Inspection on 24/05/06 for Harleston House

This inspection was carried out on 24th May 2006.

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

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

Other inspections for this house

Harleston House 25/03/09

Harleston House 11/05/07

Harleston House 28/09/05

Harleston House 16/05/05

Harleston House 11/10/04

Harleston House 07/04/04

Harleston House 25/02/04

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

CARE HOMES FOR OLDER PEOPLE Harleston House 115 Park Road Lowestoft Suffolk NR32 4HX Lead Inspector Jane Higham Unannounced Inspection 24th May 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Harleston House DS0000058556.V296375.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. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harleston House Address 115 Park Road Lowestoft Suffolk NR32 4HX 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) 01502 574889 01502 516638 harleston@greensleeves.org Greensleeves Homes Trust Post Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28th September 2005 Brief Description of the Service: Harleston House is a 25 bedded residential home for older people situated in a residential area of Lowestoft. The home was first registered in 1950 and has over the years been extended to provide additional accommodation. All resident rooms are offered for single occupancy. At the end of January 2004, the ownership of the home transferred from the Church Army to the Greensleeves Homes Trust, a national organisation which owns two other residential homes within East Anglia. It is the intention of the organisation to extend the service and to upgrade the existing premises. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Key inspection of Harleston House, a twenty-five bedded residential care home for older people, situated in the coastal town of Lowestoft and owned and administered by the Greensleeves Homes Trust. The inspection was carried out on 24 May 2006 over a period of six and a half hours. The home was inspected against the National Minimum Standards: Care Homes for Older People and the Care Standard Act 2000. The National Minimum Standards and the Care Homes Regulations 2001 are referred to throughout this report and any non-compliance identified. All key standards were assessed as part of this inspection. The Deputy Manager was present at the time of the inspection and assisted with the inspection process. The Inspector attended a staff “handover” meeting and was also able to talk to residents and gain feedback in relation to the quality of the service provided. What the service does well: What has improved since the last inspection? Whilst the plans to extend the existing premises have been delayed for another eighteen months the home has continued with its programme of redecorating and refurbishing resident bedrooms. At the time of the inspection, the home was in the process of in-putting residents care plan details onto the computer system and expanding on the current information provided. The care plan template system for another Greensleeves Trust home was being utilised. Since the resignation of the previous manager in January of this year, a new manager has been appointed and has made an application for registration with the Commission for Social Care Inspection. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 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 Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 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): 1,2, 3, 5 and 6 Residents cannot necessarily expect to receive sufficient written information on which to base their decision about whether they wish to live at the home. Residents can be assured that their needs will be appropriately assessed prior to taking up residence and that they will be issued with a contract and receive information about the terms and conditions of placement. EVIDENCE: The home has a Statement of Purpose, which contains information as required by Schedule 1 of the Care Homes Regulations 200. On the day of the inspection, the home was unable to evidence that each resident was provided with a Service user Guide. However, the service was able to confirm that all prospective residents are provided with an information leaflet, which details the services and facilities available. This leaflet does not contain all the information as required by Regulation 5 of the Care Homes Regulations 2001. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 9 As part of the inspection process, the pre-admission assessments for the two most recently admitted service users were examined. One of the service users had been placed at the home via the local authority and the home was able to evidence that they had received a detailed Community Care Assessment before confirming that they were able to meet this person’s needs. In the case of the other resident who had been privately placed, the Manager of the home had carried out a detailed assessment of need prior to admission taking place. This assessment was carried out during a half-day visit to the home of the prospective resident. This initial assessment was reviewed a month later to ensure that there had been no changes in assessed need. The resident who had been placed on a private basis had been issued with a placement contract which also contained a detailed terms and conditions of residence document. The Deputy Manager confirmed that the home does not offer an intermediate care service but can accommodate service users who wish to receive respite care, if a vacant room is available. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 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 Residents can expect to be provided with an individual plan of care which sets out how their assessed needs will be met. Residents can also expect that their general health needs will be monitored and met via community health services. The system currently used for the safe keeping and administration of medication are not secure and do not ensure that residents are protected. EVIDENCE: As part of the inspection process, the care plans for the two most recently admitted service users were examined. A basic core care plan had been produced for each resident. The core care plan detailed each person’s need in relation to personal care, diet and weight, sight and communication, mobility and dexterity, promoting continence, mental state and cognition, special healthcare needs, social interests and hobbies and religious observance. Care plans provided basic information in relation to these areas but should include a more detailed account of the interventions and assistance required. The home was able to evidence that residents care plans were reviewed on a regular basis in line with the National Minimum Standards. The care planning process included risk assessments, mobility assessments, pressure Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 11 assessments and daily routine sheets which detailed preferences such as time of rising. It was noted that the care plan, which provided details of assessed need in relation to weight and diet, was not used to its full potential and the weight chart included in the care plan was not completed. Best practice would suggest that, if in agreement, residents are weighed on a regular basis as part of an overall monitoring of general health. Care plans evidenced that residents are enabled to access community health facilities such as district nursing services, chiropody, optician and dental services. The Deputy Manager advised that some of these services provided domiciliary visits and that one resident had received a new pair of dentures via this service the previous day. The home receives medical guidance and support form the local GP surgery. On the day of the inspection, one service user was supported by a staff member to attend a hospital outpatient appointment and another was admitted to hospital via the emergency ambulance service. As part of the inspection, the Inspector observed the mid-day medication being administered to service users by a senior member of care staff. During the previous Announced Inspection, which took place in September 2006, it was noted that the medication trolley was left unlocked and unattended outside the dining room whilst the member of staff went into the dining room to administer medication to each resident. On this occasion it was found that this practice still continued. The Inspector was advised that the medication trolley was not taken into the dining room as residents tended to distract the member of staff. However, this practice means that the medication trolley is left unattended and therefore insecure. The trolley should either be taken into the dining room or locked on each occasion that it is left unattended. The medication administration records were being completed appropriately directly after each resident’s medication had been administered. The home uses the Monitored Dosage System for the majority of prescribed medication. Medication not appropriate to be stored in blister packs was maintained in original containers within the trolley. It was noted that the frequency and dosage of a morphine based medication as detailed on the pharmacy label did not reflect the way in which the medication was administered, which was “as and when required.” Prescribed medication must be administered in compliance with the pharmacy label. Residents care plans evidenced that they were supported to make informed decisions and express the manner in which they would like to be assisted with personal care. Care staff were observed to knock on resident’s doors before entering and residents were at liberty to have private telephones installed in their bedroom, although the payphone was sited in its own private area. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 12 Harleston House DS0000058556.V296375.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents living at the home can expect to be offered a range of activities, which are appropriate to their needs and abilities. Residents can also expect to be supported to maintain contact with family and friends and to access local community resources. The home provides residents with a varied and nutritious diet. EVIDENCE: The home was able to evidence that it offered residents a planned programme of activities. The service employs an activities co-ordinator for 16 hours per week. Unfortunately on the day of the inspection, this member of staff was on sick leave. The home was able to evidence that activities offered include, quizzes, bingo, card games, “sing a longs”, outside entertainers and art and craft sessions. Several female residents had had their hair done on the day of the inspection, by the visiting hairdresser. On the day of the inspection, several relatives were visiting family members and were made very welcome by staff. Residents are able to receive visitors in the privacy of their own rooms or within one of the home’s several communal areas. Staff at the home support residents to access community resources within the local area and one resident described how they used the mobile library service, stating that so much care was taken to ensure that they received the books that they were interested in. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 14 During the inspection, the Inspector observed both lunch and supper being served to residents in the communal dining room. Staff advised the inspector that residents make their meal choices for lunch and supper the previous day. Prior to the mid-day meal, many of the residents spoken to could not remember what they had ordered but in general made positive comments about the quality of meals provided and the choices offered. On the day of the inspection, residents had a choice of three different dishes for the mid-day meal. Meals were pre-plated and then served to residents from a hot-trolley. The service may like to consider the use of vegetable dishes on each table in order that residents could service themselves to the vegetables of their choice. All residents were served with drinks to accompany their meals and it was noted that in some instances special dishes were used to assist residents who had difficulty in eating. A tour of the kitchen was undertaken and found to be well equipped and maintained to a good standard of hygiene. A kitchen-cleaning rota was maintained which evidenced that all areas and equipment were being cleaned on a regular basis. There was a large storage room with hygienic shelving for canned goods. This area was very organised and maintained to a very good standard of cleanliness. The kitchen areas were provided with a sufficient number of fridges and freezers to ensure the appropriate storage of chilled and frozen foodstuffs. Cold meats and other foodstuffs were stored appropriately, although it was noted that one plate of cold meat had been left uncovered. It was noted during the tour of the premises that jugs of water were not available in all communal areas. The free availability of fluids is important throughout the year but particularly during the summer months to ensure that residents do not become dehydrated. The home was able to evidence that it supports residents to make choices around daily routines. Preferences around how people wish to spend their day and their likes and dislikes are recorded as part of the care planning process. Harleston House DS0000058556.V296375.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The service does not provide sufficient information to residents and their families to enable them to make a complaint. Service Users living at the home can expect to be protected from any form of abuse. EVIDENCE: On the day of the inspection, the home was unable to evidence that it had a full and detailed complaints procedure and available to all residents, families and visitors to the home. The terms and conditions document provided to all service users includes information on how to make a complaint, although does not provide any contact details for any external agencies whom the complainant may wish to approach i.e. The Ombudsman or the CSCI. The procedure makes reference to a Suggestions, Comments and Complaints Form which is produced by the owning organisation. However, these were found to be very limited in their content and again did not provide contact details for external agencies such as the Commission. No complaints procedure was displayed within the building and therefore not accessible by visitors to the home. Whilst the home was able to evidence that it maintained a log of all complaints which provided details of the nature of each complaint, no evidence was available to show what investigation had taken place, the outcome of such an investigation, the action taken and the date and nature of the feedback to the complainant. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 16 As detailed in the previous inspection, the home does not have a copy of the revised local authority procedure on the Protection of Vulnerable Adults. Staff undertake training on the prevention of abuse as part of NVQ studies. Since the previous inspection, the Commission has received one written complaint in relation to the service (05.09.05). This complaint was investigated by the Commission on 19 September 2005. There were five elements of the complaint, three of which were found to be “not upheld” and two, which were “upheld”. One service user spoken to at the time of the inspection, advised that they had expressed concerns about a member of staff and this concern was being dealt with to their satisfaction. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 In general, residents can expect to live in accommodation which is well maintained, furnished comfortably, homely and appropriate to their assessed needs. Residents can also expect to be provided with a choice of wellmaintained and comfortable communal areas and a sufficient number of bathroom and toilet facilities. Accommodation is both clean and hygienic. EVIDENCE: Harleston House is a Victorian building, which has been extended over the years to provide additional accommodation. Bedroom accommodation is sited on three floors, all of which are accessible by a passenger lift or stairway. There are twenty-four bedrooms all of which are currently offered for single occupancy. Whilst none of the bedrooms have the benefit of ensuite facilities, the home has a sufficient number of communal assisted bathrooms and communal toilets. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 18 The home has a varied provision of lounge accommodation, consisting of two lounges, which can be opened up via folding doors to provide a larger space for functions and an open plan chapel area where a daily service takes place. Plans are in existence to extend the present accommodation but the Inspector has been advised that this has been delayed by about eighteen months. However, the owning organisation continues with its programme of redecoration and renewal and currently one bedroom is being redecorated and refurbished every six weeks. A selection of residents’ bedrooms were viewed as part of the inspection. In general these were furnished comfortably and maintained to a good standard of decorative order and repair, although some require decoration but this is being addressed as part of the refurbishment programme. Many of the bedrooms had been made to look very attractive by the occupant and their families with the addition of personal belongings such as small items of furniture, photographs and ornaments. Many of the residents had their own televisions and personal telephone lines. Lounge and dining areas were furnished comfortably and provided a very pleasant area in which residents could socialise with each other and with their visitors. As stated in the previous inspection, corridor and stairway areas would now benefit from redecoration. As the refurbishment plans have now been delayed by eighteen months, corridor areas require redecoration as a matter of urgency. Additionally corridor areas located on the first floor of the building are somewhat institutional in their appearance and would benefit from redecoration. The home has pleasant gardens to the rear of the building and a summerhouse for the use of residents. The garden would benefit from a general tidying and maintenance programme. All areas of the home had been maintained to a good standard of hygiene and cleanliness. Whilst liquid soap is provided in all communal toilets and bathrooms it was noted that tablets of soap were still provided in one communal toilet block. Soap in tablet form should only be made available at a hand basin used exclusively by one resident. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The current staffing level during the day is insufficient to ensure the health and safety of residents and their individual assessed needs are met. Residents can expect to be supported and cared for by experienced and competent staff, although not necessarily staff who have received all mandatory areas of training. The current recruitment procedures do not ensure the protection and safety of service users. EVIDENCE: On the day of the inspection the Deputy Manager was managing the home, as the Manager was not rostered to work. Three care staff were on duty throughout the waking day and during the night period residents were assisted by two care staff on an “awake” basis. The provision of three care staff during the day is at a minimum level to care for twenty-four residents and is dependent on the assessed individual needs of the current resident group. At the time of the inspection, four residents required assistance from two care staff at any one time and another two required the same level of assistance on a variable level. If the third member of care staff is occupied administering resident medication then residents are left unsupported. Care staff are also responsible for attending to resident’s laundry, which again may take them away from providing direct assistance to residents. Feedback from residents was very positive in relation to the quality of staffing but were described by some as being “rushed off their feet”. The Inspector attended a staff “handover” meeting attended by four members of care staff. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 20 The senior staff member going off duty gave a detailed breakdown of the current status and welfare of each resident. Staff members indicated that the current staffing levels were not adequate to meet the current dependence levels of residents and advised that they were unable to spend time simply talking to residents. Taking the above into consideration, the home must be able to evidence that it provides a sufficient level of care staff to meet the individual care needs of residents currently accommodated. The home was able to evidence that well over 50 of the staff group have obtained NVQ qualifications and should be commended on this achievement. The Deputy Manager has successfully completed the Registered Manager’s Award and the Manager is currently undertaking this qualification. The Inspector was provided with a copy of the overall training record for staff. This record identified shortfalls in the provision of training in that the majority of staff had not received updated training in moving and handling within the last year and only five staff members had been provided with training on infection control. The training record also indicated that not all staff had undertaken basic food hygiene training. The Deputy Manager was reminded that all care staff who are in any way involved in the preparation of foodstuffs must be provided with this training. As part of the inspection process, the personnel file of the two most recently employed members of care staff were checked. Records confirmed that both members of staff had undertaken an Induction training Programme. Whilst the home was able to evidence that both members of staff had been subject to a POVA check prior to the commencement of duties, in the case of both staff members, only one satisfactory written reference had been obtained. The Care Homes Regulations 2001 requires the responsible persons to ensure that two satisfactory written references are obtained before a person is considered “fit” to work in a care home. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Residents can expect to live in a home, which is effectively and appropriately managed, and that the service actively seeks feedback from service users. Procedures employed for the administration and safekeeping of resident finances do not necessarily protect their financial interests. The health and welfare of service users is protected. EVIDENCE: At the time of the inspection, the Manager of the home was not rostered to work. The home is managed by Ms. Pearl Barrowman who has been in post since February of this year and who has made an application to the Commission for Registration. The home was able to evidence that residents meetings are held on a two monthly basis, providing them with the opportunity to voice their opinions and air their concerns about the day to day running of the home. A copy of the minutes of the most recent meeting was available for inspection. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 22 The Inspector was informed that a resident satisfaction questionnaire had been distributed and returned by service user within the last few weeks. The Commission can confirm that a representative of the owning organisation visits the home on a monthly basis for the purpose of quality assurance and reports of such visits are submitted to the Commission. Procedures for the safekeeping and administration of resident finances were examined as part of the inspection. The home handles money for a small number of residents and a record of transactions is maintained for each person. It was identified that whilst transactions made on behalf of service users were documented, in most cases these entries were not signed and therefore provided no evidence as to who had carried out the transaction. Good practice would suggest that the record of transactions made on behalf of service users is signed by two staff members. A random check of cash held for one service user indicated a small shortfall. Transaction records did not evidence that regular audits of monies held for service users was being carried out. The home maintained a fire safety log, which evidenced that fire alarms were tested on a weekly basis and emergency lighting on a monthly basis. The home was also able to evidence that it held a current Gas Safety Certificate. Whilst the home was able to evidence that a recent accident in the home had been recorded appropriately, the information was limited and should have included details of precipitating factors. There was no evidence to suggest that this particular accident involving a service user had “triggered” a review of that person’s risk assessment. Staff members spoken to at the time of the inspection were able to confirm that they received regular formal supervision sessions. Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 4 x 2 3 3 2 Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5(1) Requirement The Registered Persons must ensure that each resident is provided with a Service User Guide, which provides the information as required under Regulation 5(1) of the Care Homes Regulations 2001. The Registered Persons must ensure that resident care plans provide sufficient information on the assessed needs of the resident and the interventions required in order to assure that these needs will be met. The Registered Persons must ensure that the medication trolley is not left unlocked and unattended at any time. This is a repeat requirement. The Registered Persons must ensure that medication is administered in compliance with the pharmacy label. The Registered Persons should ensure that all packaged foodstuffs, which have been opened, are covered and labelled with the date of opening. Timescale for action 24/05/06 2 OP7 15(1) 03/07/06 3 OP9 13(2) 24/05/06 4 OP9 13(2) 24/05/06 5 OP15 13(3) 24/05/06 Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 25 6 OP16 22 7 OP16 Sch.4.11 8 OP19 23(2)(b)& (d) 9 OP26 13(3) 10 OP27 18(1)(a) The Registered Persons must ensure that the home has a written complaints procedure which is available to all residents and visitors to the building and which includes the contact details for the CSCI. The Registered Persons must ensure that the home maintains a log of all complaints received which provides an audit trail of the nature of the complaint, the investigation carried out, the outcomes reached and action taken. The Registered Persons must ensure that corridor areas within the building are maintained to a satisfactory standard of decorative order. The Registered Persons must submit a proposal as to how and when this requirement will be addressed. This is a repeat requirement. The Registered Persons must ensure that liquid soap is provided in all communal toilet facilities and that tablets of soap are only provided at sinks in bedrooms which are occupied by one person. The Registered Persons must ensure that an adequate number of care staff are available throughout the day to ensure that the individual needs of current residents are met. 03/07/06 24/05/06 03/07/06 24/05/06 03/07/06 11 12 OP30 18(1)(c) (i) 18(1)(c) (i) OP30 The Registered Persons must ensure that care staff receive training in all mandatory areas. The Registered Persons must ensure that all care staff receive appropriate training in infection control. DS0000058556.V296375.R01.S.doc 03/07/06 07/08/06 Harleston House Version 5.2 Page 26 13 OP29 Sch.2.3 14 OP35 16(2)(l) 15 OP38 Sch.4.12 The Registered Persons must ensure that two satisfactory written references are obtained prior to any prospective staff member commencing duties. The Registered Persons must ensure that all financial transactions carried out on behalf of service users are supported by two signatures and that a regular audit of resident finances held at the home is carried out. The Registered Persons must ensure that all accidents occurring in the home are documented in detail and that a review of the existing risk assessment is triggered by this entry. 24/05/06 24/05/06 24/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 16 17 18 19 Refer to Standard OP8 OP8 OP15 OP18 Good Practice Recommendations The Registered Persons should ensure that with their permission, residents are weighed on a monthly basis as part of the overall monitoring of general health. The Registered Persons should ensure that jugs of water are available in all communal areas of the home. The Registered Persons should consider the provision of vegetable dishes for residents having lunch in the dining room in order to maximise choice. The Registered Persons should obtain a copy of the revised local authority procedure for the Protection of Vulnerable Adults. The Registered Persons should ensure that the rear gardens to the property are part of a regular tidying and maintenance programme. 20 OP19 Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Harleston House DS0000058556.V296375.R01.S.doc Version 5.2 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. 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