CARE HOMES FOR OLDER PEOPLE
Hadleigh Court Stanley Road Torquay Devon TQ1 3JZ Lead Inspector
Stella Lindsay Key Inspection (unannounced) 1st August 2007 9:45 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 Hadleigh Court DS0000018364.V341881.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. Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hadleigh Court Address Stanley Road Torquay Devon TQ1 3JZ 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) 01803 327694 01803 327771 Babbacombe Care Limited Paula Heather Hounslow Care Home 31 Category(ies) of Dementia (31), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (31), Old age, not falling within any other category (31) Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category- Code OP Dementia- Code DE(E) Mental disorder aged 65 years and over on admission excluding learning disability or dementia- Code MD(E) The maximum number of service users who can be accommodated is 31. 9th March 2007 2. Date of last inspection Brief Description of the Service: Hadleigh Court is registered to provide accommodation with personal care for up to 31 people aged 65 or over, who may have a level of dementia, other mental disorder or physical disability. The home is developing its specialism in dementia care. The home is on two floors and has a shaft passenger lift connecting the ground and first floors, as well as a newly fitted stair lift to the main stairway. Private accommodation is provided in 25 single bedrooms, 21 of which have en suite facilities, and 3 double bedrooms all of which have en suite facilities. One single room is kept as a respite room so that bookings can be made in advance. There is a large lounge and adjoining sun lounge, and a dining area. There is an attractive and enclosed level garden with ramped access, and a car parking area. This detached house is in a level residential area of Torquay, adjacent to a local park and near to shops and other amenities in St Marychurch and Babbacombe. The home has a minibus to offer transport to appointments and social outings. The fees range from £300 to £650 - dependent on the level of need. The home’s Statement of Purpose is given to all prospective residents and in addition can be obtained from the home’s office. A copy of the latest CSCI inspection report was available in the entrance hall. Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over two days in August 2007. It included a tour of the premises, and discussion with the Home owner, Registered Manager, fourteen residents, and six staff on duty. The inspector shared a meal with residents, spent some time in the lounge, and visited some residents in the private accommodation. Surveys and comment cards had been returned to the Commission for Social are Inspection by staff, relatives, and health professionals, and their views are represented in the text. The Registered Manager supplied information about the running of the home prior to the inspection visit. What the service does well: What has improved since the last inspection?
The assessment procedure for prospective residents had improved, with the Manager meeting every resident prior to making the decision about offering accommodation, and recording this decision following full assessment. This is to make sure that accommodation is offered appropriately. Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 6 Care records were seen to be carefully recorded and up to date. A new format had been introduced, which would prompt staff to carry out regular reviews of care. The storage of medication had been improved, to separate residents’ medication more clearly, to avoid any risk of mistakes. Care practice at meal times had been improved, with the Manager ensuring that individual needs of more dependent residents are sensitively met. Attractive garden railings and gates had been provided, to ensure the garden is safe for residents. Keypad locks had been provided on external doors, to assure residents’ safety. Identification badges had been provided for all staff, to assist both residents and visitors in identifying staff members and their position in the home. The recruitment procedure had been improved, to protect residents from potential harm. An induction and foundation training programme had been obtained. The new Manager had registered with the Commission for Social Care Inspection, and was completing her qualification in the nationally recognised qualification known as National Vocational Qualification level 4 in Care and the Registered Managers’ Award, in order to provide a competent and qualified service. What they could do better:
The home provides a lively social life but would benefit by obtaining a greater variety of materials for promoting activities that are appropriate to this age group. It would be good to keep up the record of activities, with photos, to help residents remember what they have enjoyed, and to share with their visitors. A good programme of staff training is being provided. The Manager should ensure that all staff receive training in the Protection of Vulnerable Adults, in order to assure the safety of residents Training specific to the care of people with dementia should be provided, in order to develop the service in a way that promotes residents’ individuality, and encourages their independence and engagement, within their capabilities. The staffing arrangements around tea-time and afterwards need to be improved, as this is a busy time, and residents currently need attention at this time. Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 7 The Manager is introducing a programme of individual supervision sessions with staff, to give them support and feed back on their performance. This needs to be put into practice, for all care staff. Fire doors must provide proper protection in the event of an emergency, to protect residents from possible smoke inhalation. The kitchen must be clean and hygienic, as a safe place to prepare residents’ meals. The bathrooms and laundry need attention, to avoid potential risk of cross infection. The lounge, dining room and some bedrooms need redecoration and new carpets, to maintain the comfort and good appearance of the home, and also to make it more enabling for the residents, by avoiding patterns that can make them feel disorientated, and considering signs or pictures for doors to help people find their way around. More dining room chairs with arms should be provided, to enable residents to get up with more ease. Lockable storage space should be available for residents who could use it. Toilets should have locks for privacy, which staff may get into in an emergency. External doors should have alarms fitted, to alert staff when residents open them. There should be a Quality assurance programme, and the improvement plan should be shared with residents and their representatives. The home owner should carry out a formal visit to the home monthly, to monitor its progress, and keep a record. 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. Hadleigh Court DS0000018364.V341881.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 Hadleigh Court DS0000018364.V341881.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): 1,3 Quality in this outcome area is good. Clear information is provided, and careful assessment of needs is carried out prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear and comprehensive Statement of Purpose and Service User Guide, which has been up-dated to provide accurate information. The Manager said that she intends to further update this document with new photographs. The home has a pre-admission assessment form. The records of two recently admitted residents were examined, and seen to have been completed fully. The information gathered had been carefully considered, and the decision about whether or not the home could suitably offer accommodation was recorded at the end of the assessment. The Manager said that she always meets a prospective resident, including when it is considered to be an emergency situation needing prompt action. This is in order to satisfy herself that the newly admitted person will be able to live in satisfactory harmony with
Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 10 the people already living at Hadleigh Court. The Manager was aware of the requirement to inform new residents in writing of the decision to offer accommodation, though copies were not seen on files. All prospective residents and their families are encouraged to visit the home before moving in, to see the facilities and meet the staff and the other residents. Intermediate care is not offered at Hadleigh Court. Hadleigh Court DS0000018364.V341881.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 Quality in this outcome area is good. Residents’ health, personal and social care needs are clearly set out in care plans and needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents had a full care plan, to allow staff to be aware of their needs. A sample of care plans and daily records were inspected – in particular for recently admitted residents and residents who currently had a high level of need. Recording was clear, and showed careful monitoring and action taken promptly to call for medical help. Where there is concern over a resident’s intake of food, their weight had been checked monthly and the GP called when weight loss was recorded. Records for diabetes care and catheter care were seen, with regular visits from District Nurses. Life stories and family histories were recorded for some residents, to help give staff a good understanding of them. Some residents had signed to evidence that they had read and approved of their own care plan. Not all the residents who spoke to the inspector were aware that they had a written plan. The
Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 12 format that is used for these records is designed to encourage staff to review the care regularly. The home has a policy and procedure for the safe storage, recording and administration of medication, and staff were seen to be working carefully according to the procedure. A Senior Carer is given time each month to check the accuracy of the medications on delivery, and the Controlled Drugs are checked daily by the Deputy Manager. These were also checked by the inspector and found to be accurate. The medication cupboard had been reorganised to provide clearly separated ‘pigeon holes’ for each resident, to prevent any risk of error in administration. The inspector spent a considerable amount of time observing staff interacting with residents, and saw they were positive and respectful at all times. Privacy and dignity were regarded as important generally, but some toilet door locks needed attention, so that residents could maintain privacy but staff could gain access in an emergency. Hadleigh Court DS0000018364.V341881.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): 12,13,14,15 Quality in this outcome area is good. A choice of social activities is provided, and the quality and variety of meals is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ preferred times for getting up and dressed are not recorded, as most are able to use their call bell, and staff respond, so that people can get up at the time of their choice. This was seen to happen during this inspection visit. Social activities are promoted within Hadleigh Court. Two residents were highly dependent. Staff were aware that they responded to singing and music, and engaged them in a positive way. Two care staff held a quiz during the morning, which many residents joined in. The home would benefit from obtaining game materials designed to promote discussion while avoiding right or wrong answers. The weather was fine, and during the afternoon several residents spent some time in the garden. One staff member spent time making fluffy models with a resident, which gave much pleasure. Residents are often taken out for drives or walks to the local shops. An Activities Book is kept, but nothing had been recorded for a fortnight. It would be good practice to complete it fully every day, and also to keep photo
Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 14 albums of daily activities. Surveys returned by relatives to the CSCI said that the lounges were quiet, with not much happening. Staff on duty told the inspector of many social activities that are offered. Residents may not remember or be able to tell their visitors what they have enjoyed. All residents who spoke to the inspector were satisfied with their meals. They did not know what they were going to receive, but were confident that they would like it. A member of kitchen staff had been to each resident to tell them what was on the menu, and to record their choice. This also forms a record of food eaten. It might be helpful to have the menu of the day on display, to help people to remember. Plenty of fruit and fresh vegetables were available. On the day of this inspection visit, there was a choice of vegetarian sausages or ham and egg with chips and peas or salad. Two people regularly have a vegetarian diet, and four need low sugar diets. Blended food and supplements were given as required. Residents who needed support with eating were given this with care and sensitivity. Teapots are put on the tables at tea-time for residents to help themselves, except on Wednesdays and Sundays when there is a popular tradition of a buffet tea being brought to residents in the lounge. Hadleigh Court DS0000018364.V341881.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): Quality in this outcome area is good. Residents can be confident that complaints are taken seriously and acted upon. They are protected from abuse by good procedures, and by the competence and good attitude of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager kept a book to record concerns that had been brought to her attention, and what had been done to put it right if necessary. These included meal sizes, organisation of laundry and the new door locking arrangements. One complaint had been received by the Commission for Social Care Inspection in April 2007. It concerned staff levels and competence which was investigated and accounted for satisfactorily by the Home owner. It also brought attention to occasional improper practice with regard to administration of medication, and procedures were altered to put a stop to this. Training in the Protection of Vulnerable Adults from Abuse had been provided, and most staff had benefited from this, and knew what must be done in the event of any allegation. The Manager has incorporated the local “Alerters Guidance and Policy” into the home’s procedure. Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,26 Quality in this outcome area is adequate. Hadleigh Court is a comfortable and accessible home. Work was in progress to make it safer and more enabling for people with cognitive problems, and to bring the kitchen, bathrooms and laundry to a safe and satisfactory standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Maintenance work has continued to keep this large house comfortable and attractive. The flat roof on the downstairs extension recently needed to be replaced, which was a major project. A new stair-lift has been installed to improve access and provide choice for residents, but also to provide an emergency back up for when the shaft lift is out of action. This is a great benefit to assure residents’ continued access. Some bedrooms had been refurbished, with residents being given a choice of colour scheme. Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 17 There are still too many patterned carpets, which cause disorientation for some residents. One resident was seen stooping to pick a thread off the floor in the lounge, and it was a worn edge of carpet. There is easy access from the sun lounge to the garden, and some residents can come and go unaided. Railings have been provided to allow for safety while not feeling confined. The garden is very attractive, and suitable garden furniture had been provided. New dining room furniture had been provided. One resident had been provided with a dining chair with arms for support, but others would also benefited, and would be able to get up with little or no assistance. Call bells had been provided in all bedrooms, but not in en suite toilets. Not all rooms had the possibility of lockable storage, although new bedside cabinets had been purchased. Bedroom doors had locks, for privacy and security. Some residents are able to hold the key to their own door, but others need help from staff to access their private accommodation. There were two bathrooms, both with hoists. Another bathroom was out of action. The Manager said that there was a plan to install an accessible shower, to offer choice to residents. The bathrooms needed attention to seal gaps around baths, to avoid any danger of contamination. The kitchen floor needed repair or replacement, and some wall tiles were missing. The cooker, floor and ceiling were in need of cleaning. The Environmental Health Officer had visited on 19/07/07, and had made requirements with regard to these matters, as well as fridges, the meat-slicer and microwave. Chopping boards and racks had already been replaced, and new equipment was being ordered. The laundry was small, and needed care to avoid cross-contamination between clean and soiled items. A new place to hang clean clothes to dry was needed urgently, as they were being hung over the washing machine where dirty clothes were handled. Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. Staff who are competent and had a good understanding of residents’ needs were provided in sufficient numbers for most of the day. The recruitment procedure was sound, and a good training programme was being provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels had been improved, with an extra Senior appointed. A Senior plus three carers are on duty from 8 – 2pm, plus the Manager and Deputy Manager. From 2 – 8pm a Senior is on duty with two carers. It was considered that another carer is needed in the busy time during and after tea. A cook and kitchen assistant are employed to provide breakfast and dinner, and a kitchen assistant is provided from 4.30 – 6pm. Two domestics, a gardener and a driver are also employed. At night two care staff are on duty, and the Manager is on-call. The night staffs’ duties are clearly recorded, including the residents who need to be checked and those who need regular attention through the night. Identification badges had been provided for all staff, to assist both residents and visitors in identifying staff members and their position in the home. Duty sheets had been introduced to improve accountability for work. Staff were seen to engage with the residents in a positive manner.
Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 19 The files were examined of two staff members who had been recently recruited. It was found that all the checks necessary to assure protection of residents had been carried out. The Manager said that they had been asked to work alongside experienced staff (a shadow shift) when starting work at Hadleigh Court. Induction training had been provided, and a foundation training programme was available. Agency staff had been used on a small number of occasions. The agency had been able to send the same staff consistently, so that they would be familiar to the residents. The Manager was preparing a wall planner to show training up-dates as they become necessary. Training provided included Fire Safety, the Protection of Vulnerable Adults, First Aid, Infection Control and Food Safety. NVQ training was continuing. Some staff had benefited from specific training in care for people with dementia, but this should be extended and provided for all. Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is good. The Registered Manager has a clear view of the improvements needed to develop this home and provide a good service in the best interests of the residents, with health and safety issues as a priority. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection the Manager, Mrs Paula Hounslow, has registered with the Commission for Social Care Inspection. She is working towards the nationally recognised qualification known as National Vocational Qualification level 4 in Care and the Registered Managers’ Award, in order to provide a competent and qualified service. She estimated that she would complete this by September 2007. The Home owner, Mrs Christina Walton, visits frequently, and holds a monthly meeting with the Registered Manager to discuss developments as well as any
Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 21 issues. She needs to produce a report on the conduct of the home and supply a copy to the CSCI. A Deputy Manager had been appointed since the last inspection, to give management support. Communication with in the staff team was improving. A staff meeting had been held in March at which staff were able to raise concerns, and improvements to the environment were considered. Another meeting was planned for the week following this inspection. The Senior Carers had been given specific areas of responsibility, including Care Planning, and Medication. A residents’ Meeting had been held in January at which the staffs’ manner had been discussed as well as meals and entertainment. Residents had asked for a clock in the lounge, and a large clear clock had been provided. The Home owner and Registered Manager have detailed plans for improving the environment and service at Hadleigh Court. They should present it in a report or plan to share with residents and their relatives in order to gather and include any suggestions. The Manager is introducing a programme of supervision and appraisal for staff, but has not yet involved all staff. She said that she intends to fully implement this by December 2007, in order to give staff feedback on their performance, as well as check their knowledge of the home’s policies and procedures, and to check their training needs. The fire precaution system had been serviced professionally on 12/04/07, including the alarms, extinguishers, and emergency lighting. However, some fire doors were found to be unsafe, which places residents at risk of potential harm. The home owner said that she intended to have alarms fitted to external doors, in order to alert staff if a resident were to leave the building. Arrangements to commission this work were started during the course of this inspection. Accidents are recorded, and action taken to prevent fall if possible. Where one resident had been found to fall more than once, advice was sought from a specialist nurse (Parkinsons). Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X X X 1 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 X 2 X 3 2 X 2 Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 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 OP21 Regulation 23(2) Requirement Complete the refurbishment of the assisted bathrooms and WCs, including provision of suitable locks. Previous timescale 30/06/07 The home owner must ensure that the kitchen is brought to a good hygienic standard, and supply the CSCI with a copy of the next report of the Environmental Health Officer. Laundry procedures must avoid any potential risk of cross contamination. Staffing arrangements from 4.30pm to 7pm must be considered, in order to meet residents’ needs in a safe and satisfactory manner. Ensure that all staff attend a detailed training course in relation to caring for persons with dementia. Complete the Quality Assurance programme and further develop the annual development plan to make it available to residents and other stakeholders
DS0000018364.V341881.R01.S.doc Timescale for action 31/12/07 2. OP26 13(3) 31/10/07 3. 4. OP26 OP27 13(3) 18(1)a 31/10/07 31/10/07 5. OP30 18(1) 31/12/07 6. OP33 24 31/12/07 Hadleigh Court Version 5.2 Page 24 7. OP38 26 8. OP38 23(4)c(1) Previous timescale 30/05/07 The owner must carry out formal 31/10/07 visits to the home with records kept for inspection or supplied to the CSCI. Previous timescale 31/03/07 The home owner must ensure 30/09/07 that the fire precaution system is complete, with fire doors providing protection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP24 OP20 Good Practice Recommendations Continue with refurbishment of lounge, dining room and bedrooms to a good standard, in line with residents’ preference. To include provision of dining chairs with arms (carvers) and bedside cabinets with lockable drawers where this would benefit the resident. Re-instate the activity record as before and ensure that this is kept up to date. Obtain a greater variety of materials for activities which are appropriate to this client group, to promote engagement and self esteem. Remaining staff members to attend POVA training as the date becomes available. Ensure that all staff receive supervision a minimum of six times a year and appraisals once yearly. 2. OP12 3. 4. OP30 OP36 Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Hadleigh Court DS0000018364.V341881.R01.S.doc Version 5.2 Page 26 - 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!
