Inspection on 16/06/05 for Hollin Knowle

This inspection was carried out on 16th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Hollin Knowle 29/04/08

Hollin Knowle 06/11/07

Hollin Knowle 05/06/07

Hollin Knowle 30/05/06

Hollin Knowle 23/03/05

Hollin Knowle 05/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE HOLLIN KNOWLE 78 FAIRFIELD ROAD BUXTON DERBYSHIRE SK17 7DR Lead Inspector MARIE BONYNGE Unannounced Inspection Thursday 16th June 2005 at 10:00am 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 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. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hollin Knowle Address 78 Fairfield Road Buxton Derbyshire SK17 7DR 01298 22534 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mohammed Shamsul Islam Mrs Shajeda Islam Care Home only 19 Category(ies) of OP registration, with number of places HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23rd March 2005 Brief Description of the Service: Hollin Knowle is a care home registered to provide personal care and accommodation for up to 10 residents in the category of Older People (OP). The home is situated on the outskirts of Buxton where a variety of amenities are available. Local shops are near to the home. Accommodation is provided over 3 floors which are accessed via a passenger lift. There are 2 lounge areas and a dining room. Additional communal space consists of a sitting area on the first floor adjacent to bedrooms. Gardens and car parking space are also provided. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in June 2005. The main focus of this inspection was to monitor progress made regarding the requirements and recommendations made at the last inspection of the home. Inspection methods used included discussions with residents, their relatives, management and staff of the home. Records examined included care plans, accident and incident records, training, staff files, medication systems and policies and procedures. A number of the requirements in this report have been outstanding since 2004 and limited progress has been made in achieving their compliance. A meeting has taken place with the proprietor, who is also the registered manager regarding this. The CSCI will continue to monitor the situation via the inspection process. Two immediate requirements were left in respect of health and safety issues on this visit. What the service does well: What has improved since the last inspection? The range of activities has been expanded and the provision of these is now planned. Medication systems have been reviewed and some progress has been made with the implementation of systems for the receipt and returns of medication, although further progress is expected. The Registered Manager has begun to review the training programme and records in general were available for inspection on this visit. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 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 standard(s) 3, 4 & 5 Service users needs were largely being met, although there were some areas of omission identified which compromise this. EVIDENCE: The care records of a number of service users were examined and discussions were held with them and other service users about their care. Although there was a standardised format in place for the recording of individual needs assessments, including risk assessed needs, these were not always completed or up to date. For example, one service users needs had changed considerably since their recent admission and they presented at considerable risk of falls. Their documented risk assessment was not indicative of this risk. Due to their increased mobility and mental state, the potential risks in relation to their environment, particularly the location of their bedroom had not been risk assessed or their needs reviewed. There was also no copy of the single assessment and care plan as provided by way of care management/social worker admission arrangements for this service user, although these were provided for other service users whose care records were examined. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 9 Recorded needs assessments did not provide information regarding foot care and oral hygiene needs Needs assessment information was not always signed and dated. Five out of six service users said that they were generally well supported and cared for although one service user said that their religious needs were not being met. The Inspectors were unable to discuss these with one service user case tracked due to their mental capacity. Staff spoken with felt they had the skills to meet the needs of service users accommodated, although staff numbers were not always sufficient – see Staffing Section of this report. Service users said their friends and relatives could visit the home when they wished and that they could see them in private. Service users spoken to, who had been recently admitted had not been provided with opportunity to visit the home prior to their admission, although their relatives had done so on their behalf, which they said was in accordance with their wishes. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 & 10. The majority of service users health care needs appeared to be met, although significant deficits were identified, which potentially compromised some service users health and safety needs. EVIDENCE: Two of the service users case tracked had documented care plans. One had none recorded by staff in the home. The recorded risk assessments for one service user were not up to date in respect of the risk of falls and nutritional risk. This same service user had been admitted fairly recently and had identified mental health needs for which there was no discharge information provided under the Care Programme Approach. Details of a follow-up appointment with the Consultant Psychiatrist provided no outcome. The personal care needs of service users were identified within their care plans, although oral and foot care was not included. Service users spoken with had not been consulted regarding their care plans, however, all said that staff were courteous and respectful in their approaches to them and treated them with care and kindness. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 11 A number of service users were accommodated in shared bedrooms, however there were no privacy curtains/screening provided in any of these. There was a recognised approach to the assessment and monitoring of pressure ulcer risk and service users had been provided with pressure relieving equipment in accordance with these. There were also recognised approaches to the assessment of nutritional risk and individual continence needs, with inputs via district nursing services as appropriate. Risk assessments and care plans were not always up to date and some were not signed or dated by the person completing them. Visits from outside healthcare professionals were recorded. Some service users felt that they did not exercise or get out enough - staffing deficiencies impacted on this (see staffing section). The system for the management and administration of medicines in the home was examined, including the auditing of a number of service users medicines. A number of requirements previously made by the Pharmacist Inspector of the Commission had not been met and deficits were identified in relation to the administration of medicines, record keeping and storage. The members of staff who had responsibility for the administration of medication had attended training, however an assessment of carer competence had not been completed. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 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 standard(s) 12 and 14 Activities generally suited the expectations and preferences of residents, however without increased staffing recreational interests outside the home could not take place. EVIDENCE: Most of the residents spoken with on this visit expressed satisfaction with the level and provision of activities. However, four residents said that they did not go out of the home because there was not enough staff to take them out on trips or to go into town. The range of activities was limited and one resident was not attending church as previously identified. Activities included board games and a key board player visited the home regularly. Residents reported that their daily routines were flexible and they could get up and go to bed at times that suited them. (See staffing section for further comments). HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 18 The safety and security of residents cannot be fully assured without adult protection training for the manager and all staff. EVIDENCE: An adult protection referral had been made regarding practices in the home, this investigation had not been completed at the time of this inspection. However, the protocols for reporting suspected incidents of abuse had not been followed in this instance. A meeting has been held between the home and the CSCI to discuss this matter and other issues of serious concern raised on this inspection. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 Significant deficits in some areas were identified however, that do not provide for a safe and well-maintained environment. EVIDENCE: Hollin Knowle is located on the outskirts of Buxton. Residents who were spoken with said that they were satisfied with the accommodation provided and that it met with their preferences. There was no programme for the routine maintenance of the home and renewal of the fabric and decoration of the premises. Replacement of furniture and redecoration was done on an ad hoc basis rather than in accordance with a planned programme with timescales for completion. It was reported that the upstairs bathroom was not used, this was an unassisted bath and no service users were capable of using this independently. There was therefore only one useable bathroom that was located on the lower ground floor and had a medic-bath with shower attachment. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 15 A smoking room was available on the lower ground floor of the home that was also used for storage purposes. The following areas were identified that were in need of attention: • • Bedrooms did not contain all of the required furniture and fittings such as bedside lighting, a chest of drawers, lockable storage, comfortable seating, at least 2 double sockets and screening in double rooms. There was no separate telephone line to the home other than a pay phone in the office. A limited amount of money was left to enable staff to make phone calls. There was no internal means of communication for staff between the floors of the home potentially putting residents at risk when only 2 staff were on duty. There was no fax machine. Where the old call system had been replaced there remained a number of holes and some old call points that were taped up. A number of beds were worn and in need of replacement, one bed had a foul odour and was heavily stained. Mattresses and headboards were also in need of review / replacement. A number of residents reported that they should be resting their legs on footstools, however there were none in the lounge on this visit. The carpet in the doorway of the lounge and the carpet in the bedroom of the lower ground floor was worn and beginning to fray. Armchairs, commodes, bedding and towels were worn and in need of replacement. There was a crack in the bay window of the lounge. Locks had not been provided to all of service users individual accommodation. Two bedroom carpets were identified with an odour problem. Two bedrooms had window frames that were in need of repainting, repair or replacement. • • • • • • • • • HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 A list of the training available was provided, however this did not reflect the overall and individual training needs of staff. Staffing levels mean that service users needs cannot always be met. EVIDENCE: A sample of staffing rotas was examined. These indicated that 2 care staff were on duty for the morning and afternoon shifts and one waking and one sleep in staff were on duty for the night. A written risk assessment regarding staffing levels as required in the previous reports had not been provided. Concern was raised regarding the accommodation of one resident on the lower ground floor and an urgent care review was advised at the time of the inspection. A meeting had taken place with the proprietor regarding staffing levels and other areas of concern following a protection of vulnerable adults referral. The Residential Forum guidance for staffing in care homes was not being followed, there was no consistent information regarding the dependency levels of residents. The levels of staffing did not provide for residents to be able to go out and access recreational facilities or activities outside the home. During busy periods of the day such as meal times and personal care giving where 2 care staff were needed there were times when no care staff were in the lounge area. An overall training and development plan with individual training needs had not been developed although a list of the training that took place was provided. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 17 Much of this training was provided by video and a questionnaire format, the standard of this had not been verified. Two staff files were examined. The Inspector was advised that one Criminal Record Bureau check had not been received for one member of staff. Photographs of staff were not on those files examined. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 37 and 38 The health and safety of residents is potentially comprised where systems are not in place to monitor the quality of the service provided. EVIDENCE: The Registered Manager who is also one of the proprietors has owned and managed Hollin Knowle for a number of years. Some progress was found to have been made at this inspection regarding the availability of records and progress with some of the requirements from previous inspection reports. However a number remain outstanding as identified in the main body of this report. Residents spoke positively regarding the manager and staff and about the general care provided. Formal quality assurance systems had not been developed. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 19 Training records examined indicated that fire training had taken place but there was no list of who had attended the training. The Registered Manager advised that staff had completed all the mandatory training although this could not be verified on this visit. The systems for the reporting and recording of accidents and incidents in the home were examined and were satisfactory. Certificates of maintenance were examined including servicing for the lift, emergency lighting and fire equipment. These were satisfactory. The fire precautions register was seen and fire alarm testing had been commenced since the last inspection. A gas safety certificate was not available although a safety check had been carried out. Certification for systems to control Legionella had not been carried out. The key pad lock to the door leading to the lower ground floor was disabled. This door led directly onto a flight of steep steps into the cellar. This matter was raised previously and not action had been taken in the interim period. This was a potential risk to service users, particularly in relation to one resident who was wandering. An immediate requirement was left in respect of this. The water coming from the hot water outlet of the bath in the first floor bathroom was recorded using a thermometer at above 50C. The water was scalding to the touch and presented as a potential risk t residents. The Registered Manager advised that residents did not use this bathroom. An immediate requirement was left in respect of this. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 x COMPLAINTS AND PROTECTION 1 3 2 2 3 2 2 2 STAFFING Standard No Score 27 1 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 1 2 x 1 x x x 2 1 HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 21 YES Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14(1)(a) Requirement Service users documented needs assessments must contain all information as identified under NMS 3.3. From inspection report 05.05.04. Timescale for action Previous timescale 31.05.04. New timescale 31.07.05 31.07.05 2. OP3 and OP4 14(1)(b) & (d) 3. OP3 and OP7 14(2) 4. OP3 and OP4 12(4) The registered person must not provide accommodation to a service user at the home, unless, as far as practicable, a copy of the single assessment and care plans summary provided by way of care management for the purposes of placement in the home, are provided and that the registered person has confirmed in writing to the service users that having regard to the assessment, the care home is suitable for the purpose of meeting their needs. Individuals documented needs 31.07.05 assessments must be kept under review and revised at any time when it is necessary to do so, with recorded reviews at least monthly. The registered person must 31.08.05 ensure that suitable arrangements are made to ensure that service users Version 1.30 HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Page 22 religious needs are met. 5. OP7 15(1) The registered person shall ensure that documented care plans are recorded for all service users in consultation with them. Documented risk assessments for each service user must be regularly reviewed and signed and dated by the person completing them. The registered person must ensure that all parts of the home to which service users have access are free from hazard and that unnecessary risks to the health and safety of service users is identified and so far as possible eliminated. In this instance the suitability for use of the bedroom located in the basement of the home for the service user accommodated there must be reviewed in accordance with a documented risk assessment. The specialist advice/outcomes from outside healthcare professionals must be clearly documeted within the service users care files. The registered person must ensure that the home is conducted in such a manner which respects the privacy and dignity of service users. In this instance privacy curtains/suitable screening must be provided in shared bedrooms. From inspection report 05.05.04. The registered person must ensure that opportunities are given to service users for appropriate exercise and physical activity. There must be a system to check the identity of the service user prior to administration of 31.07.05 6. OP7 13(4)(c 31.07.05 7. OP3 and OP7 13(4)(a) & (c 31.07.05 8. OP7 & 8 13(1)(b) 31.07.05 9. OP10 12(4)(a) Previous timescale 31.07.04. New timescale 31.07.05 10. OP8 12(1)(b) 31.07.05 11. OP9 13 (2) Previous timescale 31.08.04. Page 23 HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 medication. From inspection report 05.05.04. 12. OP9 13 (2) 17(1)(a) Schedule 3 13(2) 17(1)(a) Schedule 3 OP9 The MAR chart must be signed immediately after administration to a resident. From inspection report 05.05.04. MAR charts must list all medication with directions that a service user is currently taking. From inspection report 05.05.04. Medication no longer needed must be returned to the pharmacy for disposal. From inspection report 05.05.04. Non medication items must not be stored in the medication trolley or cupboards. From inspection report 05.05.04. The maximum and minimum temperatures of the refrigerator for medication must be recorded daily and lie between 2C and 8C. From inspection report 05.05.04. All medication must be stored securely, including that requiring refrigeration. From inspection report 05.05.04. There must be a system to prevent over ordering of medication for residents. From inspection report 05.05.04. Medication policies must be available and include the procedures for receipt, C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc 13. OP9 14. 13 (2) 15. 13 (12) OP9 16. 13(2) 23 (2)(i) OP9 17. 13 (2)23(2)(i) OP9 18. 13 (2) OP9 19. 13(2)17(1) (a) Schedule 3 OP9 New timescale 01.08.05. Previous timescale 31.07.04. New timescale 01.08.05. Previous timescale 07.06.04. New timescale 01.08.05. Previous timescale 31.08.04. New timescale 01.08.05. Previous timescale 31.08.04. New timescale 01.08.05. Previous timescale 30.09.04. New timescale 01.08.05 Previous timescale 31.07.04. New timescale 01.08.05. Previous timescale 30.09.04. New timescale 01.08.05 Previous timescale 30.09.04. Page 24 HOLLIN KNOWLE Version 1.30 20. 13(2)17(1) (a) Schedule 3 OP9 21. 13(2)18(1) (c)(i) OP9 22. 13, 18 OP18 recording, storage, handling, administration and disposal of medication in the home. From inspection report 05.05.04. The home must have a list of staff members authorised to administer medication with a record of their approved initials that they use when signing the MAR chart. From inspection report 05.05.04. Medication training must be documented and provided by an external creditable source and involve and assessment of carer competence. From inspection report 05.05.04. The manager and staff must receive appropriate training for the protection of vulnerable adults. From inspection report 05.05.04. The policy on adult protection must be further developed to bring it in line with Derbyshire Socaila Services Vulnerable Adults procedures. From inspection report 05.05.04. The smoking room must not be used for storage purposes. All of the matters identified in the environment section of this report must be addressed, and an action plan must be provided with timescales for completion by the date given. The registered person must complete a risk assessment for the home which looks at staffing levels in relation to the safe supervision of service users when there are two staff on dutyand when there is one person on duty and one person sleeping-in. It must take into account the layout of the building and the number of New timescale 01.09.05 Previous timescale 31.08.04. New timescale 01.09.05. Previous timescale 30.09.04. New timescale 30.09.05 Previous timescale 31.05.04. new timescale 01.10.05 Previous timescale 31.07.04. New timescale 01.09.05 01.09.05 01.08.05 23. 13 (6) OP18 24. 25. 23 23 OP20 OP19 26. 18 OP27 Previous timescale 31.06.04. New timescale 01.08.05 HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 25 27. 13, 18 OP27 28. 13, 17 OP29 service users who need two staff to assist them with any tasks. A copy of this assessment must be sent to the CSCI office. From inspection report 05.05.04. The registered person must ensure that the home is staffed according to the Residential Forum guidelines for staffing in care homes and complete an audit of dependency levels. Personal files must contain appropriate staff information as laid out in Schedule 4 including photographs of staff. From inspection report 05.05.04 CRB checks must be carried out for all staff employed in the home. From inspection report 05.05.04. An overall staff training plan with individual training needs identified must be developed and appropriate records maintained. The registered person must ensure that all training provided meets with recognised standards and is appropriate for the work that staff are to perform. The Registered Manager must enrol on a course for NVQ level 4 in management and care to be completed by 2005. The registered person must put in place formal quality assurance systems. From inspection report 05.05.04. Records required by regulation for the protection of service users must be accurate, maintained and up to date as identified in the main body of this report. 01.08.05 29. 17 OP29 30. 18 OP30 Previous timescale 31.07.04. New timescale 01.09.05 Previous timescale 31.07.04. New timescale 01.09.05 01.10.05 31. 18 OP30 01.10.05 32. 9, 18 OP31 01.01.06 33. 13, 24 OP33 34. 17 OP37 Previous timescale 31.07.04. New timescale 01.09.05 01.09.05 HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 26 35. 36. 37. 23 23 13 OP38 OP38 OP38 38. 13 OP38 39. 16 (2)(g) OP38 A current gas safety certificate must be sent to the CSCI office. Systems must be put in place for the control of Legionella. The lock to the door of the lower ground floor must be in good working order and all precautions taken to ensure the safety of residents. A risk assessment must be completed for the use of the first floor bathroom and it must be ensured that hot water temperatures are maintained at close to 43C. An impermeable membrane must be provided to the floor in the food storage room. From inspection report 05.05.04. A risk assessment must be completed with regard to the use of portable heaters in the home. From previous inspection report 05.05.04. An external phone line / fax machine must be provided. 01.09.05 01.10.05 Immediate requiremen t left Immediate requiremen t left 40. 12 OP38 41. 23 OP38 Previous timescale 31.07.04. New timescale 01.09.05 Previous timescale 31.05.04. New timescale 01.08.05 01.10.05 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 OP3 OP9 Good Practice Recommendations Documented needs assessments (including risk assessments) should be signed and dated by the person recording them. The home should request the pharmacy to provide descriptions of the medication in the Nomad cassette on the reverse and to place soluble tablets in a separate compartment to enable identification and appropriate administration. From inspection report 05.05.04. An internal communications system / phone should be C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 27 3. OP38 HOLLIN KNOWLE considered. HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 HOLLIN KNOWLE C52 CO2 S20019 Hollin Knowle V234079 160605 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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