Inspection on 10/01/06 for Henlow Court

This inspection was carried out on 10th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Henlow Court 14/08/06

Henlow Court 02/08/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Henlow Court Henlow Drive Dursley Glos GL11 4BE Lead Inspector Mrs Ruth Wilcox Announced Inspection 10th January 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 Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Henlow Court Address Henlow Drive Dursley Glos GL11 4BE 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) 01453 545866 01453 549949 The Orders of St John Care Trust To be appointed Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one (1) named service user under the age of 65yrs. Condition to be removed when the named service user leaves the home. 11 November 2005 Date of last inspection Brief Description of the Service: Henlow Court is a care home for older people over the age of 65 years, which provides nursing and personal care. It is situated in the town of Dursley, and is managed by The Orders of St John Care Trust. Residents who are admitted for personal care only, but who may need the services of a nurse, have the District Nurse service accessed from community resources. One room is available to provide respite care, and is contracted to Social Services for this purpose. The home is purpose built and provides easy access throughout, including access for wheelchairs. The home has two floors, with a shaft lift providing access to the first floor. There are two lounges, a lounge dining room, and a spacious dining room divided between the floors. Residents’ accommodation is situated on both floors, and are all single rooms, each of which has its own washing facilities. Only one room has its own full en-suite facilities. There are spacious and easily accessible bathing and toilet facilities conveniently situated throughout the home. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this announced inspection over six hours on one day in January 2006. The acting manager, yet to be registered by the CSCI at the time of this report, was present throughout the inspection providing assistance where requested, remaining open to the inspection process and cooperative throughout. The home was warm and welcoming, and staff were pleasant and helpful. The availability of information about the home to assist prospective residents and their families in making their choice about it was looked at. Care records and the systems for the management of medications were inspected. The care of four residents was closely looked at in particular, and there was direct contact with eleven residents, two visitors and eight other staff. Their views regarding the standards of services and care at the home were sought wherever practicable. The opportunities for residents to engage in social activities were looked at, which included the arrangements to receive their visitors. The choices and quality of meals was also inspected. The management arrangements for the home were looked at, as were the systems for monitoring and ensuring quality of the service, and the policy for dealing with complaints. The provision of staff and the way in which they are recruited and trained was inspected, and a tour of the premises took place, with particular attention to the standard of maintenance, health and safety and cleanliness. What the service does well: Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 6 Prospective residents and their families have access to information about the home ahead of their admission, in order that they can make an informed choice about moving there. Residents themselves were very happy with the care they receive from the staff, with those spoken to saying that staff were very kind and helpful. There are good examples of the home working in collaboration with external health care professionals, for the benefit of residents. Medications are generally well managed, though there are isolated areas for improvement on the printed medication charts, further to a change of pharmacy supplier. A good standard of food is provided, with a varied and balanced diet. Meals are well presented and allow for a good degree of choice for residents; residents themselves were very satisfied with the food on offer for them. There is a satisfactory system for dealing with complaints and concerns when needed. The manager is receptive, and is committed to addressing any issues as they arise. There are also good systems for monitoring the quality of the service provided at the home, with residents and their families having opportunities to give feedback on their views and ideas. Visitors are freely made welcome into the home. The home has established a safe and transparent system to allow residents to place money or valuables in the main safe, keeping good clear records. Recruitment of staff is carried out in a methodical and thorough way, and is done in accordance with that which is required. There are good training opportunities for the staff, with staff encouraged to achieve an NVQ qualification. The home does all it can to promote the health and safety of all those living and working there. What has improved since the last inspection? Although present at the additional visit carried out two months ago, the manager is reasonably new to this home since the last inspection. She and her staff are working very hard to improve and promote good standards for the residents, and so far she has had a very positive impact in the home. Staff have worked hard regarding record keeping, and the standard of care plan documentation has greatly improved, although there remain isolated Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 7 instances where further improvements in recording could still be made; these were in respect of pressure area care and wound management. The home has focused on providing better opportunities for the residents to engage in social activities, as this had previously been lacking for some. Residents themselves confirmed that they are offered the opportunity to participate if they wish. The home itself has undergone and continues to undergo a good degree of refurbishment work to improve facilities for the residents. New furnishings, carpets, décor and fabrics are gradually being introduced. Improved laundry equipment has been provided, and generally staff are adopting improved infection control practices throughout the home. The fire alarm system and resident call bell system have both been replaced with new ones. What they could do better: The Orders of St John Care Trust have not yet produced updated and current versions of the home’s Statement of Purpose and Service User Guide, despite taking over the management of the home eight months ago. Work is reported to be ongoing at this time, and they are required to submit the new documents upon their completion to the CSCI. Despite an increase in the provision of staff, and an apparently committed and hard working group of staff, there are constraints upon deployment that are affecting the way in which some residents’ needs are being met. This is particularly so when the service of breakfast is very late for some residents, as staff are assisting others with personal care. In addition, a small number of residents have said that they can be kept waiting too long for things at times. In view of this the current staffing must be reviewed, to include a review of the long established working practices of the staff group. Staff do have access to the NVQ training programme, though the home is not currently meeting the standard of having at least 50 of its staff qualified to NVQ level 2; the home continues to try to address this by encouraging and supporting staff to train. Please contact the provider for advice of actions taken in response to this Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 9 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 Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 10 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. The pre-admission information ensures that residents have access to adequate information when making their choice about the home. EVIDENCE: Prospective residents are provided with an information brochure, which informs them and their representatives about the home and The Orders of St John Care Trust. The guides still contain information relevant to the previous registered providers at this time, though it is reported that the information is currently under review, with a revised and more up to date Service User Guide being produced. The home’s Statement of Purpose is contained in a folder, which is easily accessible for anyone choosing to read it. This is fully reflective of the requirements in the regulations, with added useful information for any reader. Henlow Court does not provide intermediate care. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 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. An improved care planning system can now provide staff with the information they need to meet residents’ needs more adequately, though continued focus is needed in certain areas. The systems for the management and administration of medications are generally good, with arrangements in place to ensure that residents’ medication needs are appropriately met, although these could be more comprehensive to ensure consistency for residents in very isolated cases. EVIDENCE: Each resident has an individual plan of care, which is based on an assessment of their needs; four were selected as part of the case tracking exercise. Since the last inspection, staff have received additional care planning training, and consequently the standard of documentation is better, with plans well written in the main; each is regularly reviewed. Most aspects of plans contained clear instructions as to how each individual’s health needs are to be met, with visual evidence confirming that this is carried out. Plans demonstrate multidisciplinary working with other health care professionals where applicable. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 12 However, in one case, there was no documented plan of care to address an identified risk of the person developing pressure sores, whilst with others, the associated care plan contained no reference to the preventative manual actions necessary by staff to prevent the problem developing. Also, wound management plans conflicted with reviews, with no clear direction regarding the cleansing, dressing type and frequency of the wound management to be carried out. All medications are stored appropriately, with clearly printed Medication Administration Records from the supplying pharmacist; the home has just changed its pharmacy supplier, in order that it remains compliant regarding the disposal of waste medicines, in accordance with the Special Waste Regulations 1996. Medication records are thoroughly recorded by the staff, and are generally well maintained. However, there were isolated instances where printed directions for the use of external medications were unclear, with the use of an ‘as directed’ instruction, or without identification of the external site at which to administer it. Residents are supported to self-medicate if they wish and are able to, and this is done on the basis of a documented risk assessment. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 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 & 15. An improved activities and entertainments programme makes better provision for residents to be provided with regular and varied opportunities for social activity. The visiting arrangements at the home ensure that residents can keep close contact with their families and friends in accordance with their wishes. Dietary needs of residents are adequately catered for, with a good selection of food available that meets their tastes and choices. EVIDENCE: Since the last inspection the home has focused on the provision of social activities for the residents, and has endeavoured to improve and increase the choices and availability for them. There is a designated activities coordinator to consult with the residents, and plan social events, and a record of activities undertaken with those participating is maintained. A programme of activities planned for each morning and afternoon is displayed, and residents confirmed that they are given choice and opportunity for participation. Many were pursuing their own particular interests on this day, by reading or watching television. The home provides a relaxed environment for visitors, and does not place any restrictions on them. Residents confirmed their close contact with their Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 14 relatives and friends, and visitors were seen coming in and out of the home. One visitor confirmed that he felt very welcome in the home when he visited. Menus are varied, and offer a good degree of choice for the residents. They are consulted regarding their choices from the menu, with a list of preferences sent to the kitchen for the cook’s reference; the cook was very aware and informed about individual requirements. One resident however, had been missed on this day, and staff had to return to him, when requested, just before the meal so that he could make his choice. The meal at lunchtime looked wholesome and appetising, and was evidently portion and diet controlled where applicable. All residents spoken to, without exception, were very positive and happy about the quality and quantity of food provided for them. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 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. The home has a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. EVIDENCE: A copy of the complaints procedure is displayed for anyone wishing to read or use it. Residents confirmed that staff are very attentive to them, with some saying that staff will do what they can to help them. Two visitors expressed some concerns, and raised some questions about issues specific to them and their relative; the first in person, and the second by telephone. The first of these visitors indicated slight reservations about the home responding consistently to any concerns raised; the acting manager resolved to meet with this visitor to discuss their continued areas of concern in person. The second visitor had not raised their concerns with the manager at all at the time, though has since done so. This was with reference to the intrusiveness of the new call bell system during the nighttime hours, which the acting manager has endeavoured to address. The home maintains a record of complaints and concerns received. The record contained evidence of two complaints received since the last inspection, which had been appropriately addressed, with corrective actions taken. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 16 Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 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. The standard of the environment within this home has improved, is generally satisfactory, and provides residents with a comfortable and safe place to live. The home is clean, with appropriate and full observations regarding the control of infection. EVIDENCE: The home has undergone, and continues to undergo a degree of refurbishment work, in order to improve the environment for the residents. Since the last inspection a large number of new soft furnishings, carpets and fabrics have been purchased. Many areas have been redecorated; this programme is ongoing. A new call bell system and a new fire alarm system have been installed. The home is cleaned to a good standard, and was largely odour free. Efforts to control certain odour problems from an identified source are proving more successful at this time, with it remaining more contained. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 18 Facilities in the laundry room have been improved, with the provision of two large washing machines, fully capable of managing the laundry loads, and with sluicing disinfection cycles. Laundry and clinical waste is safely managed, with due regard to infection control procedures; a colour coded bagging system has been introduced to improve infection control practices. New cleaning schedules have been drawn up, following consultation between a member of the domestic team and the acting manager. Gloves and aprons, liquid soap, hand cleansing gels and paper towels are provided throughout the home. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 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 & 30. Staffing provision is just adequate to meet the needs of the residents, though this is not always in a consistent and timely way. Robust recruitment procedures ensure that suitable staff are employed for the protection of residents. Staff receive appropriate training to support them and equip them with the necessary skills for their roles. EVIDENCE: The provision of staff has been increased over recent months, with additional care and nursing hours being utilised. The home is very busy, with staff evidently working very hard to meet residents’ needs, in what is a quite widely spread environmental layout. Recorded staff rotas demonstrate the staffing, and there has been significant agency usage, with a lot of staff sickness reported. There is a good ancillary team of catering, cleaning, laundry, maintenance and administration staff. Residents themselves spoke very highly of the staff group, saying that they worked so hard, and cared for them well. One resident said that although she felt she was looked after very well, she was occasionally kept waiting an unacceptably long time for things. One visitor said that most of the staff couldn’t be better, but that during shift handover times, staff were in little evidence, which concerned him. Another visitor raised questions about the provision of staff over the Christmas period; it transpired that there was some staff sickness, which the home had been unable to cover. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 20 In consideration of some resident comments, which were also validated by some staff, it was clear that a review of staff’s working practices is needed in the mornings, in respect of serving breakfast and managing the personal needs of individuals as well. Some residents were served breakfast very late on this day, and it is reported that this is not unusual, with some waiting until 09.30 for their meal. There is a conflict of the interests of some residents wishing to be assisted to get up, wash and dress before their breakfast, against some wanting their breakfast earlier. Staff themselves appear to be a very hard working and committed group; they demonstrated awareness of individual needs during the case tracking exercise. There are currently six care staff who are already qualified to NVQ level 2 standard, with one of these actually being at level 3. Two carers are awaiting external verification for their award, and there are two others making good progress on the level 2 programme at present. There are four others waiting to commence their NVQ training. The number of qualified carers does not meet the 50 target that should have been achieved by the end of 2005, though the home is making all efforts to work towards achieving it as soon as possible. A selection of staff files was chosen for inspection, on the basis of their recruitment to the home since the last inspection. Each record contained application forms, including a full employment history. Records of interviews were seen. Full and complete evidence of the required pre-employment checks was seen in each of the files. Training records demonstrate structured induction training for new staff. This is carried out in-house within the first six weeks of appointment, with new staff attending a two day induction course at the training department; the timescale for one new worker to attend the two day course had extended beyond the six week target. Staff spoke positively about recent training they had received, welcoming different opportunities for their professional development. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 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 & 38. There are good management systems in place to ensure that the interests, health and safety of the residents is safeguarded. The home reviews aspects of its performance through a good programme of self-review and consultations, which includes seeking the views of residents and their relatives. EVIDENCE: The home’s manager is a first level nurse, who has long experience of caring for people in this setting, and who has only recently joined the home. She is currently taking the NVQ level 4 Registered Manager’s Award with a local college. Since her appointment, she has undertaken additional management training, and has made a very positive impact on the home as a whole, working through priorities for her attention, whilst remaining accessible to residents, staff and visitors. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 22 An application to register her formally with the CSCI for her appointment is being processed at the time of writing this report. In terms of monitoring quality in the home, The Orders of St John Care Trust conducted a major audit ahead of the acting manager’s appointment, which has identified areas for improvement and change. A six monthly ‘Resident’s Review’ survey is carried out, in order to establish that the service is meeting the resident’s needs and expectations, and meal monitoring forms have been introduced on a frequent basis, in order that residents’ views about the quality of the food can be obtained. Residents and their relatives are invited to attend a meeting, at which they have the opportunity to voice their opinions and ideas about the home. A report has not yet been produced on the basis of all the quality monitoring work that is being carried out, but this is apparently being addressed by The Orders of St John Care Trust at this time, and it is quite clear that improvements are being implemented. The acting manager has yet to receive feedback on the existing quality monitoring tools, though carries out her own monitoring as she gets the outcomes. She carries out her own care planning and medication auditing as a regular feature, giving feedback and direction to staff as necessary. Some residents have placed personal money and valuables with the home for safekeeping. Clear and transparent records for each person, which include transaction details, running totals, and receipts, are kept. Residents or their representative sign to acknowledge some transactions, but where this is not possible in the majority of cases, two staff members sign the record to witness on behalf of the resident. There was evidence that health and safety issues are addressed well in this home, with written policies, procedures and risk assessments, provision of necessary equipment and staff training. A full fire safety risk assessment throughout the whole building is due to take place in the immediate future by an external assessor, with due regard to revised fire safety regulations. There are five members of staff currently qualified to provide First Aid. All necessary safety checks and maintenance of equipment is undertaken in a timely fashion. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 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 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 24 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 OP1 Regulation 4(2) 5(2) Requirement The home must send the revised copies of the Statement of Purpose and Service User Guide to the CSCI upon completion. Staff must devise written and detailed care plans in all cases where residents are assessed as being at risk of developing pressure sores. Staff must devise clearly written care plans, detailing the precise management of wounds. The home must avoid the use of ‘As Directed’ instructions on medication charts. Staff must ensure that there are clear instructions regarding the use of all medications, to include the use of external medications on the medication charts. In consideration of residents and staff statements, the home manager must ensure that a review of staffing provision and deployment is undertaken, and that the necessary action is taken to ensure staffing is adequate to meet residents’ needs efficiently. A review of staff working DS0000064619.V276077.R01.S.doc Timescale for action 31/05/06 2 OP7 15(1) 31/01/06 3 4 5 OP7 OP9 OP9 15(1) 13(2) 13(2) 31/01/06 31/01/06 31/01/06 6 OP27 21(2) 18(1.a) 31/03/06 6 OP27 16(2.i) 31/03/06 Page 25 Henlow Court Version 5.1 practices must be undertaken, with any necessary action taken, to ensure that residents receive their breakfast meal at a more suitable time. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP28 Good Practice Recommendations The directions for the use of ‘as necessary’ and/or external medications should be recorded and linked in to a relevant plan of care. A minimum ratio of 50 of care staff qualified to NVQ level 2 should be achieved in the home. Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Henlow Court DS0000064619.V276077.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!