CARE HOMES FOR OLDER PEOPLE
Hays House Sedgehill Shaftesbury Dorset SP7 9JR Lead Inspector
Susie Stratton Unannounced Inspection 10th November 2005 09:55 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 Hays House DS0000015916.V264903.R01.S.doc Version 5.0 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. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Hays House Address Sedgehill Shaftesbury Dorset SP7 9JR 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) 01747 830282 01747 830005 c_shephard@btconnect.com Park Healthcare Limited Mrs Catherine Maureen Sheppard Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43), Terminally ill (1) of places Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. No more than 1 person in receipt of terminal care at any one time No more than 43 service users with Old Age at any one time. There are staffing conditions as agreed following the serving of the notice of proposal of 01 October 2002. 10th June 2005 Date of last inspection Brief Description of the Service: Hays House is an old country house, parts of which date back to the early Victorian Era. The home is situated in eight acres of grounds and accommodation is provided over four floors. A new purpose built wing was completed in the summer of 2002 and provides ground floor accommodation to the rear of the building. At the time of the inspection, there were 40 persons resident in the home and no vacant rooms. The home is owned by Park Healthcare Limited and the responsible individual is Mr R Clarkson, who visits the home on a regular basis. The registered manager of the home is Mrs Catherine Sheppard, she is supported by a team of registered nurses, care assistants, administrative and ancillary staff. The home is situated off the A350, between the villages of Sedgehill, East Knoyle and Semley. It is 3 miles north of Shaftesbury and 8 miles south of Warminster. The nearest railway station is in Gillingham, Dorset. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection commenced on Thursday 10th November 2005 between 9:55am and 3:50pm, in the presence of the registered nurses in charge, as Mrs Sheppard, the manager was not available on that day, the inspection was completed on Friday 18th November 2005 between 3:05pm and 4:20pm to enable a feedback to take place. During the first day of the inspection, the Inspector met with thirteen residents and observed care for sixteen residents who were not able to communicate. She also met with three registered nurses, three carers, two chefs, the administrator and the laundress. The Inspector reviewed the notes of eight of the residents in detail and specific records for a further four residents. The Inspector toured the home, including the laundry, kitchen and clinical room. The Inspector reviewed records, including the staff rosters and residents administrative files. During the second day of the inspection, the Inspector met with Mrs Sheppard, fed back to her and heard her responses to the first day of the inspection. What the service does well: What has improved since the last inspection?
Of the seven requirements identified at the previous inspection, five had been addressed and the two which are not yet due showed considerable progress. Of the five recommendations, four had been addressed and one was not reviewed at this inspection. Where residents have a risk identified, nearly all now have a care plan in place to reduce risk. Where equipment is in use which is not in accordance with the resident’s assessed degree of risk, clinical indicators for the different
Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 6 equipment used are nearly always documented. All assessments and care plans had been regularly reviewed and up-dated where indicated. Residents’ specific needs in relation to certain drugs are documented. An archiving system for care plans which are no longer current has been put in place. All medicines’ administration records had been fully completed and where medicines instructions are completed by hand these had been countersigned. Staff who take charge of the home in the manager’s absence had all been trained in the local vulnerable adults procedure. The Commission has been informed of progress towards installing a new lift and relevant records maintained. The Commission has also been informed of the action plan for improving bathing and sluicing facilities on the ground floor. What they could do better: Please contact the provider for advice of actions taken in response to this inspection.
Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 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 Hays House DS0000015916.V264903.R01.S.doc Version 5.0 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): 2 & 5: Hays House does not provide intermediate care, so 6 is N/A Residents are protected by clear contracts. Pre-admission visits are encouraged and all residents are admitted on a trial basis, prior to deciding to stay in the home. EVIDENCE: All residents are issued with a contract on admission to the home, which they or their relative sign and return. Contracts seen were clear and included information such as which room the person would be occupying, fees for temporary periods of absence and definitions of what constituted a breach of contract on either side. The contract refers to the registration body as Wiltshire Registration Authority, not the Commission for Social Care Inspection. Several residents spoken with said that they had come into the home first for a period of respite care and when they had decided that they needed permanent care has decided to come to Hays House, as they already knew it. One resident said that when they had decided that they needed permanent care they had visited several homes in the area and had decided on Hays House as they felt it would meet their needs most. Others said that their family had
Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 10 visited on their behalf prior to admission. All residents are admitted on the basis of a months trial. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Residents are protected by clear care plans, which are regularly reviewed and reflect residents’ needs. Where requirements have been identified previously but are not due, very good progress was noted. Residents who need frequent care may be at risk, as the home cannot evidence that they are receiving this attention. Staff work to ensure that residents’ privacy and dignity is upheld. Safe systems are in place in for medication, apart from the disposal of items which have passed their use by date. EVIDENCE: Staff have put much work into the development of care plans. Care plans inspected reflected what residents told the inspector and what was observed. Care plans were written in a way that directed care, for example where a resident needed application of a topical cream, care plans directed precisely where the cream was to be applied. Where residents had additional mental health care needs, care plans were in place to direct staff on how to manage behaviours. Care plans were regularly evaluated and up-dated where indicated. Nearly all residents who are assessed as being at risk of pressure damage have care plans in place to direct staff on how to reduce risks. A requirement
Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 12 relating to this was identified at the previous inspection and is not yet due. Much work has taken place and the requirement is nearly addressed. It was also required at the previous inspection that where equipment is in use which is not in accordance with the resident’s degree of risk, that the reasons for this must be documented. This requirement is not yet due, however considerable progress has been made in meeting this requirement and only one area was identified at this inspection which needed to be addressed. It was noted that a care plan for one individual relating to this requirement was very clear. Several residents experience skin tears and these are clearly documented in their notes. It is advised that as well as documenting skin tears, residents who are at risk and their environments should be assessed to try to reduce such risks. Residents who are at risk of falls have clear risk assessments and care plans in place to reduce falls. As footwear has been shown to be a factor in falls in the elderly, a written assessment of the resident’s footwear should take place as part of the assessment. Hays House cares for some very frail residents, some of whom spend most of their time in bed or who are only able to sit out of bed for short periods of time. Such residents were observed to look comfortable in bed with brushed hair, clean fingernails and bedding. The care of such residents is monitored by the use of frequent care charts. Charts for four residents were inspected in detail and it was noted that despite it being required that they be turned two hourly, this was not always the case. This was particularly noticeable during the morning shift where residents were often noted to be turned at the beginning of the morning shift and then not turned again until after 2:00pm. Charts relating to offering fluids indicated that such residents were not always regularly offered fluids at different times of the day. Observations of care and discussions with staff indicated that lack of completion of such charts did not necessarily always relate to staff forgetting to complete them, but might also relate to the dependency of some of the residents in the home and staff finding that they did not always have the time to turn residents or offer them fluids at the frequency specified in their care plans. Staff were observed to knock on doors and await a reply prior to entering residents’ rooms, this included one staff member who had only recently been employed, who had clearly already followed the lead of more senior care staff. During the inspection, one resident was observed to become confused, this was noted quickly by a carer who took prompt action to ensure that the resident’s dignity was maintained. The carer was observed to look after the person in accordance with the resident’s care plan and managed the situation very effectively. The home has a clear system for administration of medicines. All records are maintained in full. Registered nurses are aware of the new legislative systems for disposal of drugs. Stocks of drugs are stored in a safe manner. Care plans document the drugs that residents are prescribed and assist staff in ensuring that the effectiveness of medication can be reviewed and residents’ GPs
Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 13 informed where relevant. This had recently taken place for one resident who had been prescribed a mood altering medication. The inspection showed that the home had some out of date items. This included all of the diagnostic reagents in one medicines cupboard, two bottles of a prescribed bathing preparation, some clinical dressings and some of the suction catheters. All such items must be disposed of. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 15 Staff work to ensure that residents are able to choose how they spend their days. Choice was limited for some residents as the lift was out of order. Systems which do not conform to fire safety are being used to respect residents’ choice, this could put other residents and staff at risk. Residents are offered a wide choice for meals, with food cooked from fresh ingredients. EVIDENCE: Residents spoken with said that it was up to them when they got up and went to bed. One said that they liked to get up very early and go to bed midafternoon and that this was respected. Another said that if there was a late programme on the television, which they were enjoying, that staff had no difficulty in letting them stay up to watch it, before helping them to bed. Residents are enabled to bring items of their own into the home and some rooms were highly personalised. At the time of the inspection, the lift had been out of order for two days, management are aware of the problems with the lift, a contract has been signed to install a new lift and necessary building control approval sought. The lack of a lift means that choice is limited for most residents on the upper floors as very few are able to manage stairs and some cannot manage the chair lift, so they are not able to come downstairs to go to activities or at mealtimes. The Commission had not been informed of this breakdown as they are required to do in accordance with Regulation. The owner had been advised of this requirement to inform the Commission on 19th
Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 15 May 2005, so this matter is outstanding. Three residents asked or needed to have the doors of their rooms held open. This means that wedges were used to hold their room doors open. If a resident requests or is assessed as needing their door held open, this must be respected and appropriate equipment, which has been approved by the fire officer must be used to hold the door open. Wedges or other non approved items must not be used. Residents spoken with said that they liked the meals. All residents are given a menu the day before and asked to choose. It was observed that residents were given the meal that they had chosen. This home offers three choices of meal at lunchtime and an even wider range at breakfast and suppertime. The chefs cook meals from fresh ingredients and showed an enthusiasm for their roles. They said that if a resident asked for something different, such as a sandwich or omelette, they would be able to provide this. They also said that if a resident was out of the home, for example at a hospital appointment, they would provide a fresh meal on their return. Meals are nicely presented and domestic-style plates with integral plate guards are used to support frail residents. Three residents described the meals as “very good”, one said that the home had an “amazing” choice of meals and another said “I like the sweets very much”. Nearly all the residents in the home need assistance with taking their meals, either by needing to be fed or by close observance to support the resident when they find eating difficult. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 There are systems in the home to protect residents from abuse. EVIDENCE: Staff reported that they had recently been trained in the protection of vulnerable adults. Staff spoken with showed an awareness of reporting any matters of concern to senior staff. Residents said that they knew how to bring up issues if they were not happy with the care provided. One resident said “I’d tell Matron if I wasn’t happy with anything” another said “I’d go and talk to Matron in her den.” Where resident needed protection such as safety rails, there was clear documentation relating to this and care plans were regularly evaluated. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 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): 20, 21, 22, 23, 24 & 26 Hays House offers a range of different sized bedrooms and community rooms for residents. Equipment is in place, however some residents and staff may be put at risk by insufficient numbers of variable height beds. The home is clean throughout with an efficiently run laundry, however systems for management of wounds do not meet with current principals for the prevention of spread of infection. EVIDENCE: A range of different communal rooms are provided and residents are also able to access the extensive gardens. The owner has been following a programme to improve bathing and sluicing facilities. A new wc and sluice rooms has been installed on the first floor and an action plan is in place to improve facilities on the ground floor. As parts of Hays House are an older building, most of the rooms are different in size and shape from each other, all rooms have extensive views of the surrounding countryside. The rooms in the newer section at the back of the house all have en-suite facilities, as do some of the rooms in the main building. One resident described their room as “lovely”. All
Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 18 fire exit doors have been provided with contact points which alarm if a confused resident decides to exit the building using these doors. Service users are assessed for manual handling care needs and a review of these care plans and discussions with staff indicated that many of the residents had highly complex manual handling needs. While the home does have some variable height beds, this inspection showed that the home does not have enough automatically operated variable height beds to meet the needs of all residents who have clinical indicators showing they have complex manual handling needs. Many of the residents need to be moved by use of a hoist, some of the carpets in the home are deep-pile and as it is complex to move residents using a hoist on such carpets, when putting in new carpets, it is advisable to include a consideration of the use of a hoist on the carpet. Hays House is a large building, which is over several floors and wings and while there is a call system for residents to use, it was observed during the inspection, that staff often had to take up some time looking for each other, to pass on messages or that they would have to stop what they were going to go to answer the phone or the doorbell. In order to support staff in more effectively meeting residents needs, it is advisable for a an effective system to be provided to enable staff to communicate quickly with each other and answer the phone and front door. The laundry presented a busy, efficient service. The laundress was aware of her responsibilities for ensuring that systems were in place for the prevention of spread of infection. A new dryer and linen press had been provided since the previous inspection. All parts of the home were clean and the domestic staff were observed to complete their roles in a careful manner. Staff were observed to use gloves and aprons when indicated and dispose of them properly. The home does not have stocks of sterile gloves or dressings packs and it was reported that aseptic procedure is only used for catheterisation. The home are advised that the Health Protection Agency consider that a risk assessment is needed for all complex wound dressings including such dressings as leg ulcers and pressure ulcers and that if a resident’s circumstances mean that they or their wound are assessed as being at high risk, the wound dressing must be performed using aseptic technique. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 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 The home does not provide evidence that they can consistently meet the needs of residents in relation to numbers of staff on duty or continuity of staff. EVIDENCE: Hays House is required to staff the home in accordance with a Condition of Registration set out by the Commission. They were not meeting this requirement at the time of the inspection in that there was only one registered nurse on duty. This was not a planned non-compliance but related an individual circumstance. A review of the off-duties which were available for inspection showed that there was only one registered nurse on duty for morning shifts at weekends. This is contrary to the home’s Conditions of Registration. The manager clarified on the second day of the inspection that she routinely planned for two registered nurses to be on duty at weekends but that for the rotas inspected, only one registered nurse had been available for duty. The home had not informed the Commission as required under regulation when they were not complying with their Conditions of Registration. Discussions with staff indicated that as they did not have access to these Conditions, they did not know when the home were not complying with it and so could not inform the Commission. The off-duty also showed that the home uses agency care staff frequently. On the week of the inspection, there was at least one agency carer on for each day shift and this number increased at weekend. Not all agency shifts can be covered by the same persons, so residents do not receive continuity of care. The manager confirmed on the second day of inspection that the home were
Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 20 up to establishment for staff and that the use of agency staff related to holiday and sickness amongst permanent staff. .If this is the case, the home should also inform the Commission of what steps they are taking to improve continuity of care to residents. Several residents said that they felt that the home were short of staff. As noted in Standard 8 above, there may be some evidence that residents who need frequent care do not receive it at the frequency required. There was no evidence that additional staff are brought on duty to support residents who are dying or present particularly complex care needs as is stated in the home’s minimum staffing levels. The dependency of residents across the home appears to be high and it was reported that only one resident was able to independently perform their personal care without physical assistance. When the home registered their new wing in 2002, it was on the basis that residents in the new wing would have low personal care needs and the Condition of Registration agreed then related to this expectation. This inspection shows that residents in this wing do not have a lower dependency and therefore the basis on which the Condition of Registration was agreed no longer relates to actual resident care needs. In the light of this increased dependency, the manager and owner will need to review the dependency needs of residents in the home and either ensure that all newly admitted residents have a lower dependency or that staffing levels are increased to reflect current residents admitted to the home. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 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): 37: Hays House does not look after any residents’ moneys, so 35 is N/A Hays House has a system to ensure that residents’ rights are protected by their record keeping and policies and procedures. EVIDENCE: Hays House has clear systems for record keeping. Required records are maintained in an ordered manner. Confidential records are safely stored. All visitors are reminded of their own responsibilities about confidentiality by a statement in the visitors book. Staff spoken with were aware of the home’s polices and procedures and know how to access them. Hays House DS0000015916.V264903.R01.S.doc Version 5.0 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 X 3 x X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X 3 3 2 3 3 X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X N/A X 3 x Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 12(1)a 13(4)(c) 15(1) Requirement Where a service user has a risk identified, a care plan must always be put in place to direct staff on how the risk is to be reduced. (This requirement was identified at the previous inspection and is not yet due) Where equipment is in use which is not in accordance with the service users assessed degree of risk, the clinical indicator(s) for this different equipment must always be documented. (This requirement was identified at the previous inspection and is not yet due) Records must be in place to show that service users who need frequent care are receiving this care. If additional staff are needed to meet such persons care needs, they must be provided. All out of date items used in service user nursing and care must be disposed of. The Commission must always be informed of any event which
DS0000015916.V264903.R01.S.doc Timescale for action 30/11/05 2. OP7 12(1 a) 13(4 c) 15(1) 30/11/05 3. OP8 12(1)(a) 31/12/05 4. 5. OP9 OP14OP27 13(3) 37(1)(e) 31/12/05 30/11/05 Hays House Version 5.0 Page 24 6. OP14 12(3), 23(4)(a) 7. OP22 23(2)(n) 8. OP26 13(3) 9. OP27 18(1)(a) 9. OP27 18(1)(a) could seriously affect service users’ well-being. If a service user requests or needs their room door held open, this must be respected and a device which has been approved by the fire officer must always be used. An audit of service users manual handling care plans must take place and the home must submit an action plan to the Commission, detailing when all service users who have clinical indicators showing they have complex manual handling needs will be provided with an automatic variable height bed. All wounds must be assessed for risk and if the wound or service user’s circumstances indicate high risk, aseptic procedures must always be used when performing wound dressings. The home must always have two registered nurses on duty on the morning shift as set out in their Conditions of Registration. A written review of the current staffing levels must take place and be submitted to the Commission, to ensure that adequate staff are available to meet the service users needs at all times. 30/11/05 28/02/06 31/12/05 30/11/05 31/01/06 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. Refer to Standard OP2 Good Practice Recommendations Where service users’ contracts refer to the registering
DS0000015916.V264903.R01.S.doc Version 5.0 Page 25 Hays House 2. 3. 4. 5. 6. 7. 8. OP7 OP7 OP22 OP22 OP27 OP27 OP36 authority, the correct title - the Commission for Social Care Inspection should be used. Where a service user experiences skin tears, a risk assessment and care plan should be put in place to direct staff on how risk is to be reduced. Assessments of service users’ footwear should take place when assessing risk of falls. When new carpets are being provided, the suitability of the carpet for use with a hoist should be considered. A system should be put in place to enable staff to communicate with each other across the home and answer the ‘phone and front door. The Condition of Registration relating to minimum staffing levels should be made available to all staff who may be in charge of the home. The home should inform the Commission of what steps they are taking to ensure that service users are given continuity of care. The induction for experienced staff should be in writing and a copy retained on their file. (This recommendation was identified at the previous inspection, information was not available at this inspection, so it will be reviewed at the next inspection.) Hays House DS0000015916.V264903.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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