued to the manager of the home with copies submitted to CSCI and FSH board members. Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 X 2 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X X 1 Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP6 Regulation 14 Requirement The Registered Person must ensure that the pre-admission assessments contain all necessary information to ensure that the specific needs of the service users can be met. This remains outstanding from previous inspections. Timescale for action 23/06/06 2. OP7 15 The registered person must 30/06/06 ensure a plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. This remains outstanding from the last inspection. 23/06/06 The registered person must ensure that all risks to the health and safety of service users are identified and so far as possible eliminated. This remains outstanding from the last inspection. The registered person promotes and maintains service users’ DS0000063096.V291238.R01.S.doc 3. OP7 13(4)(c) 4. OP8 17(1)(a)S chedule 3 23/06/06 Emmanuel Christian Care Home Version 5.1 Page 24 health and ensures access to health care services to meet assessed needs. This remains outstanding from the last inspection. 5. OP9 13(2) The registered person ensures that the staff follow the policy and administration and recording of medications. The registered person must ensure the routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. This remains outstanding from the last inspection. The registered person must ensure the safety of service users through appropriate storage. The registered person must ensure that effective training is given with regard to adult protection, abuse and medications. This remains outstanding from the last inspection. 23/06/06 6. OP12 12(1)(b) 23/06/06 7. OP19 13(4) 23/05/06 8. OP18 19(5)(b)1 3(6) 30/06/06 9. OP38 13 The registered manager ensures 30/06/06 so far as is reasonably practicable the health, safety and welfare of service users and staff. Evidence of this is required through the provision of safety certification. This remains outstanding from the last inspection. The registered person must ensure that effective training is given with regard to adult protection, abuse and DS0000063096.V291238.R01.S.doc 10. OP28 19(5)(b)1 3(6) 30/06/06 Emmanuel Christian Care Home Version 5.1 Page 25 medications. This remains outstanding from the last inspection. 11. OP30 19(5)(b)1 3(6) The registered person must ensure that effective training is given with regard to adult protection, abuse and medications. This remains outstanding from the last inspection. The Registered Person must ensure that the pre-admission assessments contain all necessary information to ensure that the specific needs of the service users can be met. This remains outstanding from previous inspections. 30/06/06 12. OP3 14 23/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Emmanuel Christian Care Home DS0000063096.V291238.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!