Inspection on 13/11/06 for Heliosa Nursing Home

This inspection was carried out on 13th November 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

Heliosa Nursing Home 12/07/06

Heliosa Nursing Home 05/10/05

Heliosa Nursing Home 10/05/05

Heliosa Nursing Home 28/10/04

Heliosa Nursing Home 05/07/04

Heliosa Nursing Home 23/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heliosa Nursing Home 54 Boundary Lane Congleton Cheshire CW12 3JA Lead Inspector June Shimmin Unannounced Inspection 13th November 2006 09:00 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 Heliosa Nursing Home DS0000018732.V315451.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. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heliosa Nursing Home Address 54 Boundary Lane Congleton Cheshire CW12 3JA 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) 01260 273 351 01260 297794 Takepart Limited Mrs Lyndis Swinden Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 42 service users to include: * Up to 42 service users in the category of OP (old age, not falling within any other category. Date of last inspection 15th August 2006 Brief Description of the Service: Heliosa can care for up to 42 older people requiring nursing care. The home was originally three cottages built in the early 1800`s and was converted for use as a nursing home in 1970. The home is detached and has a private garden. It is located in a quiet residential area of Congleton. The town centre of Congleton is approximately two miles away. The home is on two floors and there is a passenger lift and staircase to the first floor. There are a variety of aids and adaptations around the building to allow residents to move about more independently. The owners have recently extended the home to provide an additional 11 single bedrooms with en suite facilities. All of the bedrooms are single and thirty-one bedrooms have en suite facilities of toilet and wash hand basin. The home has a dining room and three lounges. The current weekly fees range from £473.35 to £560. regarding fees are available from the manager. Further details Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on 13th November, 2006 and feedback was given to the owners on 15th November, 2006. The visit and feedback lasted eleven and a half hours. A regulatory inspector carried out the inspection. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social services. We are currently testing a method of working where `experts by experience` are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term `experts by experience` used in this report describes people who have been appointed by Help the Aged, under the direction of the Commission for Social Care Inspection, to take part in the inspection of services for older people. The visit was just one part of the inspection. Other information received was also looked at. Before the visit the home manager was asked to complete a questionnaire to provide up to date information about Heliosa. Questionnaires were also given to residents, families and health and social care professionals to find out their views. During the visit various records and the premises were looked at. A number of residents and relatives were also spoken with and they gave their views about Heliosa. What the service does well: What has improved since the last inspection? Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 6 Residents moving into the home are given a written statement of terms and conditions on the day of admission so that they know their rights and responsibilities. The manager makes sure that all residents are fully assessed before admission so that the home can meet their needs. Care planning has now been transferred to a computerised system and is now more efficient and easier to audit. The standard of care planning is much improved. The manager has taken steps to identify residents at risk of malnutrition. The management of medication has improved. Heliosa have employed more care and domestic staff. The manager has taken steps to find out the views of staff. Cleaning materials were kept safely. 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. Heliosa Nursing Home DS0000018732.V315451.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 Heliosa Nursing Home DS0000018732.V315451.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are given sufficient information about the home and care costs so that they can decide if the home will meet their needs. Residents are fully assessed prior to admission so that care staff are able to meet their care needs. Intermediate care is available. EVIDENCE: The owners have provided the CSCI with a revised copy of the Statement of Purpose and Service User`s Guide, which are information leaflets about the home. A copy of the information leaflet was seen in an empty room. The relative of a resident recently admitted to Heliosa said that written information had been provided about the home. The resident was given a choice of two rooms. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 9 Heliosa has given all recently admitted residents a contract. A number of contracts were seen and these were signed and dated by the resident or their representative and the owner of Heliosa. The contract also referred to “any social or cultural traditions that the service user requires to keep” which is good practice and ensures that any individual needs are identified. One resident said that several items had gone missing whilst being laundered. A nurse said that this would be followed up. During feedback, the owners said that these items had been found and labelled. The owners said that they could not take responsibility for missing items. However, there was no reference to this in the contract so that residents may not be aware of their rights and responsibilities. The owners could include more information about the laundry service in the contract or statement of terms and conditions. The assessments of three new residents were looked at. The registered manager or another nurse completed these. The registered manager has just appointed a senior carer as Care Manager. This new Care Manager is learning to undertake assessments by accompanying the registered manager. Initial assessments are handwritten and then transferred onto computer. The content of the assessments was good and included most information that the home needed to meet the needs of new residents. There was however only limited information about the social and family history of several residents. Where possible, potential residents are invited to visit the home and spend time there to see if the home will meet their needs. The registered manager said that someone had spent half a day at Heliosa the day before and took lunch. Heliosa accepts residents under the Intermediate Care Scheme. However, the registered manager said that no one had been admitted under this scheme since the last inspection so that no care records could be looked at. Heliosa Nursing Home DS0000018732.V315451.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health care needs of residents are mainly met but there is room for some further improvement in relation to the prevention of pressure sores. Medication is generally well managed. EVIDENCE: Heliosa has recently introduced a new computerised system for recording information about residents. Most staff have received training to use the computer. Information about assessments, care plans and risk assessments is stored on the computer. The registered manager said that once information has been recorded it cannot be changed or any additions made, which is good practice as it means that records must be correctly completed. It also ensures that care records can be easily audited to demonstrate that care plans have been fully and accurately completed. The registered manager has ensured that steps have been taken to maintain the confidentiality of information kept by the home on the computer system. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 11 Four care plans were looked at. These were all stored on computer and the content of the care plans and risk assessments was good overall. Records indicate that residents or their representative were involved in the care planning process. In one case the risk assessment indicated that the resident was at high risk of developing pressure sores. There was however no care plan for this care need. There was evidence on the daily records that the resident had developed skin changes consistent with a pressure sore. A complaint received by the home alleged that the resident was not provided with a pressure-relieving cushion during the day. However, the resident was being nursed in a specialist bed. There was better documentation about the prevention of pressure sores on the other care plans. Another resident had a leg bandage but there was no care plan addressing this need although there was reference to a wound in the daily records. Care plans and risk assessments had been reviewed on at least a monthly basis and the care plans amended accordingly. Records indicated that there was good communication between care home staff and other professionals. Referrals to health care professionals are made in a timely way. The nursing home GP visits the home weekly and commented “Medication seems to be monitored carefully. Staff have managed complex patients well – specifically palliative care.” The registered manager has introduced a nutrition risk assessment for identifying residents who are underweight, which is good practice. Several residents had been identified as being at risk of losing weight. This was fully recorded on the care plan and the registered manager said that the dietician had been very quickly involved. Where appropriate, records were kept of the food and fluids taken by residents. Medication management has improved. The medication administration records were looked at and were of a good standard. Several gaps were noted where staff had not signed to indicate that medication had been administered. The management of controlled drugs is good. The manager has been carrying out weekly audits of medication records to ensure that good standards are maintained. Six staff have attended medication training organised by an approved trainer and two further staff are to attend in the future. The medication room is too small to store the medication of 42 residents in an organised way. However, the manager intends to provide a larger medication room in the near future. Observation of care practices demonstrated that care staff were sensitive to the needs of residents and that all residents were treated equally. Residents said that staff treated them with respect and courtesy. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 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, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered choice in their daily lives but the individual social care needs of residents are not always met. The standard of catering is good. EVIDENCE: An “expert by experience” spoke to a number of residents about their life at Heliosa. Comments made were mainly positive, “it`s lovely, I`m glad I`m here” and “the food is very good.” Heliosa had arranged a trip to Trentham Gardens the previous week and there had been a recent Bonfire Night party and display. There were no activities taking place during the inspection. Several residents expressed a wish to play the card game Whist. Heliosa does not employ a member of staff to provide activities. There was also no record on care plans to indicate how individual residents` social and cultural needs were being met. Information provided by the registered manager before the inspection indicated that the following activities were provided at the home: sing and music session, music for health, oriental exercise, Malcolm and his organ, one to one hand care, pub day, jigsaws/games, sing-a-long with staff and church services. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 13 The expert by experience said that a suggestion box, a list of future activities and photographs of recent events could be introduced which the registered manager agreed to consider. Activities did not appear to be provided on a regular basis. Relatives are welcome at the home and are free to visit at any reasonable time. Residents are able to express choice in a number of ways. They are able to stay in their own room if they wish and are also offered choice at mealtimes. A local church minister visits the home on a regular basis and residents can participate in the service if they wish. Heliosa have introduced a new menu, which offers variety, choice and quality. This includes a cooked breakfast on request, a main meal at lunch and a lighter evening meal. There are two sittings at lunch to enable staff to support residents needing assistance to eat. The lunch menu was either cottage pie with two vegetables or spaghetti Bolognese followed by apple crumble. The registered manager said that the home was introducing a “red tray” system whereby residents at risk of malnutrition could be identified and monitored. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all complaints are recorded which means that the concerns of residents and/or relatives might not be addressed. Residents are protected from possible abuse. EVIDENCE: Information provided by the registered manager before the inspection indicated that the home had received one complaint in the last twelve months. However, the complaints book contained more complaints. A further complaint from the family of a former resident was not recorded in the complaints book. The care home was aware of this complaint as the resident had moved to another home. The registered manager had recorded the actions taken as a result of other complaints and the outcomes. The complaints procedure is contained within the Service User Guide (information leaflet) and is displayed near the previous entrance to the home. Neither relative who returned a comment card had needed to make a complaint but one relative was unaware of the complaints procedure. Staff confirmed that they would take appropriate action if they suspected a resident was being abused. Heliosa had policies and procedures for the protection of vulnerable adults. The registered manager said that this topic is included within the induction of new staff and also forms part of the NVQ level 2 qualification, which many staff have achieved. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 15 The registered manager and a nurse have recently attended training on this topic and will be passing on what they have learned to other staff. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, safe, clean and generally well maintained environment. EVIDENCE: Since the last inspection the owners have continued to upgrade the home. A new staff office has become fully operational. Its situation near to the main entrance means that it is accessible to residents and relatives. It also enables staff to observe residents in two lounges from the office. The owners have also redecorated eight bedrooms and provided a new GP/meeting room and separate staff room. Heliosa provides a number of communal living areas so that residents have a choice of where to sit. The inspector and the expert by experience both found the home clean and tidy with no offensive smells. Rooms were personalised so that residents could make their bedroom more homely and familiar. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 17 The expert by experience noted that the older part of the home was noticeably colder than the new extension. One relative told the expert by experience that a relative was often confined to bed and that the temperature in the room was always cold. Although the relative had reported this nothing had been done. A concern was raised that there was a cracked window in the room of one resident in the older part of the building, which had been reported but not repaired. The owners informed the inspector during the inspection that there had been a problem with the heating on one wing of the home. The owners had bought thermostatically controlled fan heaters as an interim measure until the heating could be repaired. The inspector received information from four different sources about inadequate heating at the home. During the inspection the inspector spoke to a resident on the affected wing who said that the fan heater was adequate. The owners sent the CSCI a notification several days after the inspection that repair work had been completed. However, a follow up call indicated that the problem had not been resolved. The owners said that they were also experiencing difficulty finding a contractor to complete building work to damp areas on the walls of the bathroom and a first floor bedroom and bathroom in the older part of the building. This work was outstanding from the inspection of October 2005. The owners said that they expected this work to be completed within the following three weeks. The owners said that the affected bedroom was not being used and was to be converted to an en suite bedroom. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are cared for by an adequate number of well-trained staff. Recruitment practices are not thorough, putting residents at potential risk. EVIDENCE: On the day of inspection the registered manager, who is a first level registered nurse was on duty with two registered nurses. In addition there were six carers. The nursing home GP commented that since the last inspection “there are more care staff and residents are having more attention.” The registered manager said that new staff have been recruited since the last inspection and that more staff were awaiting recruitment checks. In particular a new member of staff has been appointed to work in the kitchen in the evenings to prepare and serve the evening meal and clear away dishes after the meal so that carers are no longer involved in these activities. This member of staff was not working on the day of inspection and care staff were carrying out this work. However, the manager said that an extra carer had been brought in to help out. The registered manager has also recently promoted a senior carer to Care Manager and she will have responsibility for ensuring that carers deliver a high standard of care. Staff were described as being “very good and caring.” Information provided by the manager before the inspection indicated that eleven staff have achieved NVQ level 2, which is virtually 50 of the care staff. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 19 Remaining staff have been given the opportunity to undertake this qualification. The registered manager is very supportive of staff undertaking training. Staff are also able to undertake other training such as infection control, palliative care, prevention of falls and venepuncture. The expert by experience commented that staff had a good relationship with residents. The registered manager has completed the induction of three new staff members. The recruitment records of three new staff members were looked at. These contained necessary initial security checks (POVA first) and an enhanced disclosure was awaited from the Criminal Records Bureau. The registered manager said that there had been a long wait for these documents. Two staff were working in the day under supervision. A third staff member was a nurse working nights but was not directly supervised. The nurse had worked six nights but the registered manager said that she had spent part of the shift with the nurse on several nights. The registered manager undertook to remove the nurse from the night duty until the enhanced disclosure had been received. It was also noted that friends or former colleagues provided both references for this nurse. The registered manager said that she had sent references to the managers of the previous homes where the nurse worked but not received any response. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The management Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. of Heliosa has greatly improved and the owners are committed to providing good standards of care. The home is generally well maintained. EVIDENCE: The owners have worked cooperatively with the CSCI since the last inspection to improve standards of care at Heliosa. The registered manager has become more involved in ensuring that medication and care planning in particular are of a better standard. The manager is well regarded by residents, staff and relatives and has undertaken various training updates to enhance her skills and knowledge. Staff said that the registered manager was approachable and easy to talk to. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 21 The management of Heliosa have applied to be assessed for the Investors in People award again. The home originally achieved this award in 2004. The registered manager has tried by way of meetings to find out the views of staff to discuss the `way forward` for the home. The registered manager provided the CSCI with information before the inspection, which indicated that family members handle residents` monies. Since the last inspection a maintenance person has been employed for 25 hours a week. Information provided by the registered manager before the inspection indicated that the home is well maintained. Staff have attended regular fire drills and the home has an up-to-date fire risk assessment. There were no records that emergency lighting had been tested every month although the owner said that this had been done. There were however, a number of incidents that had not been immediately notified to the CSCI. These included the recent problems with heating and the deaths of residents in hospital. Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 13 &15 Requirement The registered person must ensure that residents are protected from developing pressure sores and that accurate documentation is maintained in respect of this. (Previous timescale of 12/10/06 not met) The registered person must ensure that there are no gaps on medication administration records and that a record is kept of the reason for the nonadministration of medication. Timescale for action 15/12/06 2. OP9 13 15/12/06 3. OP16 22 The registered person must 15/12/06 ensure that a record is kept of all complaints, together with the actions taken as a result of the complaint and the outcomes. The registered person must ensure that a written response is made to the complaint received from Social Services and a copy sent to the CSCI. 15/12/06 4. OP16 22 Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 24 5. OP25 23 The registered person must record the temperature of bedrooms at regular intervals, and particularly at night, to ensure that minimum temperatures are maintained. 15/12/06 6. OP29 19Schedul es 2 & 4 The registered person must 15/12/06 ensure that employees do not work in an unsupervised capacity until an enhanced disclosure has been received from the CRB. The registered person must ensure that all incidents under this regulation are notified in writing to the CSCI without delay. 15/12/06 7. OP38 37 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 The registered person should ensure that details about laundry services are incorporated within the contract or statement of terms and conditions on admission to the home. The registered person should ensure that more information is recorded about the residents` social and cultural needs on admission. The registered person should provide larger facilities for the safe storage of medicines. Care plans should demonstrate how the individual social care needs of residents are being met. 2. OP3 3. 4. OP9 OP12 Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 25 5. OP12 The manager should consider employing a person to deliver individual and group activities. The registered person should ensure that a reference is obtained from the employee`s most recent employer. The registered person should ensure that records are kept of the monthly testing of emergency lighting. 6. 7. OP29 OP38 Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Heliosa Nursing Home DS0000018732.V315451.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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