Inspection on 14/02/06 for Hadleigh House Care Home

This inspection was carried out on 14th February 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

Hadleigh House Care Home 20/01/09

Hadleigh House Care Home 13/10/08

Hadleigh House Care Home 05/02/08

Hadleigh House Care Home 13/03/07

Hadleigh House Care Home 04/10/05

Hadleigh House Care Home 18/11/04

Hadleigh House Care Home 16/07/04

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

CARE HOMES FOR OLDER PEOPLE Hadleigh House Care Home 350 Pelham Road Immingham North East Lincs DN40 1PU Lead Inspector Mrs Jane Lyons Unannounced Inspection 09:30 14th and 21 February 2006 st 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 House Care Home DS0000002861.V281923.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. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hadleigh House Care Home Address 350 Pelham Road Immingham North East Lincs DN40 1PU 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) 01469 572514 Mr Michael Thomas Bailey Allison Smith Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: Hadleigh House provides comfortable, homely accommodation for up to 38 service users over the age of 65. The home is situated close to all amenities in Immingham. It has pleasant gardens; its own car park and is on a bus route. The home is a two-storey building with access to the first floor via stairs and a passenger lift, it is well maintained in terms of décor and furnishings. There are 32 single bedrooms and 3 shared, en-suite facilities are provided for the five new single bedrooms on the first floor. There are four bathrooms and a shower room with separate WC facilities provided on each floor. The home now provides 3 lounges and a pleasant dining room for service users to use. The rear garden has been landscaped and an attractive courtyard area provided, with seating and shade for service users and their visitors. Ample car parking space is provided. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days in February 2006, the manager was off sick during the first day and the inspector returned to discuss all the findings. During the visits the inspector spoke to the manager, four staff, nine residents, six visitors, a district nurse and care manager to find out how the home was run and if the people who lived there were satisfied with the care and facilities provided. The inspector looked at a number of bedrooms, bathrooms and communal rooms such as the dining room and lounge areas during the visit. Paper work relating to staff recruitment, staff training, activities, accidents, care plans, resident finances and health / safety checks were looked at to make sure it was all in place, up to date and residents were safe. What the service does well: What has improved since the last inspection? The home has a continuing programme of physical refurbishment and improvement. Bedrooms are regularly decorated with furniture and bedding replaced. The kitchen has been completely refitted with new flooring, units and new fridges/ freezers provided. The home now employs an activity organiser who works at the home five days per week. A weekly programme of activities and entertainments has been arranged which residents are enjoying. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 6 The manager has completed her registration with the commission and is working towards a level four NVQ course in management and care. Records to support the recruitment of staff at the home has improved which will ensure that the residents are better protected. Documentation such as the statement of purpose and the complaints procedure have been reviewed which will provided clearer information to the residents and their families. Staff have been provided with more training which will better equip them for their role. What they could do better: Continence management needs to be more robustly managed to ensure that there are no odours in service users rooms which would better maintain their dignity and comfort. The use of transit wheelchairs to transfer residents around the home would also better protect their dignity. Care planning records had not improved which is important to make sure that all the staff understand the care that everyone needs and can make sure that the care they are giving is working or not. Further work to improve drug storage and recording is required to ensure safer practice and the prevention of errors. When residents have accidents it is important that appropriate records are completed; more thorough audits of all accidents by the manager would better ensure that risks of accident re-occurrence have been addressed. The management must ensure that the home is appropriately staffed at all times to ensure service users needs can be met; the management must now utilise a formal staffing dependency tool to support staffing levels. Further courses for staff in moving/ handling, food hygiene and first aid must be provided to ensure staff have met their statutory targets and that their current practice is safe. The management have not maintained or further developed the quality assurance system since the last inspection, however works to improve the documentation and administration systems would take priority at the present time. The owner of the home has a legal duty to visit the home un-announced on a monthly basis and to provide a report of these visits; this would ensure the management of the home is being closely monitored. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 7 Improvements in the storage of equipment throughout the home is required to ensure the safety of the residents. 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. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 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 House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1and 6 Progress had been made to update the information at the home to ensure potential service users have current information on the facilities and services at the home. Minor work is still required. EVIDENCE: The statement of purpose and service user guides had been updated in October 2005 to reflect current information about the facilities and services at the home. Information relating to emergency admissions needs to be included in the statement of purpose otherwise the document complied with Schedule 1 and NMS 1. The home does not provide intermediate care support. Hadleigh House Care Home DS0000002861.V281923.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 and 10 Although care plans were not always adequately developed or maintained which could leave the service user at risk of inadequate care and unidentified health problems there was sufficient evidence that health and care needs of the service users were met. Medicines administration, recording and storage arrangements are mostly satisfactory, but have some potential to place residents at risk. Residents are cared for respectfully for the most part, but some poor practice risks their dignity being undermined. EVIDENCE: In general the format of the documentation was good however little progress had been made to improve the overall standard of the care plan recording. Three care plans were examined as part of the case tracking process; gaps were identified in the documentation with regard to identification of all the current problems; minimal recordings in the care intervention section, incomplete and absent risk assessments and inconsistent maintenance of supplementary records such as weight charts. There were numerous gaps Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 11 identified in the daily record charts. The standard of written English recorded in the care plans had not improved. An immediate requirement notice was issued around improving the monitoring of service users weights as the records had not improved since the previous inspection. There was evidence in the records and from discussions with staff that service users had access to health care services such as G.P. dietician, chiropodist and diabetic liaison nurse. All the service users spoken to were satisfied with the care provided; they told the inspector how kind, polite and patient the staff were and that they felt very supported. They confirmed that they were addressed by their preferred title and noted that the staff always knocked on doors before entering. The inspector was able to talk to the local district nursing sister during the visit; she confirmed that she was very satisfied with the overall care provision at the home, the staff were friendly and she had observed how they promoted choice and independence to service users. She went on to say that communications in the past had been patchy however there had been good improvements in recent times; she found the senior care staff very knowledgeable about the service users needs. The medication policy still requires review to include the management of service users who wish to self medicate. Although no gaps were identified on the medication administration records, the standard of transcribing was poor when changes to the individual prescriptions had occurred; it is good practice to rewrite the prescription to ensure the instructions around dosage and frequency of administration are clear. The medication storage cupboard requires a lock and efforts must be made to separate the storage of internal and external medications. The inspector noted that there was a surplus of a number of stored medications, which requires review. Monitoring of the room temperature where the medications are stored was now taking place. The manager confirmed that further staff had been enrolled on the safe handling of medications course. Observation of staff interaction with service users during the visit was very positive; all the staff spoke and engaged with the residents throughout the day and prompt support was provided. During the visit the inspector observed the staff using portable commode chairs for transit purposes; these chairs were used for two service users in the dining area where they remained seated for their lunches; staff must use transit wheelchairs for this purpose to uphold the service users dignity. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 12 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 and 14 Activity provision in the home has improved significantly to meet service users expectations, preferences and capacity. Service users were seen to experience a full life with support in place to make decisions. EVIDENCE: Service users were very complimentary of the homes environment and how they were supported in their daily lives. Throughout the day visitors came to the home; they were all comfortable in entering the home and offered refreshments during their stay. Activity provision in the home had improved since the previous inspection. An activity organiser had been employed and provides two hours support MondayFriday. A varied weekly programme was in place which included manicures, crafts, quizzes, dominoes, games, music etc. The service users commented that they enjoyed the activities; one service user told the inspector how much she looked forward to the regular quizzes and how she had enjoyed the cooking session the previous week when they had made scones. Policies are in place to support advocacy and risk management; there was evidence from observation and interviews with staff and service users that systems are in place to support choice and decision making. Service users Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 13 commented that they could rise and retire to bed at times to suit themselves, choose where to have their meals and what clothes they wanted to wear. They also commented that they could spend time in their rooms if they wanted to but usually preferred to sit during the day in the lounge areas. One of the residents had recently celebrated her 99th birthday; it was pleasing to see that all her birthday cards (46) had been put up in the lounge area where she prefers to spend most of her time. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 14 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 Service users are generally confident that their concerns will be listened to. EVIDENCE: There was evidence that the manager had reviewed the complaints procedure to include current contact details for the CSCI; the wording of the document requires minor review to clarify how serious issues will be dealt with. Complaint records were examined which demonstrated that the home had not received any complaints since February 2004; records of the complaint issues made under the joint adult protection procedures the previous year and recent concerns raised by a service user about the staff allowing the doors to bang need to be fully documented with outcomes. All service users spoken to confirmed that they would feel confident in raising issues with the staff or owner. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 15 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 and 26 The standard of décor and furnishings within the home provide residents with an attractive and homely place to live in, significant improvements have been made to the home over the last twelve months however outstanding issues around odour control impact on the overall quality of the environment. EVIDENCE: Hadleigh House provides a homely environment with furniture and décor of a good standard. An extension to provide five first floor bedrooms and a new dining room on the ground floor had been completed the previous year and was seen to be well utilised. There has been a lot of upgrading with the provision of new windows and flooring; this programme is now near completion with the recent refitting of the kitchen, which is a significant improvement. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 16 Outstanding issues regarding odour management to three bedrooms needs to be addressed more robustly; the manager must review continence management and cleaning schedules, if the problems persist further then new carpets must be provided. An immediate requirement notice was issued in respect of this. Other areas of the home were seen to be clean however storage in the home remains problematic; the area outside the manager’s office needs to be cleared of boxes and equipment as does the ground floor bathroom which was full of wheelchairs and hoists etc. Service users spoken to were very happy with the home and their bedrooms; there are plenty of communal rooms for people to meet. The gardens are very attractive and the rear gardens have been landscaped following the building works. Rails have been provided to the ramp exits, which promote safety. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 17 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 and 30 Service users are cared for by sufficient staff to meet their needs on the majority of occasions, however occasional shortfalls have occurred. The training of staff has improved however gaps in the provision of statutory training may place service users at risk. The homes recruitment practices remain robust to safeguard service users living at the home. EVIDENCE: The care staff rota was being maintained at five staff on a morning shift, three and half staff on an afternoon shift and two waking staff on night duty. Occupancy was 25. The manager has continued to experience problems with staff sickness; all staff are now interviewed on return to work and recent recruitment has been positive. Interviews with staff confirmed that they considered the staffing levels were satisfactory in the morning however the staff on the late shift reported that they were struggling at tea- time with just three staff on duty as the extra cover did not start until 6p.m., which requires review. The manager had not implemented The Residential Homes Forum staffing tool which is a requirement since the home varied their registration the previous year. The staffing calculations must be made in line with the RHF staffing matrix and evidence of the calculated levels must be kept. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 18 The manager has recently introduced new shift times with all shifts commencing an hour earlier; it was too early for staff to comment on how the new shifts were working out however the manager must ensure that the workload is evenly distributed and service users choice around times to rise and retire are upheld. The deputy manager had recently left and this position had been filled by the previous deputy manager. Three recruitment records were examined and found in general to be satisfactory; there was evidence that CRB/ Pova First checks and two written references had been obtained prior to employment. Advice was given to the manager to document decisions to employ following receipt of poor references. The inspector noted that any disciplinary actions taken were recorded on file. The registered manager has made significant improvements to the provision of training however gaps remain in the provision of statutory training and further courses on moving/ handling, food hygiene and first aid need to be provided. Records evidenced that staff had accessed other courses in health/ safety, accredited medications, infection control and dementia. The manager had recently obtained a Care Sector Skills training manual to provide new staff with induction and foundation training. Records evidenced that new staff had completed the in-house induction programme. Significant progress had been made with enrolling staff on NVQ courses; 10 care staff had recently enrolled on NVQ level 2 courses. . Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 19 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, 36 and 38. Limited progress had been made in maintaining and developing a number of the management systems; the manager has a better understanding of areas to be prioritised and improved however needs to manage her time more effectively. EVIDENCE: The new manager achieved her registration with the commission in December. It was clear from the visit that the new manager is popular and has the respect and support from the staff; residents commented that she was very kind and helpful. From discussions with the manager it was clear that she was enjoying the challenges of her role but felt that her progress in developing the management systems had been hampered by the amount of time spent sorting out staffing issues. It was positive that she was delegating clearer areas of responsibility to the senior care staff although there was a lot of work to be done with developing their confidence and competence in areas such as care Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 20 planning and supervision. Advice was given to the manager to protect her time better to focus on actioning the outstanding requirements; she should develop a management plan with timescales which prioritised all the work required. The manager has already completed four units of her Registered Managers Award and is on line to complete the course before summer. No progress had been made to re - implement the quality assurance programme; however given the enormity of work to be done in developing the recording and management systems advice was given to delay work in developing the quality assurance system for some months. Examination of the homes policies and procedures revealed that a number of documents were very minimal; given that detailed comprehensive policies and procedures are fundamental in ensuring staff are provided with the necessary information and direction for all care and service provision, consideration should be given to improving the depth and quality of these documents. There was evidence from records and staff interviews that progress had been made recently to provide staff with more formal supervision sessions. Management of service users finances was checked and found to be satisfactory. The registered provider although involved in the daily running of the home needs to provide a report to support monthly visits where he inspects the premises, record of events, complaints and interviews a number of the staff and service users to assess the standard of care provision; since the previous inspection he had only provided the commission with one report. Records evidenced that the five year electrical certificate was not in place, this was due to be provided on completion of the building works. The radiators in the first floor WC’s had been provided with low surface covers. Gaps in the provision of moving/ handling and fire safety training had been addressed with the manager arranging further sessions. Courses on food hygiene and first aid training need to be arranged. The EHO had visited the home recently and inspected the kitchen areas; although the report was not available during the visit, the manager confirmed that all the environmental issues had been addressed satisfactorily and requirements had been made to improve the risk management documentation within HACCP guidelines. Records of accident monitoring were examined; little improvements had been made to develop records of further action taken to reduce risks of reoccurrence especially with regard to falls, and clearer advice was given to the manager. Case tracking care records revealed an incident where a service user had knocked her face whilst being transferred in the hoist however no accident record had been made. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 21 Hadleigh House Care Home DS0000002861.V281923.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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 x 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 2 X 2 Hadleigh House Care Home DS0000002861.V281923.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 OP33 Regulation 26 Requirement The registered person must complete reports to support formal visits to the home under Regulation 26 and forward to the CSCI. Previous timescale 30/11/05 unmet The registered person must ensure there is a five year electrical certificate in place. Previous timescale 15/12/06 unmet. The registered person must ensure that staff receive mandatory training in food hygiene, first aid and moving/handling. The registered person must ensure that the quality assurance programme is restarted and maintained. Previous timescale 30/01/06 unmet. The registered provider must ensure that staffing levels are DS0000002861.V281923.R01.S.doc Timescale for action 31/03/06 2. OP38 23(2)and (4)a 31/03/06 4. OP38 18(1)c,23 (4)d &13(5) 30/04/06 5. OP33 24 30/06/06 6. OP27 18(1)a 31/03/06 Hadleigh House Care Home Version 5.1 Page 24 maintained to ensure that appropriate levels of staff are provided to manage current care needs. The home must now utilise The Residential Homes Forum to determine staffing numbers required. Previous timescale 04/10/05 unmet. 7. OP38 13(4) The registered person must 31/03/06 ensure that accident management is reviewed to record all further action that staff take to further reduce risk e.g falls. Previous timescale 30/11/05 unmet All accidents in the home must be recorded on the appropriate accident recording documentation. The registered person must 15/04/06 ensure that staff receive induction and foundation training within the first 6 months of employment, which is compatible to NTO specification. Previous timescale 15/12/05 unmet. Programme to be implemented by: The registered person must 10/03/06 review odour management of the rooms identified and replace flooring if problem continues. Previous timescale 15/12/05 unmet. Immediate requirement notice issued. The registered person must ensure that service user care programmes are sufficiently detailed to identify all problems; they are updated to reflect current care needs, DS0000002861.V281923.R01.S.doc 8. OP30 18(1) 9. OP26 16(2)k and c 10. OP7 15 30/04/06 Hadleigh House Care Home Version 5.1 Page 25 individualised and contain detailed evaluations. Daily records must be maintained. Previous timescale 30/11/05 unmet 11. OP8 13(b) The registered person must develop safe systems to monitor significant changes to service users’ weight and that appropriate support is accessed and actioned when required. Previous timescale 04/10/05 unmet. Immediate requirement notice issued. The registered person must ensure all medications in the home are recorded and stored in line with guidance from the Royal Pharmaceutical Society and CSCI. Previous timescale 04/10/05 unmet. The registered person must ensure that records of complaint investigation and outcome are maintained. 03/03/06 12. OP9 13(2) 15/04/06 13. OP16 22 15/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP16 OP28 Good Practice Recommendations The registered manager should investigate concerns raised by a service user regarding doors banging in the home. The registered manager should ensure that 50 of the care staff have gained NVQ level 2. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 26 3. 4. 5. OP1 OP16 OP33 The registered manager should further develop the information on emergency admissions within the statement of purpose. The registered manager should review the wording in the complaints procedure around the handling of serious issues to ensure complainants have clear information. The registered manager should review all the homes policies and procedures to ensure they are comprehensive, comply with current legislation and demonstrate current good practice. Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Hadleigh House Care Home DS0000002861.V281923.R01.S.doc Version 5.1 Page 28 - 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!